At the onset of the New Poor Law period, in the mixed economy of welfare, the voluntary sector was the greatest element of welfare support. For the majority of people, minimal relief was provided through family, charity and philanthropy (Baldock, 2012 p.29). By 1951 the role of the state had grown exponentially, the Welfare State became ‘an almost untouchable institution’ in British politics (Laybourn, 1995 p.237). However by 1997 challenges to the welfare state consensus had seen quasi-marketisation significantly change the welfare mix. This transformation can be explained through various narratives. It can be seen as mere inevitable progress by the ‘whig interpretation of history’. However, the following essay will argue that a more credible account of change comes from analysing: economic changes, demographic changes, ideology, institutions and interests. Individually these provide only partial explanations, showing an inconsistent story with no decisive trajectory. For a comprehensive understanding each of these must be understood to be constituents in the triangulation of social policy throughout the period. Within this some factors largely demonstrate continuity. However change in any one or more factors can result in a radically different policy. This will be demonstrated through the assessment of policies addressing public health, primarily through the transformation of the state’s role in healthcare provision from 1834 to 1997. Sanitation and housing policy will be included at the beginning of the period; where they are pertinent in the narrative of the state’s evolution.
In 1834 industrialisation and demographic change were significant drivers in producing a slow acceptance that only state intervention could curb the worst excesses of unacceptable living conditions (Lowe, 1989 p.196). Between 1801 and 1851 the population of Britain almost doubled, with the greatest concentration in industrial towns such as Manchester increased from 75,000 to 376,000 in the same period. The population of Bradford increased eightfold (Lowe, 1989 p.205). The provision of back-to-back housing, cellar dwellings and cheap accommodation increased exponentially, but not enough to keep up with demand. In 1847 a ‘typical’ street (Church Street, East London) had 1095 people living in only 27 houses, an average of nearly forty people in each house and eight people in each room. In the newly urbanised towns severe overcrowding caused significant health problems, not least due to a lack of state infrastructure. Public sanitation was non-existent with amenities such as street cleansing, clean water, drainage and sewage disposal being luxuries of the rich. The main source of water, and only source for some, in London was the River Thames which had over 237 sewers emptied into it at various points. Moreover corpse disposal was an unhygienic, slow process as they remained in houses until families could afford a funeral, even when an infectious disease such as cholera was the cause of death. In response the state slowly accepted an increasing role in an attempt to tackle the health question, although Lowe argues that progress was due more to advances in medicine and great engineering projects. Nonetheless the introduction of acts between 1848 and 1900, beginning with the ‘pioneering’ 1848 Public Health Act which curbed individual property rights in favour of the Edwin Chadwick’s sanitary movement (Lowe, 1989 p.119). At this point public health, including limited housing and health policy became a ‘legitimate concern’ of government ‘which although limited marked a watershed in the sphere of state responsibility’ (Baldock, 2012 p.30).
However it was not demographic changes alone that caused this expansion of state intervention in public health. An expanding knowledge of not only medical practice, which was limited until the late 19th Century with the beginning of ‘specific aetiology’ theory, but of the population itself played a significant role in the evolution of the state’s intervention. Although medical knowledge at this time was still highly limited, with ‘miasma theory’ being the accepted consensus. However medically inaccurate, this did contribute to the production of progressive policy thought. Moreover, as chair of the Poor Law Commission upon seeing the 1834 Poor Law Amendment Act’s implementation Chadwick observed that it were not working age poor but largely orphans, the sick and the elderly who relied on workhouses, to whom ‘less eligibility’ was not an appropriate principle. His 1842 Report on the Sanitary Condition of the Labouring Population of England provided evidence to that point, handling statistical evidence conclusively establishing an incontrovertible link between the environment in which people lived and health (Fraser, 2003 p.69). With the institutionalisation of relief in workhouses records of those whom entered and left, or were born and died there were hereafter kept. Furthermore local and inconsistent parish and church records began a shift towards centralisation in 1837, as well as the introduction of the Census in 1841. This led to an increase in the state’s knowledge of the population. This allowed a greater understanding of the reality of life in the Victorian era. From hereafter knowledge of the population became to be one of the key bedrocks to the production of social policy and in arguments for intervention one of the key legitimising factors.
The ‘whig interpretation of history’, of inevitable growth of the state as an actor, can be seen to be vindicated in the ‘inevitable’ increasing role of the state in tackling ‘the health question’ from hereafter. However, the rise of demographic information alone did not produce progressive policy. Nor did it mean that there was thereafter a clear trajectory in state intervention. Forty years after Chadwick’s strictures on housing the 1885 Report of the Royal Commission on the Housing of the Working Classes was released asserting that ‘the working classes are largely housed in dwellings which would be unsuitable even if they were not overcrowded’ (quoted in Bruce, 1968, p.71). Yet no sufficient housing act was passed for another five years, and the housing crisis as it was known then remained unsolved, truly, until the 1930s; and only temporarily.
The extent to which the state intervened in this, and all, period(s) was limited by the prevailing political ideas, institutions and interests of the time, which invariably changed. The dominant strand of political thought in the Victorian period was a ‘laissez faire’ approach to political economy, with minimal intervention, but only to encourage the development of an individualistic society (Laybourn, 1995 p.170). For a great period of time this significantly limited the extent to which the state was prepared to intervene, even fund, other spheres of the welfare mix to effect public health, another demonstration of how ideas of inevitable progress are limited. Due to the size of public health issues the funding that would be required was great. It was not in the interests of local or national elected politicians to raise the significant revenue required from their upper and middle class male electors; the only franchised groups and the groups they comprised themselves. Nor would it have seemed ideal. Victorian England was very sensitive to the ‘inequity’ of redistributive taxation and any changes to perceived individual liberty, reinforced by self-interest (Fraser, 2004 p.71-78). Moreover, even if the political will were there to significantly tackle the issues with radically progressive policy as they were unearthed at the beginning of this period, the institutions were not. This did change, however during the period, with the administrative changes influenced by Chadwick and Sir John Simon. It is argued that by the 1930s the power and administration of local and central government were then appropriate for the social provision of these common ills (Midwinter, 2000 p.71).
Whilst the late 19th Century lay firmly on the side of laissez faire liberalism and one nation conservatism the beginning of the 20th Century began in a more radical manner with the 1906-1914 Liberal Government’s (Bruce, 1968 p.200). With stronger administrative apparatus, a newly extended franchise and continued studies into poverty, the Liberals had the tools to evolve the role of the state and lay significant foundations for the future welfare state. David Lloyd George’s 1909 ‘People’s Budget’ sought to introduce pensions, along other domestic affairs, requiring £15m, most of which would be revenue raised through tax on the wealthy. This was a significant step forward for the role of the state as it was, for its time, one of the first budgets which laid that these domestic and social needs gave an entitlement to the resources of others, what Ignatieff claims distinguishes legitimate need and hereafter social policies from desires (1990, p 27). The Liberal reforms were informed by the enquiries into poverty of Seebohm Rowntree (1899) and Charles Booth (1903) which showed around 30 per cent of Britons living in serious poverty and, and the awful condition of volunteers for the Boer War, half of whom were medically unfit to serve (Lowe, 1989 p.387). The 1911 National Insurance Act provided health insurance for workers earning under £160 a year, though not their families. The worker paid in compulsorily as did their employers and the state. This established the principle that healthcare should be contributory, transforming the role of the state as a part-financer and promoter of healthcare. This was a serious and positive transformation in the role of the state, which had previously played no part in the provision of healthcare for the general population, leaving this to voluntary hospitals, the voluntary sector generally, or often non-treatment. This demonstrated a shift in public and government opinion/ideology. Industrialisation and demographic changes brought about social issues that could now be understood to a certain extent, and administrations were in place with the resources that allowed the potential to provide the necessary social provision. It was the political will of the Liberal government, alongside the above mentioned factors that allowed the resultant National Insurance Act. The policy was a triangulation influenced by an array of ever changing factors, in which Lloyd George ‘showed his brilliance in reconciling interests’ (Lowe, 1989 p.391).
Whilst the 1909 Minority Report led by Fabian, Beatrice Webb, did, and was the first to, recommend a free, universal system of healthcare, the 1920 Dawson Report did not. There was no clear consensus on what form a healthcare system should take and how much involvement the state should have, only that that reform was necessary to ensure better access for those who need it. Hitherto the private insurance system, backed by the state was extended, but less than half the population remained covered – it was not comprehensive or universal and the state remained a mere promoter and part financer (Timmins, 2001 p.20).
However, during the Second World War the medical service, was taken into national control alongside most UK industries in the national interest. These industries ran effectively and shifted public perceptions of nationalisation and collectivism. Moreover the 1942 Beveridge Report reinforced this new found public collectivism providing a framework for social insurance. However it did not provide a blueprint for a healthcare system. Under a Conservative administration this could have resulted in a universal system funded from general taxation, but one that was delivered by contracted-in private firms. This demonstrates one way in which the ‘whig interpretation of history’ is fundamentally flawed. There was no inevitability about the National Health Service that was produced. The NHS that was produced was the result of the political will of the Labour government, particularly Aneurin Bevan enabled by the afore mentioned factors, and the compromises made between opposing cabinet colleagues Herbert Morrison and invested interests such as private doctors in the BMA. The result of this was an exponentially enlarged state, not only part-financing and promoting of healthcare, but a universal and comprehensive provider with a legal ‘duty’ to provide (NHS Act, 1946).
Although a large public consensus around the principle of universal and comprehensive healthcare funded by general taxation remains, the extent to which the NHS has remained a publicly provided service has changed quite significantly since its inception. Only two years after the inception of the NHS Aneurin Bevan resigned from the cabinet upon the introduction of charges for dentistry and optometry to fund the Korean War. Following this however, there was broad continuity within the 1960s and early ’70s, the ‘golden age of social policy’ and ‘welfare consensus’ (Fraser, 2003, p.265) for the role of the state in healthcare. The only significant changes that occurred affected the health and social care occupation because of professional and technological progress, through de-institutionalisation and the personalisation of health and social care. However the late 1970s and ’80s saw economic and ideological challenges. Resources available to the state were restricted. Moreover the state’s accepted role in healthcare provision, as a public provider, now faced ideological challenge from an economically neo-liberal administration (Baldock, 2012, p.39). The late 1980s and 1990s oversaw the introduction of a purchaser-provider split within the NHS, which introduced free-market, service commissioning principles in to the health service. This reduced the role of the state in the provision of health services and particularly of non-care and non-primary care staff/services. The aim was to reduce government spending and increase efficiency in the face of an aging population, economic frailties and a new ideological consensus – an acceptance of the market.
In conclusion, the transformation of the state’s role in welfare is the result of five key factors: economic changes, demographic changes, ideology/ideas, institutions and interests. A fundamental change in any one can cause a ripple across the others. As demonstrated by the Poverty and Social Exclusion Report (Gordon et al, 2013) a change in economic circumstances can significantly harden attitudes towards poverty, whether the state should act and whether it has the resources to act. Moreover professional knowledge changes can change the role of, or demand new things of, the state. These five factors are in a constant trade-off, whether in continuity or change, it is the state’s triangulation of these that results in the evolution of policy – ‘an erratic and pragmatic response’ (Fraser, 2003 p.1).
Baldock, J. (2012) Social Policy. Oxford: Oxford University Press.
Bruce, M (1968) The Coming of the Welfare State. London: B. T. Batsford Ltd.
Department of Health (1946) The National Health Service Act. London: The Stationery. Office.
Fraser, D (2003) The Evolution of the Welfare State. 3rd ed. Basingstoke: Palgrave Macmillan
Laybourn, K (1995) The Evolution of British Social Policy and the Welfare State. Keele: Keele University Press
Lowe, N (1989) Mastering Modern British History. 2nd ed. Basingstoke: The Macmillan Press.
Midwinter, E (1994) The Development of Social Welfare in Britain. Buckingham: Open University Press
Timmins, N (2001) A Biography of the Welfare State. 2nd ed. Harper Collins, London