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As the state withdraws from welfare provision, the mixed economy of welfare – involving private, voluntary and informal sectors – has become ever more important. This second edition of Powell’s acclaimed textbook on the subject brings together a wealth of respected contributors. New features of this revised edition include:
• An updated perspective on the mixed economy of welfare (MEW) and social division of welfare (SDW) in the context of UK Coalition and Conservative governments
• A conceptual framework that links the MEW and SDW with debates on topics of major current interest such as ‘Open Public Services’, ‘Big Society’, Any Qualified Provider’, Private Finance Initiative (PFI) and ‘Public Private Partnerships’ (PPP)
Containing helpful features such as summaries, questions for discussion, further reading suggestions and electronic resources, this will be a valuable introductory resource for students of social policy, social welfare and social work at both undergraduate and postgraduate level.
This chapter examines the NHS in a cold climate of a decade of austerity. This period has first seen a broad move from the optimism of its 60th anniversary and greater pessimism of its 70th anniversary. Second, it has seen a game of two halves from a preoccupation with the reorganisation of the Lansley Health and Social Care Act towards ways of working around or undoing that reorganisation. One sad constant in the period is the continuation of Inquiries into failings in the NHS. The chapter concludes with an assessment of the ‘birthday present’ of increased funding associated with the NHS’ 70th anniversary, and some thoughts of the outlook of things to come. While the increased funding is welcome, it is unlikely to have the promised ‘transformatory’ effect because it is less than the NHS’ historical rate of funding increase; it includes promises that have been made in the past but have not been delivered, and excludes wider elements of health-related activity and social care. If life is to begin at 70 for the NHS, futures birthday presents for its 75th or 80th birthday must include greater integration with social care, perhaps a phoenix-like transformation into a National Health and Social Care Service.
This chapter contains an analysis of the development of the NHS under the Coalition Government. While some argue that under the Coalition Government the UK approaches the end of the NHS, the analysis shows that the reforms initiated by the Coalition Government have diverging directions and diverging ideological foundations. Whereas in the first part of the Coalition Government’s rule merely competition, privatization and marketization dominated the debate, the second part stills carries the heritages of the neo-liberal paradigm but also introduces other measures to improve the performance of the NHS and guarantee its financial sustainability: prevention, integration and localisation. But the question is if these initiatives are strong enough to guarantee a bright future for the NHS.
In Essays on ‘the Welfare State’, Richard Titmuss (1963, p 53; note the use of inverted commas) pointed to ‘three different systems of social services’ (social, fiscal and occupational welfare) which ‘are seen to operate as virtually distinct stratified systems’. The Labour politician and author, Frank Field (1981) pointed to Britain’s five welfare states: the traditional welfare state; the tax allowance welfare state; the company welfare state; the private market state; and the unearned income from inherited wealth. This text focuses on these wider welfare states, which tend to be less visible than traditional state or ‘social’ welfare. The distribution of welfare services through a range of social mechanisms beyond the state itself has been termed ‘one of the most important categories in the contemporary study of social policy’ (Spicker, 2008, p 136). However, there seems to be no broadly accepted or dominant term to signal this welfare beyond the state. Different writers point to the mixed economy of welfare (MEW) (eg Murphy, 2006), welfare pluralism (eg Dahlberg, 2005), the welfare mix (eg Lee et al, 2016), the welfare triangle (Pestoff, 2014), the welfare diamond (eg Christensen, 2012) or the care diamond (eg Razavi, 2007). Most writers appear to use these terms broadly interchangeably (Johnson, 1999; Dahlberg, 2005).
Moreover, the MEW and SDW tend to be invisible or hidden. Burchardt and Obolenskaya (2016, p 217) state that the ‘pure public’ (public provision, finance, and decision) segment is what we might consider to be the archetypal post-war British welfare state. Prasad (2016) points to the terms that have been used to describe the ‘indirect’ and ‘private’ American welfare state: hidden, divided, submerged, and invisible.
The informal sector is perhaps the most important but least visible component of the mixed economy of welfare (MEW). For example, Johnson (1987, p 65) stated that in the case of elderly people not living in institutions the informal system is almost certainly more important than both the statutory and voluntary sectors. More recent commentators confirm that the most important source of welfare for disabled and older people in the UK is informal care provided by family and friends (Pickard, 2016).
Jenson (1997) suggested three key questions that needed to be placed at the heart of any care-centred typology and analysis of social policy: Who cares? Who pays? How is care provided? However, the informal sector may be rather different from the other three (formal) components (eg Qureshi and Walker, 1989; Finlayson, 1990). This suggests that it is difficult to apply the three-dimensional analysis of provision, finance and regulation to informal care.
Informal provision is usually regarded in terms of ‘provision’ in the sense of hours of care. There is limited ‘finance’ like the state paying for (say) private hospitals, as informal care is unpaid, although there are some policies in place such as providing carers with cash benefits or benefits in kind (Glendinning, 2016; discussed later in this chapter). However, it has been estimated that the contribution of carers such as family and friends is worth about £132 billion per year in the UK, roughly equivalent to the National Health Service (NHS) budget (Carers UK, 2017). Finally, there is limited ‘regulation’ of the ‘private sphere’ of caring.
The title of this chapter is derived from the pioneering account of Sinfield (1978). While ‘analyses’ may promise a little too much, this concluding chapter aims to reinforce the importance of the mixed economy of welfare (MEW) and the social division of welfare (SDW). Drawing on the material from earlier chapters, it examines the importance of the MEW and SDW over time and space. The MEW and SDW are important in an analytical as well as a descriptive sense. It is important to examine changes in the complex three-dimensional space of provision, finance and regulation rather than focusing on simple and misleading changes in one dimension such as provision. It then examines how the MEW and SDW are linked to important debates in social policy, and how they are associated with complex differential impacts on service users.
The MEW and SDW are vital, but relatively neglected, concepts in social policy. Mayo (1994, p 26) writes that ‘the MEW has been fundamental to the welfare state in Britain, although the mix has clearly varied between services and over time, just as the mix varies between Britain and the USA, for instance’. John Stewart (Chapter Two) draws attention to the historical importance of the MEW. While many authors claim that the mix changes over time, he points out that the components of the MEW themselves change over time. For example, the ‘voluntary sector’ in the 19th century was not the same as the ‘voluntary sector’ today. Nevertheless, the different components of the MEW in the UK follow a fairly broad trend – or ‘moving frontier’ – over time.
The inverse care law, which states that good medical care varies inversely with need, has become the conventional wisdom in a number of disciplines. However, studies which examine the spatial relationship between need and provision suffer from a number of weaknesses. These are outlined and then a number of studies are critically reviewed. It is concluded that the problems of measuring need and provision across areas make any firm conclusion about their relationship premature.
A central concern of the New Labour government was to modernise the welfare state. Welfare reform featured heavily in the 1997 Manifesto, and it has been a major feature of government policy ever since (for example, Powell, 1999; Burden et al, 2000; Timmins, 2001). The main aim of this text is to evaluate the welfare policies of the first term of the New Labour government (1997-2001). It is concerned with evaluation of policy rather than evaluation for policy. The government has invested heavily in the latter, commissioning a significant amount of research with the main aim of improving the policy process. For example, it has set up many area-based policies such as Action Zones in education, health and employment. Changes in these zones are evaluated in order to ‘mainstream’ any improvements to the national level. Similarly, policies such as the New Deal have been subject to evaluation (see Chapters Five and Ten of this volume). Moreover, it has encouraged evidence-based approaches in health, education and social care in order to determine ‘what works’ (for example, Davies et al, 2000).
However, this text is concerned with evaluation of policy. There is a rapidly growing literature that examines the changes that New Labour has made to social policy. Some of this literature is implicitly evaluative in that it gives a broadly positive (for example, Glennerster, 1999) or negative (for example, Hay, 1999; Burden et al, 2000; Critical Social Policy, 2001) verdict on the changes. However, there is much less material that is explicitly evaluative in that it gives a clear verdict (for example, Glennerster, 2001;Toynbee and Walker, 2001; Boyne et al, 2003: forthcoming).
Existing verdicts give a mixed but generally positive evaluation on New Labour’s welfare reforms. On the one hand, Rawnsley (2001, p 382) writes that the five promises of the pledge card, supposedly easy and early, had proved difficult and slow to deliver. A generally negative verdict is given in Critical Social Policy (2001). On the other hand, Toynbee and Walker (2001, p 7) claim that the five pledges have “all just about been realised, without too much equivocation”. They conclude that “things did get better” (2001, p 240). According to Rawnsley (2001, pp 382-3), the achievement is “quite considerable”. He continues that, compared with many governments, this was well above average record. By the measure of the expectations aroused by the size of the majority, New Labour’s transformatory rhetoric and the ambitions that Blair had trumpeted, his government looked less impressive. The vital and virtually unquantifiable issue is clearly individual expectations. As Philip Gould put it, “If I’d have gone to a focus group on April 29th 1997 and said this Labour government is going to run the economy more competently than any other, it’s going to invest unprecedented amounts in public services plus it will create a million jobs plus it will lift a million people out of poverty, they would have thought I was mad. It was difficult enough getting them to believe our five pledges. They would have called me a Martian!” (in Rawnsley, 2001, p 383). Glennerster (2001) gives New Labour’s social policy an ‘alpha minus’: alpha for the strategy, gamma for presentation, beta for some of the detail.
This chapter discusses the way in which the foundation and development of the National Health Service can be seen as an example of a shift from negative (reactive) to positive (proactive) welfare. It observes that policy makers and practitioners have themselves taken the opportunity of the sixtieth anniversary of the foundation of the NHS to review the organisation in the light of the contemporary challenges it faces: these reviews have been mixed in their conclusions about the success in moving from a national ‘sickness’ service to one that genuinely promotes and provides ‘health’ to its citizens.
