Social Policy and the welfare state

national | miscellaneous | opinion/analysis Sunday March 04, 2007 01:57 by jim travers jimtravers at eircom dot net

Yellow pack, Harney's public health service

What is the mixed economy of welfare and why, despite Mary Harney's assurances in that, what she is doing is really in the interest of all the Irish people and not a back door method of promoting the privatisation of our health service in the interest of the doctors and consutant's who collectively and directly contribute to the demise of the same public heath service from within.

The Celtic Tiger has seen many changes in our welfare services, with greater emphasis being placed on the advantages of a mixed economy of welfare that is fuelled by an increasing drive towards privatisation and an open competitive market where competition is supposed to bring with it a better quality of service and a greater choice for the consumer. Social stratification ranks individuals and families into levels of class that share unequally in the distribution of status and wealth resulting in the inability of individuals to financially access the full potential of medical and health care services instantly, if those services are provided more readily outside the state public health care system. The sub-contracting of health and other social services to the private sector or the privatisation of services such as transport and education will see a change in direction by the welfare state in its responsibility for the provision of social services, to one of the state providing the finance in order for the private sector to provide the service.

Frequently we see the private sector providing services to the public that are far more successful and cost efficient than similar services provided by the state. On the other hand the private sector cannot provide services that reach out to all sections of our society and embrace every strata or class equally in the provision of a quality service where that service is not governed by one’s ability to pay for it.The mixed economy of welfare promotes and encourages the rise of health insurance schemes in order for people to cover the increasing costs of medical care that result from the capitalist attitude of the medical profession in upholding its ethical values, once the piper has been paid.

In a mixed economy of modern welfare, we increasingly experience the inability of at least two-thirds of our society (class divide) to purchase vital and important medical welfare services, while at the same time witness an increasing reluctance by the medical profession to provide an equal, consistent and comprehensive medical service to the public, that is not conditional on one’s financial ability to pay for that service or treatment. Are governments being impeded in their ability to develop a truly inclusive and workable public welfare system or are they promoting or being coerced into agreeing a half way public, private system of welfare, where the initial strategy is to develop a public private partnership that will eventually be controlled by doctors, consultants and their private hospitals, thereby leading to a two-tier economy of welfare that sees the state provide finance to the private sector for the provision of very basic and minimal welfare services.

What is Social Policy?

Social policy relates to guidelines for the changing, maintenance or creation of living conditions that are conducive to human welfare. Social policy is the part of public policy that has to do with social issues such as public access to health care or other social programs. The aim of social policy is to improve human welfare and to meet the human need for education, health, housing and social security.

When trying to understand any shift that reduces the state’s responsibility in the provision of welfare services that are based on government social policy strategies, we must take into account the advantages or disadvantages posed by the mixed economy of welfare, if that same economy of welfare leads to a dilution of public access to services and care, thereby undermining the aim of social policy to improve human welfare and meet the needs for human development and social progress. The market economy is capable of generating great wealth but it has no imperative to share that wealth. Left to itself the market will concentrate wealth in the hands of the most powerful actors and will tend towards ever greater inequality.1
The mixed economy of welfare consists of public, private, voluntary and independent health care providers, offering medical and other health care services to the public in the form of public/ private partnership initiatives or independent private health care services that are collectively or individually financed through personal, state or voluntary health insurance company payments and contributions.

The Poor Law in Ireland
Prior to 1839, Ireland had no poor law system of any kind. With the increasing pressure of population (six million people in 1851), it became increasingly obvious that a system for alleviating poverty was becoming more and more apparent. The Elizabethan Poor Law did not apply to Ireland, with only limited measures being adopted to deal with the poor prior to 1800. Public debate in England led to the establishment of the ‘New Poor Law’ in 1834. Two contrasting personalities dominated the introduction of the Poor Law in Ireland, Richard Whatley a scholar and churchman and George Nicholl's a banker and a Poor Law Commissioner, who both produced different solutions for dealing with poverty in Ireland.
The United Kingdom government rejected proposals by the Royal Commission of Enquiry into the Conditions of the Poorer Classes in Ireland (Whatley Commission) and instead opted for the proposals of George Nicholl's who strongly recommended the use of workhouses as a stepping stone for economic development in Ireland.This divided the country into 130 Poor Law Unions which were to be the responsibility for the relief of poverty in their own areas.Each Union was governed, subject to the overall supervision of the United Kingdom Poor Law Commissioners, by a board of Guardians, partly appointed ex officio and partly elected. Unlike the position in the United Kingdom where outdoor relief was allowed in certain circumstances, relief was to be provided only in the workhouses which were to be established in each Union.2
In 1847 the Poor Law Relief Extension Act was passed, which allowed workhouse guardians provide relief to a very limited number of people. This relief was of no real benefit as the terms and conditions for relief were restrictive.

By the turn of the century it was becoming evidently clear that the Poor Law system needed to be reformed, although consensus as to the shape of this reform was far from being agreed. A commission was established by Lord Lieutenant, the earl of Dudley to recommend ‘ How, if at all a reduction could without impairing efficiency be made in the expenditure for the relief of the poor, and at the same time to show, if possible,how an improvement in the method or system of affording relief might be effected’.3

The Poor Law, although lacking at that time in bringing real and meaningful relief to those in extreme poverty and need, was a stepping stone for the development of the welfare state we see today.

The Birth of the Irish Health Care System
The State provided limited health care services for people under the Poor Relief Act of 1838 in Ireland.The Poor Relief Act of 1851 further divided unions into dispensary districts where doctors were given a duty to look after the health care of those who came under the terms of condition for state treatment. Anybody falling outside the terms of the Poor Relief Act were treated by doctors as private patients. In 1924 The Department of Local Government and Public Health was established. A bill introduced in 1945 under the stewardship of Dr. Con Ward was fiercely opposed by both clerical and medical profession who seen their interests potentially diluted by a bill that provided an extension to maternity and child care services without a means test, combined with doctor services for children up to sixteen years of age. The bill became law in 1947 although some changes were made to it by the then Minister for Health Dr.James Ryan.4

Tracing the mixed economy of welfare
The phrase ‘the mixed economy of welfare has long been used to characterise the partnership between the capitalist modes of production and state enterprise in the provision of medical and welfare services. Ireland has always had some form of a mixed economy of welfare that provided limited but necessary health services to many people unable to cope or recover from their illness. Ireland has a long tradition of hospital care: the first Irish hospital on record was that founded by Princess Macha ‘within the precincts of the royal residence in Ulster’ three hundred years before Christ. During the early Christian period the onus of caring for the destitute and the sick fell on the monasteries.5
During the eighteenth century several voluntary hospital were established by philanthropic individual and groups of doctors. Despite the fact that some of the most well known hospitals were established during the years from 1718 to 1745 through generous donations from individuals, philanthropists and famous people like Jonathan Swift Dean of Saint Patrick’s Cathedral, many poor people especially those outside the pale of Dublin were unable to access meaningful medical care that was readily available to those within the upper classes. In the Dublin of the late Nineteenth, and early Twenty Century, doctor services and medicines were restricted to those who could afford to pay medical fees, and left to those in inner city slums and country places to use the knowledge of potions and remedies handed down through generations in order to cure their own illnesses. In the socially divided Ireland of the Nineteenth Century, very many poor people were admitted to hospitals in order to die rather than secure medical attention or a cure for their illnesses.

During the 1950S both the medical professions and the Catholic Church showed their real hand, by their reluctance to support and stifle meaningful welfare schemes that were aimed at the elevation of poverty through the provision of free medical welfare services. In 1950 Dr.Noel Browne proposed the introduction of a scheme which would provide free maternity care for all mothers and free healthcare for all children up to the age of sixteen, regardless of income. It met with ferocious opposition from conservative elements in the Catholic hierarchy and the medical profession. Many doctors disapproved of the scheme, some on principle, others because they feared a loss of income and a fear of becoming a kind of civil servant, referring to the plan as "socialised medicine".6

In the now early years of the 21st century the medical profession through its representative body the Irish Medical Organisation, promotes the financial self interests of its members over the welfare and health of those its professional ethical oath is supposed to cherish. It does this by stifling and opposing proposals made by the Department of Health and the Department of Social and Family Affairs by refusing to participate in welfare schemes unless their interests are addressed above all other considerations. The Organisation’s decision also reflects the fact that the IMO has been assured that the HSE will be moving from its previous position of exclusively proposing public only contracts for Consultants. We expect that significant new HSE proposals, providing for a menu of contract options, will be ready for our immediate consideration on the resumption of talks.7

In hospital and medical consultations, patients are at the mercy of the medical profession in the treatment they receive based on their ability to pay or take up private medical insurance in order to cover the fees sought by doctors and consultants. The extent of that treatment can often mean patients prolonging their illnesses, exacerbated by their inability to secure life saving but costly medicines, or acquire modern technological prostetic implants and surgical treatments purely because they cannot afford to meet the cost of the surgeon’s time. Various levels of Voluntary Health Insurance schemes provide a selective level key for one’s ability to access meaningful services that are graded from a nurse’s uniform to a consultant’s suit. The classic economic model assumes consumer sovereignty with supply and demand independent of each other, yet there are cases where it is the supplier, not the consumer, who decides what quantity and quality of service will be bought. Someone who approaches their doctor with a pain in the stomach is in the doctor’s hand as to whether the treatment ordered will be a simple antacid syrup or major stomach surgery. The patient is hardly in a position to shop around for a cheaper remedy, a surgeon with lower fees, or a shorter hospital stay.8

This form of selective treatment is promoted in favour of private sector medical practices simply because public sector hospitals provide comprehensive information relating to waiting times for patients receiving treatment within the public health service, thereby inadvertently or deliberately portraying state public health services as inefficient and second rate despite the fact that the same doctors and consultants work within the public and private sector in tandem with one another. Private hospitals are commercial bodies so information on waiting times for procedures in those institutions is only available directly from them. Similarly, waiting times for procedures for private patients in public hospitals is not on the Register. This is because these patients pay private health insurance that pays the cost of their care. In other words, care for private patients in public hospitals is not State funded. Public patients have to pay hospital charges, unless they are among the exempted groups.9

A Two-Tier Mixed Economy of Welfare
A two-tier mixed economy of welfare system is further exacerbated by the refusal of judges in certain medical negligence court cases to uphold Medical Council rulings that individual doctors or consultants are not fit to practice medicine.There again the Irish Medical Council’s recommendations that certain conditions must be met prior to a doctor or consultant being allowed to practice medicine once again, is but a well thought out legal initiative by the council to elay public disquiet at both doctors and consultants appearing to be let off the hook. A consultant obstetrician at Sligo general Hospital who was found guilty of professional misconduct over his treatment of three female patients at the hospital over a two-year period is fit to practice and return to work the High Court has decided…………The Medical Council had urged the court to attach conditions, including ongoing medical supervision to any return to work by Dr. Victor Moore but Mr Justice Michael Hanna said that, while he believed this was a”most appropriate “ case to issue recommendations he has no power to do so under the Medical Practitioners Act.10

National Treatment Purchase Fund

The National Treatment Purchase Fund is a government agency funded by the Department of Health and Children to reduce waiting time for public patients awaiting surgery on public hospital waiting lists. On paper it appears to be a significant development in providing public patients access to private treatment, thereby promoting the advantages of a mixed economy of welfare. The main focus of the NTPF is to enable public patients to get their operations faster. Patients attend an out-patients consultation appointment where a decision on the procedure is required. Once the patient decides to accept this procedure the hospital places them on its internal register. If the patient is still on the waiting list after three months, the NTPF writes to eligible patients and offers treatment under the fund in a private hospital.

Once again the emphasis is placed on a public patient receiving treatment in a private hospital, where surgeons carry out similar medical procedures that are available but stifled in public hospitals. A consultant or surgeon’s time is split between their willingness to conduct or advise on surgical procedures within the public hospital service framework, and a preference for their time being provided under a public, private partnership arrangement where the state pays a fee to a private hospital based on the complexity of the surgical procedure undertaken. From a private practice point of view, it is in the private sectors interest that public hospital waiting lists grow and grow, as public concern and anger is directed at elected public representative’s inability to resolve health and welfare issues that are being fuelled by sources outside their control or ability to control.

Everything the Irish people struggled to achieve is systematically being dismantled by our political representatives who use globalisation, competition and an open market economy to place the health and welfare of our citizens, as yet another commodity to be traded, bought and sold to the highest bidder. And let us not also forget both the Catholic church and the medical profession, who seen the best place for us all to be, so that their interests are not undermined. is..................poverty. We have the creeping privatisation of all our public service that is promoted by political parties of all colours and to which is detrimental to the health, welfare and security of all our people. It appears that our politicians are systematically trying to convince us that our public services are better managed in the hands of the private sector despite the overwhelming fact that the private sector in many other countries has proven a divisive sector when it comes to the interests of all people irrespective of their ability to pay for the services provided. In other words the dentist will gouge out your teeth if you are under the public health system but will provide you with a soothing mouth wash if you are prepared to pay for it. And lets not forget the waiting list that can suddenly be jumped once you say you are prepared to pay the crooks for their services.

Restricting access promotes privatisation

Social policies that characterise our modern welfare state are now seen as luxuries that we can no longer afford to finance entirely from the public purse. The same policies can be seen as vital necessities in helping people adjust to modern economic changes that include the health and welfare of all citizens in our country. The institutional mix of public and private finance in social policy is conditioned and influenced by political ideologies and corporate interests that tear apart the underlying reasons for developing meaningful social policies that provide access and assistance to services for those who require it. ‘For example, access without charge to the full range of services is available to only 30% of the population, and private health insurance pays a significant role in structuring access to a wide range of services- notably hospitals. This is associated with differentiated and unequal utilisation of health care; accordingly, this two-tier system is implicated in public debate about fairness and equality.’ (Wren, 2003) 11

A two-tier system of hospital admission segregates and categorises every potential patient entering the hospitals environment, thereby promoting and encouraging among the professional medical fraternity a yellow pack system of medical treatment from the moment one enters the hospital gates.Patients who opt to avail of public consultant services under the Health Act will be deemed to be public patients. Public patients will only be accommodated in public beds. … … …Patients who opt to avail of private consultant services will be deemed to be private patients. Private patients will only be accommodated in private or semi-private beds. 12 The emphasis on public consultant services and private consultant services imply a two tier system of service from a single consultant source and therefore an openly divided economy of welfare based on ability to pay rather than need.

A divided state of hospital and medical welfare

The welfare state of medical treatment and care is under increasing pressure of being dismantled from within. The people who are entrusted to provide, promote, advance and maintain the availability of welfare services to all sections of our society are the same people who are slowly but surely dismantling the system from within. At the November meeting of Health Forum West, Mr Pat O’Byrne, Chief Executive of the National Treatment Purchase Fund, revealed that part of its mandate is to send 90% of patients on waiting lists for treatment to private hospitals, with just ten per cent being directed to public hospitals. The revelation generated an outcry among the 40 county council members sitting on the forum, with one Galway Independent Councillor claiming that Bertie Ahern’s Government was ‘actively promoting’ private hospitals over public facilities. His celebratory mood was not shared by Independent councillor, Catherine Connolly, however. “This is clearly not about public waiting lists, but about the promotion of private hospitals,” she said. “I have figures here showing wards closed and no staff available in public hospitals. The Government has successfully run down public health services while actively promoting private hospitals.13

The Irish welfare state has evolved and changed over time to a point where taxpayer’s money is increasingly being pumped into what appears to be a bottomless pit of state supported health and welfare services. Entitlement to benefits for a wide range of disabilities or services is increasingly placing financial strain on the system, thereby forcing a continuous evaluation and restructuring of the system to a point where more people become entitled to increased financial assistance or eligibility to health services but find the quality and waiting period for treatment is compromised in favour of a system where private health insurance schemes and treatments financed from one’s own personal financial resources is promoted and encouraged by both the state and private sector.

The mixed economy of welfare embraces many aspects of Irish social policy and directly affects the people who are seen as the most vulnerable in or society. In order to reduce the state requirement to provide an adequate pension to those who have reached the end of their working lives, the state is now encouraging young people to contribute to private pension schemes in order to maintain their standard of living at retirement age, where the state pension falls short of that provision. ‘The state spends as much on tax relief for private pensions (Euro 1.5 billion in 2000/2001) as it spends directly on contributory and non-contributory public pension schemes (Euro 1.6 billion 2000/2001). Stewart (2005) has argued that current system redistributes state resources away from vulnerable sections of the population (i.e. those entirely dependent on the state pension) and towards the better off. The Combat Poverty Agency (2006) has observed that tax relief on pensions has a strong inequality effect. ... … … … One reason for the regressive nature of the pension system is that, in Ireland, it has evolved to serve the interests of the industry and not the consumer or citizen’.14

This also impacts on the provision of health and welfare services, where private hospital and medical service sectors see the opportunity to capitalise on the requirement of consumers and citizens to either pay for the privilege of service or turn to the state for financial assistance in an effort to secure those services. The mixed economy of welfare is a divisive method of providing services on an equal basis to all citizens, and is only sustainable due to the medical professions inclusive involvement in the promotion of private medical health care practices.

The medical profession is collectively helping to dismantle health and medical welfare services in preference to a system controlled by a profession that sees an ability to demand increasing fees for services provided to the state from a bottomless pit of financial gain. As countries throughout the world experience revolution, class division is torn further apart as ordinary people revolt, resulting in actions that see people who once commanded authority, respect and praise for their interests in the health and welfare of people, suddenly become the same people who meet their fate on the gallows at the hands of the people they were supposed to be helping.

Independent councillor Catherine Connolly said “One million of the population has private health cover, while three million are without it. Health is the most essential resource for us all to live and we must have health for all.” 15
Government and public representatives may discuss, debate and implement social policy strategies, but the medical profession at the end of the day will be the deciding factor in what it perceives as value for money for its services to the state.

References
1. Address by David Begg, General Secretary, Irish Congress of Trade Unions to the Green
Party Annual convention, Kilkenny-24th Match 2006.
http://www.ictu.ie/html/news/briefcase/s240306.htm Ref: 1-12-2006

2. Cousins, Mel, ‘The Birth of Social Welfare in Ireland 1922-1952’. P10, P11. Publishers, Four
Courts Press Ltd, 2003.

3. Cousins, Mel, ‘The Birth of Social Welfare in Ireland 1922-1952’. P14. Publishers, Four
Courts Press Ltd, 2003

4. Disability Federation of Ireland, An Overview of the Irish Health Care Service, 2002.
http://www.wheel.ie/user/content/download/168/730/file/...c.pdf
Referenced: 09-12-2006

5. Burke, Helen “The People and the Poor Law in 19th Century Ireland” C1.P3
First Published in1987 by WEB, The Irish Women’s Education Bureau.

6. http://en.wikipedia.org/wiki/Mother_and_Child_Scheme Referenced: 5-12-2006

7. IMO Consultants to Resume Contract Talks
http://www.imo.ie/view_categories.php?cat_id=10&doc_id=...at=10
Referenced; 10-12-2006

8. Kiely. Gabriel, Anne O’Donnell, Patricia Kennedy, Suzanne Quin, “Irish Social Policy
in Context”. Publishers: University College Dublin Press, Newman House, 86 Saint
Stephen Green, Dublin 2. C 15, P 272.

9. National Patients Treatment Register
http://www.dohc.ie/public/information/hospitals/nationa....html
Referenced 22-12-2006

10. Kilfeather, Vivion. article ‘Doctor guilty of misconduct allowed to practice medicine’
Irish Examiner Newspaper, P5. 20-12-2006.

11. Payne, Diane, Anthony Marsh UCD, Geary Institute, Geary Discusion Paper Series, ‘Welfare
State Legitimacy: The Republic of Ireland in Comparative Perspective’
http://www.ucd.ie/geary/publications/2005/GearyWp200510.pdf
Referenced: 28-12-2006

12. Rotunda Hospital Dublin, Patient satus
http://www.rotunda.ie/showpage.asp?p=patientcharges
Referenced: 01-01-2007

13. Geraghty, Joan, article “Private versus Public” The Mayo News.
http://www.mayonews.ie/index.php?option=com_content&tas...id=38
Referenced: 01-01-2007

14. Green Party, ‘A Policy on Pension Provision’ (PDF file)
www.greenparty.ie/en/content/download/9418/101459/file/pension%20policy_sml.pdf-
Referenced: 29-12-2006

15. Geraghty, Joan, article “Private versus Public” The Mayo News.
http://www.mayonews.ie/index.php?option=com_content&tas...id=38
Referenced: 01-01-2007