Topic 1 202 - Collins

THIS UNIT IS ABOUT SOCIAL ISSUES AND WELFARE NEEDS. It will help you to developyour knowledge and understanding of the perceived social issues and welfare needs inour society. Some of these issues have been with us since records began – andprobably before that. Others are new areas of concern and, arguably, a product ofmore recent social and economic changes. This unit will provide you with thebackground knowledge that you will need to complete Unit 11 of the Edexcel GCEHealth and Social Care award. You will learn about:• The origins of issues that are of social concern.• How changes in the size and structure of the population can present new issues and

influence welfare provision.• How social and welfare issues are linked with the political, social and economic

circumstances of the society. • How governments have responded to the identified areas of welfare need.

Topic 1 Social factors and areas of welfare need 202

Topic 2 Demographic change and welfare need 206

Topic 3 An ageing society 212

Topic 4 Discrimination and access to health and care services 216

Topic 5 An unequal society 222

Topic 6 Poverty and welfare support 226

Topic 7 Mental health 230

Topic 8 Ability and disability 234

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Unit 11

Social Issues andWelfare Needs

Key questionsBy the end of this unit you will be able to use the knowledge and understanding that youdevelop to answer the following questions:1 How are social issues linked with the wider social and political culture of the society?2 How do changes in the population affect the welfare needs of the society?3 What are the perceived key issues and welfare needs that exist in our society?4 How have government and other influential groups responded to identified welfare

social needs?

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Getting you thinking1 Should the family look after frail older relatives, or should the state provide residential care?

2 Should people put money aside for a ‘rainy day’ – periods of ill health or unemployment, forexample – or should the state help?

3 Should the state help only the poor – and others should pay for their care?

4 Do social security benefits lead to people becoming scroungers?

Dependency cultureThe view that a welfare state willcreate a society where people rely onstate benefits and services rather thanworking, planning for the future andtaking responsibility for their own lives.

IndustrialisationThe move towards basing aneconomy on the production of goodsin factories, mills and mines ratherthan on agriculture and other cottageindustries.

Laissez-faireA view that the government shouldnot interfere in the workings of theeconomy or in the provision ofwelfare services. The governmentshould ‘leave well alone’.

Post-industrial societyA society whose economy is nolonger dependent on the productionof goods but is now based onservices and office-based occupations.

The New RightA political viewpoint committed tominimal state provision of welfareservices. Taxes should be low andpeople should decide how they spendtheir money – making their ownprovision for health and welfareneeds.

The Third WayAn approach to welfare that tries tocombine individual freedom andresponsibility with state provision forthose most in need.

Urban livingLiving and working in towns andcities, rather than living and workingoff the land in agriculturalcommunities.

Welfare stateA term, first used during the 1940s,referring to a system in whichgovernment took a primaryresponsibility for the health andwelfare of the nation through theprovision or monitoring of services.The services, developed following theSecond World War, included theNational Health Service, FamilyAllowance, secondary education forall, and social security benefits andpensions.

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Topic 1 Social factors and areas ofwelfare need


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Who cares for thevulnerable?In all societies there are groups of people who arepotentially vulnerable. These include children, olderpeople, people with disabilities and the poor, forexample. Whether they are supported and how theyare supported, however, varies from society to societyand at different times in history.

In some societies, the care of the vulnerable is seenas the responsibility of the family or the village. Inothers, it is principally the responsibility of the state,through community provision. In Israeli kibbutzim, forexample, the care of children is seen as theresponsibility of the whole community, and notprincipally the concern of the birth parents. In othersocieties the care of children is the prime responsibilityof their parents, and in some it is the responsibility ofthe extended family. Attitudes to the vulnerable vary.Those on benefits may be seen as ‘lazy scroungers’, ortheir situation may be seen as the result of poorparenting or the inevitable consequence of economicchanges. The response to their need will vary accordingto the dominant attitudes in the society, the views andpriorities of government, the wealth of the nation, andhow that wealth is distributed and managed.

The state, the church and thefamilyIn England, the state has had some involvement inproviding for the poor since Elizabethan times. The1601 Poor Law allowed officials to collect money fromeach household in their parish and to distribute it tothe needy. There were two kinds of poor law relief –‘outdoor relief’ and ‘indoor relief’. Outdoor relief wasthe financial help given to people who were living intheir homes but regarded as destitute. In order toreceive indoor relief people had to live in aninstitution, normally called the workhouse. Statesupport, however, was minimal, and personal carewas considered to be largely the responsibility of theindividual and their family. The poor, it was thought,had only themselves to blame. If people worked hard,saved for ‘rainy days’ and understood the value offamily life they would not be needing relief.Depending on ‘poor law relief’ was seen as shamefuland unnecessary.

The political approach at the time – laissez faire –was informed by a view that the government shouldnot interfere in the workings of the economy or in theprovision of welfare services. The church and othervoluntary groups provided charitable support, but the

state ‘left well alone’. Not until the opening years ofthe twentieth century did the state begin to take aproactive role in the care and welfare of its citizens.

The Liberal reformsThe growth of industrialisation, urban living andthe associated poverty, homelessness, ill-health andhigh mortality rates led social reformers and politiciansto the view that the state would have to play a biggerrole in the provision of welfare services. The Poor Lawprovisions were not meeting the needs of theindividual or the economy. Employers needed ahealthy, educated and reliable workforce. The Liberalgovernment of the early twentieth century played akey role in increasing state involvement in personalhealth and care services and, some would argue, laidthe foundations of the welfare state (see below).There was a gradual move away from the laissez-faireeconomic liberalism of earlier years to a moresupportive welfarism by government.

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Welfare reforms introduced by the Liberal government

(1905–1915)

1906• The Education (Provision of School Meals) Act • Providing school dinners for poor children

1907 • The Old Age Pensions Act• The Labour Exchange Act• School medical inspections• The introduction of juvenile courts

1911 • The National Insurance Act

Figure 1 Reasons for state intervention

Urbanpoverty

Poorhousing and

homelessness

Industrialisation

Highmortality

rates

High levelsof ill health

The needfor a literate

workforce

Reasonsfor state

interventionin welfare


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The birth of the ‘welfarestate’The 1940s saw the development of legislation thatreflected an agreement across the main politicalparties that the state should take an increasedresponsibility for the funding and provision of welfareservices. The specific measures taken were based onthe proposals of Sir William Beveridge (1879–1963)and published in his Report on Social Insurance andAllied Services (1942), more commonly known as theBeveridge Report. Beveridge based hisrecommendations on his concern to defeat five ‘giantevils’ that, despite the measures of the early twentiethcentury, were still hindering social and economicprogress in Britain. The five evils identified were:

• Want (poverty)

• Disease (ill-health and high mortality rates)

• Ignorance (inadequate education)

• Squalor (poor housing and homelessness)

• Idleness (unemployment).

The existence of poverty in Britain was the underlyingreason for commissioning the report, but legislationwas passed and services introduced that addressedeach of the ‘five giants’. These measures, together,represented a radical approach to welfare services,building on the initiatives of the Liberals at the turn ofthe century but representing an agreement that thestate had a central role in ensuring basic standards ofcare and support for all.

The development of what came to be known asthe ‘welfare state’ was a sea change in the approachto welfare. There was a new focus on the role ofgovernment, government policy and state interventionin welfare. A brief consideration of the key services –which largely remained in place until the 1970s, andsome we would still recognise today – provides a clearpicture of how the new system would provide careand support ‘from the cradle to the grave’.

Want (poverty)• Family Allowance Act 1945 introduced a financial

payment for children under 15. This did not apply forthe first child but applied for all subsequent children.

• The National Insurance Act 1946 allowed for thepayment of unemployment benefit, sicknessbenefit and retirement pension, maternity benefitand widow’s pension for all who, when in work,paid weekly from their wages into the nationalinsurance scheme.

• The National Assistance Act 1948 provided a‘safety net’ – a minimum income for people whodid not pay into the national insurance scheme andwere, therefore, not eligible for those benefits.

Disease (ill-health and earlymortality) • The National Health Service Act 1948. Before the

introduction of the National Health Service (NHS), ifpeople needed to see a doctor or have hospitaltreatment they normally had to pay. A nationalservice was central to the post-war welfare reformsand was based on three principles:

1. That health services should be free to all at thepoint of delivery (when they are actually used).

2. That the service would be truly national, coveringthe whole population in all parts of the country.

3. That access to services would be based on clinicalneed (not on the ability to pay).

Idleness (unemployment)In the post-war period, rather than ‘letting well alone’the government intervened in the running of theeconomy, using the approach of John Maynard Keynes(1883–1946) to support a policy of full employment,which was recommended and necessary for thesuccess of the Beveridge reforms. It was through fullemployment that his reforms would be financed.

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Caring for older people

Mrs Brothers is 85 years old and lives quiteindependently in a small and comfortable flat inthe north of England. She has three adult children,one in Australia and the others, both married wholive in London. Her GP’s surgery is nearby. She hasmeals-on-wheels delivered three days a week and ahome care assistant visits her once a week to helpwith household chores. This is very different fromher childhood memories. Her grandparents lived inthe countryside. There were no pensions, they hadto pay to see the doctor, they had to find the rentfor their house and there was certainly no meals-on-wheels. While her grandfather was workingthey had managed to pay their bills. They hadsaved a bit of money too but this money ran outand in the end they were forced to go and live inthe workhouse to survive.


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Ignorance (inadequateopportunities for education)• The 1944 Education Act provided free secondary

education for all. Up until this change, most youngpeople in secondary schools paid for theireducation. Only a minority had free scholarshipplaces. The school leaving age was raised to 15,and grants were made available for peoplestudying at university.

Squalor (poor housing andhomelessness)• The New Towns Act 1946 provided for new towns

to be built or developed to address housingshortages, e.g. Stevenage, Welwyn Garden Cityand Cumbernauld.

• The Town and Country Planning Act 1947 requiredlocal authorities to agree building plans for theirlocal area that would benefit the community as awhole.

Welfare and the ‘NewRight’The services which arose after the Second World Warestablished a framework for provision and a range ofservices that remained in place for the generation thatfollowed – and many are still in place today. Thesewere not significantly challenged until theConservative victory at the 1979 election. The view ofthis government – led by the first woman primeminister, Margaret Thatcher – was, once again, thatthe government should interfere as little as possible inthe running of the economy and the provision ofwelfare. The view of her government was that careand welfare should be the responsibility of individuals,

their families or charities. The welfare state, it wasargued, supported a dependency culture. The ‘NewRight’ was concerned to see a ‘rolling back’ of thewelfare state.

The ‘Third Way’The Third Way is an approach to welfare associatedwith ‘New Labour’ and the Blair governments. Its aimis to steer a line – some would say shape acompromise – between the welfare state’s fullinvolvement of government in welfare and the NewRight’s reluctance to intervene in welfare at all. Theproponents of the Third Way aim to foster personaland family responsibility for welfare and the quality ofcommunity life but, at the same time, provide supportto avoid the extremes of deprivation. They are tryingto develop a spirit of community in which peopleaccept responsibility for themselves but also for themost vulnerable in society. People would therefore bemaintaining a balance between their individualfreedom and their responsibilities towards society as awhole.

Check your understanding

What is meant by the term ‘laissez faire’?

What is meant by the term ‘welfare state’?

What were the five ‘giant evils’addressed in the Beveridge Report?

Why may a welfare state produce adependency culture?

Briefly describe the approach of thenew right.

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1 Using the local library, find out if there wasa workhouse in the area where you live.When did it close? What provision was thenmade for the vulnerable elderly who werenot able to live in the community?

2 What provision is in place in your area nowfor the vulnerable elderly? Would you saythat it reflected the provision of a welfarestate, the new right or the third way?

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Getting you thinkingThink about all the television adverts that portray ‘families’.

1 How is the family typically portrayed in these adverts?

2 Do you think this is a typical family in modern Britain? Give reasons for your answer.

3 Are there often older people in these adverts? If not, why not?

4 Why might people chose to leave their homes and live in another country?

Birth rateThe number of live births perthousand of the population in oneyear.

Death rateThe number of deaths per thousandof the population in one year.

Infant mortality rateThe number of deaths of infantsunder one year of age, per thousandlive births.

ImmigrationPeople coming to live in a countryfrom another country.

EmigrationPeople leaving a country to live inanother country.

Net migrationThe difference between the numberof immigrants and the number ofemigrants coming to and from aspecific country.

Life expectancyA statistical measure which predictsthe average number of years a personis likely to live. This could beestimated from any particular age,but is usually expressed as from birth.

Dependent populationThe age groups who are dependenton the rest of the population foreconomic security – young peoplefrom 0–16 years, and people over theretirement age.

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Topic 2 Demographic change andwelfare need


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Population trends anddemographic dataDemography is the term used to describe the study ofthe size and structure of the population. Demographicstatistics are used by governments, planners and socialscientists to identify changes in population. Some ofthe things that governments may need to knowinclude:

• the trends in birth rate – to inform provision forchildren and young families

• the trends in life expectancy – to inform provisionfor older people

• levels of unemployment

• regional differences in the size and structure of thepopulations

• levels of migration, both within countries andbetween countries.

The censusEvery ten years since 1801, with the exception of1941, there has been a census – a detailed count ofthe population. The last census was in 2001, and thenext is planned for 2011. At the census, everyhouseholder is required by law to provide details ofeveryone staying in their household on the designatednight. Included in the census are people in hospitals,hotels, prisons and all other institutions. In addition,there is every attempt to record the number of peoplewho are homeless or in temporary accommodation.This information is used to inform central and localgovernment planning. It is also used by many otherindependent organisations to help manage their workand target their resources.

The population of the United Kingdom – England,Wales, Scotland and Northern Ireland – on census night2001 was 58,789,194, of which almost 50 million livedin England. The census website provides detailedinformation on the census findings. Informationincludes the following detailed statistical information:

• 11.7 million dependent children (0–16) lived inthe UK.

• 22.9% of dependent children lived in lone-parentfamilies.

• 17.6% of children lived in ‘workless’ households –that is, where there are no adults in work.

• 21% of the population were over 60 years of age.

• 20% of the population were under 16 years of age.

• There had been a big increase in the number ofpeople over 85 years of age – now over 1.1million,or 1.9% of the population.

There is information relating to family size andhousehold structure, levels of education andemployment, race and ethnicity, religious adherence,and the quality and sufficiency of housing. The 2011Census Programme is already in place, preparing for thenext census. There are proposed measures to employstaff to follow up areas of low-response rates and, forthe first time, to introduce internet response facilities.

The Office of National StatisticsThe Office of National Statistics (ONS) is thegovernment department that provides ongoingdemographic, economic and other social statisticsused by government and other policy-makers toinform planning decisions and to monitor progress.Data published includes the registration of all births,deaths and marriages, and regular publications,including Social Trends and Population Trends,available in hard copy and electronically.

Voluntary organisations and otherindependent sources of researchMany charitable organisations will systematicallycollect data in order to plan and monitor theiractivities, present information to their funders and toeducate and provide statistical evidence to supporttheir causes. Pressure groups and specific-interestgroups will present research data to support theircause. Academic researchers will also contribute tothe body of knowledge on a wide range of healthand care issues. Throughout this textbook you willfind evidence drawn from these sources.

When using statistical information it is, of course,essential to record the source of data and also toconsider the authors’ purpose when they supplied thedata. If the data is supplied by a pressure group, is itpresented in such a way that it will be persuasive? Ifthe data is from a newspaper, is it aimed at theparticular views and prejudices of its readers? Hasthere been important data omitted? Do you need tolook further for fuller information? Should you consultdata from an organisation known to support adifferent point of view on this issue? Statistics mustalways be used with caution, and presented with care.


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Natural changes in thepopulationNatural changes in the population include changes inthe birth rate and the death rate. The birth raterefers to the number of live births per thousand of thepopulation in a given year and the death rate to thenumber of deaths per thousand of the population in agiven year. The presentation of the statistics in thisform allows for meaningful comparisons of naturalchanges in the population over periods of time, andfrom one country to another.

Changes in the birth rate

Source: Office for National Statistics

It would be difficult to give precise reasons for thechanges in the birth rate in the last hundred years,but it would be reasonable to assume that the factorsinvolved include:

• Improved methods of contraception

• The greater availability of contraceptives

• Women choosing work and a career over largefamilies

• The high cost of child-rearing.

The birth rate across Europe is at its lowest since theSecond World War, and is continuing to fall. TheSpring 2005 edition of Population Trends reportedthat birth rates in the UK are currently below the levelneeded to replace the population – which could leadeventually to a fall in population. This fall, however,will most likely be delayed by other factors – such asthe falling death rate and inward migration.

Changes in the death rate


The fall in the death rate, of course, is another way ofexpressing the fact that people are living longer –there has been an increase in life expectancy. Thefall in the death rate may be directly attributed tosuch factors as:

• Improved sanitation

• Effective immunisation programmes

• Discovery of penicillin

• Advances in medical knowledge

• The introduction of the National Health Service

• Improved living conditions and housing

• Improved standards of living.

The fall in the death rate is leading to an ageingpopulation. The implications for social care providerswill be discussed in the next topic.


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019811971 1991 2001 2011 2021

Under 16

65 and over

Projections1

1 2003-based projections for 2004 to 2021.

Under 16s and people aged 65 and overUnited KingdomMillions

3,000

2,500

2,000

1,500

1,000

500

0

Age-standard rate per 100,000

Males

Females

1901 191119211931 19411951196119711981 1991 2003 1.2

1.1

1

0.9

0.8

0.7

0.6

0.5

0.4

Births

Mill

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1901

1909

1917

1925

1933

1941

1949

1957

1865

1973

1981

1989

1997

2005

2013

2021

2029

2037

2045

208

Figure 2

Figure 3

Figure 4


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Improved infant mortality rates

Infant mortality rates are frequently used as anindication of a society’s social and economic progress.A high infant mortality rate often indicatesinadequacies in a range of social and economicservices. Sadly, infant mortality rates are very muchhigher in developing countries than in the moreprosperous countries of the northern hemisphere. Inthe United Kingdom they are significantly higher inthe lower social class groups than in the higher socialclasses.

Despite improvements in sanitation and other areas ofpublic health during Victorian times, the infantmortality rate stubbornly remained at about 150 perthousand live births. Only when poverty decreasedand medical services improved was there a noticeableimprovement. The introduction of penicillin and thefurther development of the immunisation programmeduring the Second World War further contributed tolower infant mortality rates.

Death rates have fallen for all social groups over

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Improved mortality rates

Mrs Lee is 87 years old and has a new greatgrandson. Joshua was born in December 2005. MrsLee has two adult children, four grandchildren andnow a great grandson. This is very different fromthe family structure she knew as a child. Mrs Leehad been one of ten children. Two of her siblingsdied as babies. She never knew her grandparents.Both of her grandfathers were miners who haddied before she was born. Both of hergrandmothers died before she started school atthe age of five. Her own parents had died in theirseventies. Now there were four generations in thefamily and her friends were sharing similar stories.

Figure 6 Reasons for the relatively high infantmortality rate in the lower social classes

Lowerstandard of

living

Lower take-up of health and

care services

Stressassociated with

poverty

Poorerdiets

Poorerstandard of

housing

Reasonsfor the

relatively highinfant mortalityrate in the lower

social classes

Figure 5 Life expectancy and healthy life expectancy at birth: by sex

Year Live births Infant deaths Crude Childhoodper 1,000 per 1,000 death mortality population live births rate (per 1,000

populationaged 1 to 14)

1948 18.1 36.0 10.9 1.81949 17.0 34.1 11.7 1.61950 16.2 31.2 11.7 1.41951 15.8 31.1 12.5 1.41952 15.7 28.8 11.4 1.21953 15.9 27.6 11.4 1.21954 15.6 26.4 11.3 1.01955 15.4 25.8 11.6 1.01956 16.0 24.4 11.6 0.91957 16.5 24.0 11.5 1.01958 16.8 23.3 11.7 0.91959 16.9 23.1 11.7 0.91960 17.5 22.5 11.5 0.91961 17.9 22.1 11.9 1.01962 18.3 22.4 11.9 0.91963 18.5 21.8 12.2 0.91964 18.8 20.5 11.3 0.81965 18.4 19.6 11.6 0.81966 18.0 19.6 11.8 0.91967 17.6 18.8 11.3 0.81968 17.2 18.7 11.9 0.81969 16.7 18.6 12.0 0.81970 16.3 18.5 11.8 0.71971 16.2 17.9 11.5 0.71972 14.9 17.5 12.0 0.81973 13.9 17.2 11.9 0.71974 13.2 16.8 12.0 0.71975 12.5 16.0 11.9 0.61976 12.1 14.5 12.1 0.61977 11.8 14.1 11.8 0.61978 12.3 13.3 11.9 0.61979 13.1 12.9 12.0 0.51980 13.4 12.2 11.8 0.51981 13.0 11.2 11.7 0.51982 12.8 11.0 11.8 0.51983 12.8 10.1 11.7 0.41984 12.9 9.6 11.4 0.41985 13.3 9.4 11.8 0.51986 13.3 9.5 11.6 0.41987 13.6 9.1 11.3 0.41988 13.8 9.0 11.4 0.41989 13.6 8.4 11.5 0.41990 13.9 7.9 11.2 0.31991 13.7 7.4 11.3 0.31992 13.5 6.6 11.0 0.31993 13.1 6.3 11.3 0.31994 12.9 6.2 10.7 0.21995 12.5 6.2 10.9 0.21996 12.5 6.1 10.9 0.21997 12.3 5.8 10.7 0.21998 12.1 5.7 10.6 0.21999 11.8 5.8 10.6 0.22000 11.4 5.6 10.2 0.2


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the past hundred years. There is, however, acontinuing and growing difference between theexpectation of life of people from different socialgroups. The expectation of life for women is longerthan for men, and for people from higher socialclasses than for people from lower social classes.

The Black Report (1980) and the Acheson Report(1998) provide detailed and comprehensive evidenceof the complex relationship between social andenvironmental factors and health, illness and mortalityrates.


Immigration and emigration


600

500

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01995 1996 1997 1998 1999 2000 2001 2002 2003 2004

International migration into and out of the UK 1995–2004

Inflow

Out flow

Thousands

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75

60

45

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01921 1931 1941 1951 1961 1971 1981 1991 2001 2011 2021

1 Deaths within one year of birth.2 2002-based projections for 2003 onwards.

Projections2

Infant mortality1

United KingdomRates per 1,000 live births

Figure 7 Factors that may lead to emigration

Figure 8

Figure 10

War orthe threat

of war

Improvedstandard of

living

Marriageand family

relationships

Employmentopportunities

Educationopportunities

Politicalpersecution

Politicalinstability

Fear oftorture

Religiouspersecution

Factorsthat maylead to

emigration

Figure 9 Reasons for the fall in the infantmortality rate

Improvedpost-natal

care

Effectivevaccination

programmes

Warmer,damp-freehousing

Improvedante-natal care

Improvedservices for

infants

Improvedstandards of

living

Improvedsanitation

Reasonsfor the fall

in the infantmortality

rate

Marriages like this one celebrateBritain's ethnically diverse popualtion


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In 1991, which was the first time that a question onethnic origin was included in the census, theproportion of people from minority ethnic groups was5.5%. Britain has, however, been a country of manyraces for centuries. Mostly the immigrants have beenrefugees escaping religious and political persecution –the French protestant Huguenots in the seventeenthcentury, and the Jews since the time of OliverCromwell, and particularly during the 1880s and1890s, and in the 1930s escaping persecution inEurope. In the Second World War, a wide range ofnational groups – such as the Poles and Czechs, andCommonwealth citizens from the Caribbean, Indiaand Pakistan – served with the British forces. Somestayed in Britain after the war. Others, particularlypeople from the Commonwealth, were encouraged tocome and work in Britain. Employers in the textileindustries recruited more particularly from India andPakistan. In the late nineteenth century and the earlyyears of the twentieth century the number of peopleleaving the UK had been greater than the numberscoming to live here. For most years since the early1930s, however, more people have immigrated thanemigrated to other countries.

Following the expansion of the European Union in2004, to include the Czech Republic, Cyprus, Latvia,Lithuania, Malta, Estonia, Hungary, Poland, Slovakia,and Slovenia, there has been increased migration fromthese countries to the United Kingdom. According toHome Office figures published in August 2005, a totalof 232,000 Eastern European migrants had registeredto work in Britain between May 2004 and June 2005.The overwhelming majority of those seeking workwere young, with 82% aged between 18 and 34.Only 5% of registered workers had dependants livingwith them in Britain. Home Office statistics also showthat between July 2004 and June 2005, 5,500European migrants had taken jobs within the caresector, mainly as care assistants. However, there were

also 560 teachers, researchers and classroomassistants, 290 hygienists and dental nurses, and morethan 300 doctors, nurses and specialists. Theemployment and care of the new wave of Europeanmigrants poses new and specific issues for the caresector. These are discussed in Topic 4 and relate toensuring equality of opportunity and access to theservices provided.

In 2004 the government introduced ‘Citizenshipceremonies’ for migrants to the United Kingdom. Thegovernment holds a view that through theseceremonies foreign nationals taking British Citizenshipare able to demonstrate and confirm in public theircommitment to the country. Since 2005 applicantshave been required to also take a citizenship test. Thistests the person’s knowledge of British politicalinstitutions, aspects of the law, sources of help andassistance – including access to health and careservices, and their understanding of everyday activitiessuch as how to pay bills.


Identify and explain the most likelyreasons for the fall in the birth rateduring the twentieth century.

Identify and explain the most likelyreasons for the fall in the death rate.

Why might infant mortality ratesreflect levels of social and economicprogress in a society?

What is meant by the term ‘netmigration’?

Identify three reasons why groups ofpeople may choose to emigrate.

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1 From your own general knowledge, or byusing resources in your library or theinternet, identify the main ethnic minoritygroups in the UK.

2 Consider how the managers of a daynursery can ensure that people from allcommunity groups are welcome.


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Getting you thinking1 Describe the stereotypical image of an older man or woman that you have

seen presented in a television programme.

2 Do you think that older people are respected members of the community inwhich you live?

3 Explain how people such as those in the picture can counteract thestereotypical images of retirement and old age that exist in society.

4 What health and welfare needs do you associate with old age?

AgeismAttitudes and behaviour whichdiscriminate against people becauseof their age.

Community careProvision where people should becared for in their homes or in small‘family’ units rather than in large, lesspersonal institutions.

Age discriminationTreating people differently (andnormally less well) on the basis oftheir age.

Life expectancyA statistical measure which predictsthe average number of years a personis likely to live. This could beestimated from any particular age,but is usually expressed as from birth.

Extended familyA family group of normally three ormore generations who form a close-knit network, and provide supportand care for members.

MorbidityThe incidence of chronic ill health anddisease.

Nuclear familyThe small family unit of two generations– parent(s) and their children.

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Topic 3 An ageing society


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An ageing populationEarlier in this unit we noted the changing age structureof the population and specifically the increasedproportion of older people in our society. In this topicwe are going to consider the implications of an ageingpopulation and the sources of support for older people.

‘Simply to grow old is not in itself a problem’ saysMuriel Brown in her book Introduction to SocialAdministration in Britain. Ageing is a natural processthat affects us all. It leads to slower physical andcognitive responses, some poorer vision, less acutehearing and some loss of energy and increased frailty.This is not, in itself, a problem – but limited supportfor people in their older life may well be.

Many people in retirement live full and active lives– continuing in paid work, working as volunteers andenjoying their additional leisure time. Those over 85years of age are more likely to need support. Forthose with poor health, and especially if they are onlow incomes, older age can be lonely and depressing.This is not a comment on old age itself, but rather acomment on the support available and our responseto the vulnerable.

In 2003, according to estimates based on the 2001census, there were over 11 million older people in thepopulation. This is expected to increase to 11.4 million in2006, and 12.2 million in 2011 – and it will rise to nearly 14million by 2026 (www.ace.org.uk/Ageconcern). Further,the older population is ageing. Within the populationaged 65 and over, the proportion of people aged 85 andover has increased from 7% in 1971 to 12% in 2004(ONS www.statistics.gov.uk/cci/nugget.asp?id=881).

In many societies, older people (the elders) have highstatus and have an important role in the family and inthe wider community – notably in China, India andmany parts of Africa, and within Muslim, Hindu andSikh communities. In modern Britain, however, it couldbe argued that older people are less central to our wayof life, both in the family and in the wider community.

In 2004, Age Concern, in partnership with theUniversity of Kent, undertook a research programmeexploring the extent of prejudice and discriminationabout age and ageing. They found that:

• More people (29%) reported suffering agediscrimination than any other form ofdiscrimination.

• From age 55 onwards, people were twice as likelyto have experienced age prejudice than any otherform of discrimination.

• Nearly 30% of people believed there is moreprejudice against the old than five years ago, andthat this will continue to get worse.

• One third of people thought that the demographicshift towards an older society would make lifeworse in terms of standards of living, security,health, jobs and education.

• One in three respondents said they viewed the over70s as incompetent and incapable.

How ageist is Britain? Age Concern 2004

There has been no legislation in place to preventdiscrimination against people on the basis of theirage, but the European Directive on Equal Treatment(2000/78/EC) will require all member states to passlegislation which will outlaw discrimination inemployment and training on the grounds of age Thisis scheduled to be implemented in October 2006,extending further the equality legislation in the UK.

Figure 11 Life expectancy and healthy life expectancy at birth: by sex

United Kingdom

1961 1991 2003

MalesLife expectancy 67.8 73.2 76.2Healthy life expectancy … 66.1 …

FemalesLife expectancy 73.6 78.7 80.5Healthy life expectancy … 68.5 …

Source: Government Actuary’s Department; Office of National Statistics

Older people have high status and animportant role in African families like this one.


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The family and the careof older peopleIn the societies and cultural groups where olderpeople are particularly well respected they often live inan extended family – where a wide kinship networkis expected to provide support for the family. Inmodern Britain, however, the likelihood of living aloneincreases with age. In 2002, 48% of those 75 years ofage and over were living alone, compared with 12%aged 25–44 (www.ace.org.uk/AgeConcern). Changesin our society have arguably, however, made it moredifficult for families to easily provide support for thedependent elderly, for several reasons:

• Families are smaller than they used to be. Theaverage number of children in families has fallen(Social Trends). There are fewer adult children toshare in the responsibilities of care and support.

• There have been changes in the position and statusof women in society. Far more women are in paidemployment and unable to provide daily care fordependent relatives.

• Far fewer families live near their elderly relativesthan was the case 50 years ago, and this providesserious difficulties in providing care for the frail andvulnerable.

• The proportion of adult children who live with theirparents or other older family members is very small.

• The complications and stress that arise from theincrease in family breakdown and divorce makecaring for the vulnerable elderly more difficult.

• There was, arguably, some change of attitudetowards the care of older people in the yearsfollowing the Second World War, with thedevelopment of a welfare state. It was assumedthat older people would be cared for by the state.It was not necessary for adult children to be reliedon for their care.

• The cost of caring for older people by adultrelatives has not been fully addressed by the state.Benefits for carers have never been sufficient tocompensate for the loss of potential earnings.

• Housing policy has not addressed the potentialneed for caring for older relatives. Three-bedroomhouses with a ‘through lounge’ are not well suitedto caring for elderly relatives.

• Employers are not required by law to agree flexibleworking arrangements for employees who are alsocaring for vulnerable relatives.

Gordon Lishman, Director General of Age ConcernEngland, is quoted as saying:

‘ ...carers are caught in a no-win situation. Ifthey give up work they face poverty. If they keeptheir jobs, they must struggle with unrelenting

hours’ (www.ageconcern.org.uk).

Poverty and older ageThere have been numbers of studies pointing to thehigher incidence of poverty amongst older peoplecompared to the population as a whole. On reachingretirement age, most people give up their full-timeemployment and are then dependent on income fromtheir pensions and from savings.

Economic well-being in older age is closely linkedwith prosperity whilst in employment. Those whohave enjoyed good wages, little unemployment, andoccupational pension plans enjoy greater financialsecurity in older age than those who have hadinterrupted employment and lower wages. Because ofthis, women, who make up the larger proportion ofthe older population and experience longer periods ofill health (morbidity) in older age also experiencegreater financial hardship. They are less likely to be

214The lives of the affluent and the poor

Sally, who is 14 years of age has four grandparentsall of whom are retired and in their late sixties. Sally’smum’s parents seem to be having the time of theirlife. They were both doctors and had a good incomeall their life and now have a good occupationalpension. They have a beautiful home. They play golf,go on holiday abroad during the winter, take theirgrandchildren away during the summer holidays andreally they just don’t seem to age.

Sally’s dad’s parents, however, are not doing quiteso well. Grandad was a steelworker and was maderedundant in the 1970s. He managed to get otherjobs but they were all poorly paid and there was nooccupational pension. Grandma worked part-timeas a cleaner but she didn’t have a works pensioneither and she never paid in to the state pensionscheme. They still live in the council house thatthey moved to when they got married. It is dampand difficult to heat. Sally knows that in the winterher dad’s parents have to choose betweenspending their small pensions on eating well orkeeping warm. They do manage to go away onholiday for a week in the summer but they havenever been on holiday abroad.


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entitled to a full state pension or have paid intooccupational pensions. Their wages whilst inemployment are likely to have been lower and theyare likely to have had a more interrupted workingpattern. Most women now in older age will havegiven up paid work when their children were smalland are more likely than their husbands to havereduced their work pattern to care for older relatives.The state pension scheme does not compensatepeople (usually women) who have interrupted theiremployment to care for adult relatives.

Gordon Lishman (in the same speech as quotedabove) said: ‘Carers save the economy billions throughunpaid work each year, and they need flexibleworking as much as parents do. At the same time ouroutmoded pension system needs sweeping reforms.’

Care of the vulnerable oldMost older people do not require any regular practicalcare support. They live independent lives in thecommunity – often contributing more than theyobviously receive. Where they do need help,notwithstanding the comments earlier in this section,the help is most likely to come from family, friends orneighbours. When help is from family, despite changesin attitudes and equality legislation, it is far more likelyto be from adult daughters than from sons.

For much of the twentieth century, vulnerable olderpeople whose families were unable to provide thepractical help needed were generally cared for in largeinstitutions, very often geriatric hospitals. Many ofthese hospitals had once been the local ‘workhouse’and despite changes, care in the geriatric hospital wasoften linked with the sadness and stigma of theworkhouse. From the 1960s onwards, there were anumber of reports criticising the quality of care inthese large institutions, but it was not until the 1990NHS and Community Care Act that there waslegislative support and resources allocated for plannedcare in the community. The system continues to bemanaged by local social service departments who,

following the assessment of community care needs,will purchase care services from a range of statutory,private and voluntary providers. The care for the olderpeople may include home care services, meals onwheels, attendance at a day centre or lunch club,adaptations to their own home, or full-time care in aresidential care home. Only very rarely will long-termcare be provided in large institutions or hospitals.


1 Using the internet, your library or yourlocal benefits office, list the main welfarebenefits available to older people, anddescribe how they may support care in thecommunity policies.

2 Find out more about the statutory,voluntary and private provision whichsupports older people in your area.

215What is meant by the term ‘communitycare’?

Describe the types of community careservices that may be provided for olderpeople who need support with dailyliving activities.

Why may there be poverty in older age?

Explain why, in the twenty-firstcentury, it may be difficult for adultchildren to provide practical care forolder relatives.

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Informal carers

Sue is in her late fifties and has just given up workto care for her elderly mother, Grace. Sue herself isnot well, she has always suffered from arthritis andgets bad headaches when she is tired. Grace lives abus ride away from Sue on the other side of town.Sue and her partner Brian live with their son Tom ina two-bedroom terraced house. The bathroom andtoilet are upstairs and so it is difficult for Grace toeven visit them. Sue has arranged for Grace toreceive meals-on-wheels and also a daily home-helpduring the week. However, Sue and Brian also haveto ensure that Grace has proper meals at theweekend and that there is someone there over nightbecause Grace is nervous in the dark when she is onher own. They provide this care for her themselves.


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DiscriminationTreating people differently, and in this context normally lessfavourably, on the grounds of inherited or social categories,e.g. race, gender, sexual orientation or age.

PrejudicePre-judgements or preconceived opinions and ideas about aparticular group, which are not modified in the light of newexperiences of that group.

StatutoryRequired by law.

StereotypeAn over-simplified image of the characteristics of a particulargroup, e.g. women are better at childcare than men.

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Topic 4 Discrimination and accessto health and care services

Getting you thinkingPaul and Jane are opening a new nursery. They are currently advertising for staff in the local paper.

1 Should Paul and Jane make sure that the staff are from a range of ethnic backgrounds?

2 How do you think parents and carers will react to having a male nursery manager?

3 Should they put up notices at the nursery in a range of community languages, or should theyencourage parents and carers to communicate in English?

4 Can you think of an occasion when you felt discriminated against? What did this feel like?

5 Is it too much to ask the nursery staff to meet the individual needs of all the children?


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DiversityDiversity refers to differences, variety and contrast.Diversity focuses on our uniqueness as individuals andthe obvious and subtle differences between us.Examples of the differences that are of socialsignificance are differences in age, race and ethnicity,gender and sexuality, physical and sensory ability,religion and marital status. It is in these areas ofdifference that there has been specific action bygovernments – but they are by no means the onlyareas in which harassment and discrimination occur.Sometimes particular characteristics are associatedwith groups of people – that women are naturalcarers, for example, or that Africans have a greatsense of rhythm, or that men are good at mechanics– and then all members of the group are expected tohave these characteristics. These descriptions arestereotypes – they do not describe real individualsor address the diversity within groups. People who arestereotyped in this way can be discriminated against,because their individuality is not recognised. Each issimply treated as a member of a group with theseperceived characteristics, and not as an individual.

In health and care settings, understanding thedifferences between people is necessary to:

• understand the needs of service users.

• meet the care needs of service users.

• ensure that information is clear and accessible to allservice users.

• ensure that staff from diverse backgrounds andwith specific individual needs are not isolated ormisunderstood at work.

• encourage a wider range of people to work in thehealth and care services.

Diversity in this context is not about treatingeverybody the same, but it is about treating everybodywith equal respect and care.

Equal opportunities Views on equality of opportunity may be seen asfalling into two main categories – those relating toequality of access to services and valued opportunitiesin society, and those relating to the possibility ofequality of outcomes – that all individuals should beentitled to an equal share of the benefits.

Equality of accessEqual opportunities, in the context of policy making inmodern Britain, has been mainly concerned with thefirst category – equal access for all – to employmentand educational opportunities, our political institutions,and to the services that different organisations provide.All social groups should be provided with the chance tomake the most of their talents and to use them for thebenefit of the wider community. Policies have beenaimed at removing the barriers that disadvantagedgroups have found in achieving their potential and inaccessing services. Across all parties and across theEuropean Union there has been general and legislativesupport for equality of access. Most significantly therehas been equality legislation in the UK:

• The Equal Pay Act 1970

• The Sex Discrimination Act 1975

• The Race Relations Act 1976 and the RaceRelations Amendment Act 2000

• The Disability Discrimination Act 1995

• The Special Educational Needs and Disabilities Act(SENDA) 2001

• The Human Rights Act 1998

There have also been directives from the EuropeanUnion:

• The Equal Treatment Directive 1976 for men andwomen.

This led, among other things, to the equalisation ofretirement ages for men and women.

• The Equal Treatment Directive 2000 for religion orbelief, disability, age or sexual orientation.

This led to discrimination on the grounds of religion,belief and sexual orientation in employment tobecome illegal in 2003 and discrimination on thegrounds of age to become illegal in 2006. It is illegalto advertise jobs as open to young people only, andillegal to discriminate on the grounds of age whenadvertising and recruiting for posts, and in promotionand training.

Equality of outcomePolicies which support the view that everybody shouldbe entitled to an equal share of society’s benefits –which might include an equal share of wealth,income, quality of housing and education, and equalpower and status – have been rare. There has beenlittle political support for creating an equal society, butpolicy-makers in most advanced countries and

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certainly in Europe (including the UK) have tried toremove barriers so that all people are treated fairlyand have equality of access to a good education,good housing and a healthy life.

Government responses inareas of discriminationThe Equal Pay Act 1970 attempted to improve theposition of women in employment by making itunlawful to discriminate between men and women interms of pay and their conditions of work. Within anycompany, they should be paid the same if they aredoing the same or similar work.

The Sex Discrimination Act 1975 made it illegal todiscriminate on the grounds of sex or marital status in:

• employment

• education

• advertising

• housing

• the provision of goods and services, e.g. getting amortgage or signing a credit agreement.

The Act identified two forms of discrimination: ‘Directdiscrimination’ consists of treating a person lessfavourably on grounds of their sex or marital status,e.g. requiring that a child care worker should befemale.

‘Indirect discrimination’ consists of imposingconditions – which are not relevant to the situation –on both men and women, married and single, thatwould be a barrier for people from some categories.An example would be advertising a plumbing course‘for all’, but providing no toilet facilities for womenand no provision for women needing maternity leave.

The Equal Opportunities Commission was set upunder the Sex Discrimination Act, and has a generalremit to secure equality of opportunity on grounds ofsex and marital status:

• It runs high-profile campaigns on gender issuesaimed at changing public opinion (and the law).

• It publishes research about the relative positions ofwomen and men to show clearly where change isneeded.

• It investigates companies and other organisationswhere unlawful practice is persistent.

• It takes legal action under the Sex DiscriminationAct and the Equal Pay Act to secure equal rightsfor women and men.

The Race Relations Act 1976 strengthened twoprevious laws of 1965 and 1968. It has a very similarstructure to the 1975 Sex Discrimination Act, andmakes it illegal to discriminate on grounds of race,colour, nationality and national or ethnic origin. As withthe Sex Discrimination Act, it provides protection in thefields of employment, education, training, housing andthe provision of goods, facilities and services.

The Race Relations (Amendment Act) 2000 wentfurther:

• prohibiting race discrimination in all public places.

• requiring public bodies (which includes all state-fundedschools and care settings) to promote race equality.

The ‘public bodies’ are expected to provide evidencethat they are carrying out their duty to:

• eliminate unlawful racial discrimination.

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DisabilityDiscrimination

Act 1995

RaceRelations Act

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SpecialEducational Needsand Disability Act

2001

Equal PayAct 1970

EuropeanUnion EqualTreatmentDirectives

HumanRights Act

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SexDiscrimination

Act 1975

Equalitylegislation

Discrimination in employment

Lola worked as a clerical assistant in a medium-sized engineering company. Following a serious caraccident on holiday she needed to use a wheelchairat work. The company were initially sympathetic butthen gave her notice that she was being maderedundant. The premises, they said, were not suitedto wheelchair users. Lola knew about the DisabilityDiscrimination Act (1995) and contacted her localCitizens’ Advice Bureau (CAB). The CAB wrote tothe company on her behalf pointing out theirresponsibilities to ‘make reasonable adjustments totheir premises’ for people with disabilities. Theyreminded the company that Lola had the right totake her case to an employment tribunal should sheconsider their response to be discriminatory.

Figure 12


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• promote equal opportunities.

• promote good relations between people fromdifferent races.

The publicly funded organisations should make raceequality a central part of the way that they work, byputting it at the centre of their policy making, servicedelivery and employment practice.

The Commission for Racial Equality, set up underthe Race Relations Act 1976, forms a very similarfunction to the Equal Opportunities Commission, witha general remit to promote equal opportunities formembers of all racial groups. In practice, of course,most discrimination is against people from minorityethnic groups, and it is those groups who directlybenefit from their work.

The Disability Discrimination Act 1995 definesdisability as ‘a physical or mental impairment whichhas a substantial and long-term adverse effect on[someone’s] ability to carry out normal day-to-dayactivities’. The Act was passed with the aim of endingthe discrimination that people with disabilities werefacing. It gives disabled people rights in the areas of:

• employment

• access to goods, facilities and services

• buying or renting land or property.(Adapted from www.disability.gov.uk)

Since1996, under Part 2 of the Act – which focuseson employment – it has been unlawful to discriminateagainst someone with a disability as a job applicant oras an employee:

• by treating him or her less favourably (withoutjustification) than other employees or job applicantsbecause of his or her disability.

• by not making reasonable adjustments.

Under Part 3 of the Act – which addresses the accessto goods, facilities and services:

• It is unlawful to treat a person less favourablybecause they are disabled.

• Service providers have to consider makingreasonable adjustments to the way they delivertheir services so that people can use them.

• Service providers have to consider makingpermanent physical adjustments to their premises.

The Disability Discrimination Act is different from theSex Discrimination Act and the Race Relations Act in anumber of ways. Generally there is not as strong arequirement for equal treatment as in the otherequality legislation. First, the Act applies only toemployers with fifteen or more employees. Secondly,there is no reference in the legislation to ‘indirect’discrimination and, thirdly, employers and serviceproviders are required only to make ‘reasonable’adjustments. What is reasonable will be open todebate, and may have to be tested in the courts or atan Employment Tribunal.

The Special Needs and Disability Act 2001introduced the right for school pupils and studentswith disabilities not to be discriminated against ineducation and training. This includes a wide range oflinked services – such as field trips and other schooloutings, examinations, arrangements for workplacements and access to libraries and other learningresources.

The Disability Rights Commission was set up in2000 to replace the less powerful Disability RightsCouncil established in 1996. The Commission’s goal isto see ‘ a society where all disabled people canparticipate fully as equal citizens’. Its functions arevery similar to the those of the other equalitycommissions:

• giving advice and information to disabled people,employers and service providers.

• supporting disabled people in getting their rightsunder the Disability Discrimination Act.

• providing legal assistance, as appropriate.

• campaigning to strengthen the law.

• producing policy statements and research ondisability issues.

(See www.drc-gb.org.)

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Access toadvocates

Picturesand displaysof minority

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Writtencommunication in

minority languages

Opportunitiesfor religiousobservance

Booksand

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Linkswith ethnic

minoritycommunity

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Access totranslators

Celebrationof culturalfestivals

Ways ofpromoting

race equality incare settings

Figure 13 Ways of promoting race equality incare settings


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The Human Rights Act 1998, which came into force in2000, incorporated most of the articles of theEuropean Convention of Human Rights into ourdomestic law. Those areas covered by the Act are:

• Right to life (Article 2)

• Prohibition on torture (Article 3)

• Prohibition on slavery and forced labour (Article 4)

• Right to liberty and security (Article 5)

• Right to a fair trial (Article 6)

• No punishment without law (Article 7)

• Right to respect for private life and family (Article 8)

• Freedom of thought, conscience and religion(Article 9)

• Right to freedom of expression (Article 10)

• Freedom of association and assembly (Article 11)

• Right to marry and found a family (Article 12)

• Prohibition of discrimination (Article 14)

• Protection of property (Article 1 of the First Protocol)

• Right to education (Article 2 of the First Protocol)

• Right to free elections (Article 3 of the FirstProtocol).

The European Directive on Equal Treatment(2000/78/EC) requires all member states to passlegislation which will outlaw discrimination inemployment and training on the grounds of age,sexual orientation, religion and belief, and disability.This is scheduled to be implemented in October 2006,extending further the equality legislation in the UK.

As what may be seen as a natural development fromthe European Directive (2000/78/EC) the governmentplans to set up, in 2007, a new Commission for Equalityand Human Rights (CEHR) which will replace theDisability Rights Commission, the Commission for RacialEquality and the Equal Opportunities Commission. Theaim of the new Commission will be to widen scope andend discrimination and harassment in areas of disability,race, age, gender, religion and belief, and sexualorientation. The government believes that a singlecommission will:

• bring together equality experts, and act as a singleresource of information and advice – instead of theseparate organisations.

• provide a singe point of contact for individuals,businesses and the voluntary and public sectors.

• help businesses by promoting awareness ofequality issues, which may prevent costly court andtribunal cases.

The provision of additional learning support

Wayne is nine years old and attends WoodgreenPrimary, his local infant school. He is making goodprogress in numeracy but very slow progress inreading and spelling. His writing is very untidy andhe is beginning to lose confidence. TheHeadteacher of Woodgreen Primary thinks thatWayne’s parents are fussing but has agreed todiscuss the issues with them. The school’s SpecialEducational Needs Co-ordinator is going to be atthe meeting.

Following the meeting it was agreed that aneducational psychologist would be asked to assesswhether Wayne might be dyslexic and, using thisand other information they have on Wayne’sprogress, agree an Individual Educational Plan toprovide appropriate support for him.


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• tackle discrimination on multiple levels – somepeople may face more than one type ofdiscrimination.

• give older people a powerful national body totackle age discrimination.

In September 2005, the Home Secretary, CharlesClarke, announced plans for a ‘Commission onIntegration’, not to replace the equality commissions,but a separate commission that would aim to fosterhealthy, mixed communities with shared norms andpatterns of behaviour. The aim is to develop practicalways to overcome the barriers to integration. TrevorPhillips, the Chair of the Commission for RacialEquality had claimed that Britain was increasinglydividing on racial lines, living in segregatedcommunities, and ‘sleepwalking into apartheid’.


Define the following terms: prejudice,discrimination, stereotype, diversity.

Why is it necessary to understandindividual differences when supportingpeople in health and care settings?

Which groups of people are protectedfrom discrimination by law?

What is the difference between directand indirect discrimination?

What are the main functions of theequality commissions?

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1 Using the internet, check the mainfunctions of the proposed Commission forEquality and Human Rights. If they havechanged from the proposals outlined in thissection, make a poster for your classroomwith the up-to-date information.

2 Collect a copy of the equal opportunitiespolicy of any organisation that you areinvolved with, e.g. school, college,workplace or work placement. Examinehow far the objectives or policy statementsare met.

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Getting you thinking1 ‘There are plenty of

opportunities for everyone.Nobody needs to be poorthese days.’ Is that how it is?

2 Are we all middle class now?

3 Is it true that we’re all farbetter off than ourgrandparents’ generationwere?

4 Are some groups alwaysexcluded from the goodthings on offer?

Social stratificationThe grouping of people together according to theirperceived status or rank within society.

Egalitarian societyA society in which everyone is regarded as equal.

Social classThere are many competing definitions of social class. Central toall definitions is the idea that position in society is determinedby our economic circumstances, which will then influence ourlife choices, our opportunities and future prospects

Social exclusionA term used to describe a situation where people are unableto participate fully in society for a number of related reasons –including poverty, unemployment, poor housing (orhomelessness), poor health and poor educational achievement.

UnderclassCoined by Gunnar Myrdal (1969) and closely linked with theidea of social exclusion, this term is normally used now torefer to the people in poverty who are excluded from fullyparticipating in society because of the social and economicchanges that are outside their control.

PrejudiceA strongly held attitude towards a particular group whichwill often persist, even when shown to be unjustified orunfounded.

DiscriminationTreating a person or a group of people differently (usuallyless favourably) than others.

StereotypeDefining a group of people – black people or lone parents,for example – as if they all possess the same personalcharacteristics, ignoring their individual differences.

LabellingClosely linked with stereotyping. When a person is ‘labelled’then usually the stereotypical characteristics of that groupare applied to them, and their individual characteristics areignored.

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Topic 5 An unequal society


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Inequalities in societyInequalities in our society are well documented bysocial scientists, journalists and governmentstatisticians. The observable consequences ofinequality, though, are probably all too visible ineveryday life. They are seen in the range of housing inmodern Britain, the contrasting environments withintowns and cities, differences in schools and children’seducational achievements, and differences inindividual levels of wealth and income. Theseinequalities are reflected in the fact that:

• Children from manual social backgrounds are 1.5 times more likely to die as infants than childrenfrom non-manual backgrounds.

• Babies from manual social backgrounds are 1.3times more likely to be of low birth weight thanthose from professional backgrounds.

• Teenage motherhood is six times as commonamongst those from manual social backgrounds asfor those from professional backgrounds.

• Forty per cent of lone parents are not in paid work.

• Overcrowding is more than three times as prevalentin social rented (local authority and housingassociation) housing as in owner-occupied housing.

• People of black Caribbean, Bangladeshi and Africanethnicity are twice as likely to be out of work (andwanting work) as white people.

(www.poverty.org.uk)

Social stratificationSocial stratification is a term that sociologists haveadapted from geologists’ terminology, where‘stratification’ refers to the different layers of rock,one on top of another. Almost all known societieshave had a concept of some groups being of higherstatus than others. In America, before the civil war,groupings in the South were based on race. In feudalBritain, land ownership was a key determinant ofstatus.

Hindus have a strict hierarchy of social ‘castes’, withthe Brahmin (the priestly caste) regarded as the mostsuperior and the Sudras (the labouring caste)considered to have the least status. Beneath the Sudracaste are the casteless – the ‘untouchables’, a groupnow theoretically prohibited by the Indian government,but still of considerable actual significance.

Those in the higher social groups are normallymore wealthy and have access to a quality of lifevalued within that society. There have, however, beenexperiments in establishing unstratified, more

egalitarian societies. Probably the best known andmost developed example is the kibbutz system inIsrael. There are currently about 240 kibbutzim inIsrael, with populations of several hundred each. Allproperty and land are communally owned, and allgoods are distributed to members according to theirneed. Children are brought up and educatedcommunally. Money is not normally used. Generalassemblies are held to discuss and make majordecisions. Studies of kibbutzim, however – mostnotably by Eva Rosenfeld (1957) – have suggestedthat there is some stratification, particularly betweenthe leaders, elected to run the kibbutzim and the‘ordinary’ members who carry out the tasks.

Social classMost modern societies today are stratified by socialclass, a system based largely on economic factorslinked with income and wealth. In modern Britain,most research into the impact of social class on healthand well-being has used occupation to locate people’sclass position. Occupation has long been seen asclosely linked with level (and security) of income, andalso with people’s standing in the community.

Since 1911, the census data has been analysed byclass categories, based on occupation. This system, whichwas usually known as the ‘Registrar General’s Scale’ (theRegistrar General being the head of the Office forNational Statistics) remained largely unchanged until1991, and consisted of six ‘social classes’:

1 Professional occupations, e.g. architect,accountant, doctor, judge, optician

2 Managerial and technical occupations, e.g. farmer,nurse, school teacher,

3 (non-manual) e.g. clerical worker, secretary, shopassistant

3 (manual) e.g. bricklayer, bus driver, carpenter,cook, police constable

4 Semi-skilled occupations, e.g. bar person, postman,bus conductor, farm worker

5 Unskilled occupations, e.g. chimney sweep, officecleaner, window cleaner.

For the 2001 census a new occupational classificationwas introduced, which is thought to be more flexible,and which includes those people who are not in paidwork:

1.1 Employers and managers in large organisations,e.g. managing director


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1.2 Higher professionals, e.g. doctors, solicitors,teachers

2 Lower managerial and professional occupations,e.g. nurses, journalists

3 Intermediate occupations, e.g. clerks andsecretaries

4 Small employers and own account workers, e.g.taxi drivers, painters and decorators

5 Lower supervisory, craft and related occupations,e.g. plumbers and electricians

6 Semi-routine occupations, e.g. shop assistants,hairdressers

7 Routine occupations, e.g. cleaners, refuse collectors

8 Those people who are not in paid employment.

These systems of classification – and others which arevery similar in structure – have been used to analyseresearch into levels of poverty and the impact of socialclass on a wide range of social and economicactivities, including the inequalities identified at thebeginning of this section.

Social exclusionSocial exclusion is a term closely linked with issues ofpoverty and deprivation, but it refers to wider issues ofparticipation in society. The Social Exclusion Unit, set upby the Labour Government in 1997, describes ‘socialexclusion’ as a shorthand term for what can happenwhen people suffer from a combination of linkedproblems, such as unemployment, poor housing, poorskills, low income, high crime environments, bad health,poverty and family breakdown.

The Social Exclusion Unit was set up to addressperceived social problems, which were seen as havinginterlinked causes, and therefore needed co-ordinatedsolutions. They were looking for ‘joined-up solutions tojoined-up problems’. Tony Blair when launching the unitwas quoted as saying that social exclusion is ‘aboutmore than financial deprivation. It is about the damagedone by poor housing, ill-health, poor education, lackof decent transport, but above all lack of work.’ (quotedin Tossell, D. and Webb, D. (2000) Social Issues forCarers). Unemployment – especially prolongedunemployment – was seen as a crucial factor inindividuals and their families becoming excluded fromthe social, economic and political life of society.

The term ‘social exclusion’ has come to replace aclosely linked concept of the underclass, a term youmay come across in some sociology and social policytexts. Both these terms are used to describe peoplewho are ‘on the edge’ of our society, and not able to

take a full part in economic, political and social life. The overall effect of the interrelated causes and

consequences of social exclusion is to ‘marginalise’those individuals and groups in our society who arenot able to fully participate. Marginalised groups willnormally lack the income to take a full part in theeconomic and social life of our society.

Those groups are likely to be the subject ofprejudice. This term is not easy to define, but it refersto strongly held beliefs and attitudes about peoplewhich often have no basis in factual evidence, butwhich are held so strongly that they are difficult toshift. The beliefs and attitudes are often directed atdisadvantaged groups, and usually attribute negativecharacteristics to them. People who have prejudicialattitudes to specific groups rarely look for robustevidence to support their view – and even when it ispresented to them it rarely makes any difference.

This process is closely linked to stereotyping. Astereotype is a set of characteristics that members ofa particular group are said to possess, e.g. ‘that allhoodies are school drop-outs, they often shoplift andthey cannot be trusted’. People who have beenstereotyped tend not to be seen as individuals but asa typical member of the group. When a stereotype iswidely held it is sometimes said that the individual orgroup has been labelled, because the stereotypicalcharacteristics are routinely applied to them.

It will be becoming clear how prejudicial attitudesand stereotyping can lead to discrimination ordiscriminatory behaviour. If we have negative attitudestowards a particular group we are likely to be wary of

Social exclusion

Joe and his friend Winston are 20 years old. Theyhave never managed to obtain paid work. Bothgrew up in an area of high unemployment. Joe andWinston’s parents were all made redundant alongwith many of their neighbours when the local coalmine closed. They have been unable to find paidwork since. There is over 30% unemployment onthe estate where Joe and Winston live and littlechance of this improving. Because both of themstopped going to school regularly in year 10neither has any GCSEs. They didn’t see the point atthe time because there was no work or jobs forthem to get anyway. Joe and Winston have a verynegative view of the future and don’t believe thatthey have any real opportunities in life. They haveno training, they have never voted, they are notpart of any organised community groups and admitthat they are just drifting into the future with noplans, no ambitions and few prospects.


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them and treat them less favourably than othermembers of society.

Social exclusion will potentially lead to a range ofnegative consequences for the social, emotional,intellectual and physical development of the peopleaffected. They are likely to become socially isolatedbecause they are marginalised. They also are unlikelyto have the income which will support an active sociallife. This is likely to lead to a poor self-image, low self-esteem and little self-confidence. These social,emotional and economic circumstances will not easilysupport educational success, and are likely to impactnegatively on general health and well-being, andphysical health in particular.

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Define the terms social stratification,social class, social exclusion.

Describe the social issues that thegovernment tried to address throughthe Social Exclusion Unit.

Explain why prejudice may lead todiscrimination against disadvantagedgroups in our society.

Explain why the idea of stereotypingand labelling may be seen as closelylinked.

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1 Working with another member of yourgroup, try to describe how a society couldoperate if everybody was equal. Whatwould be the advantages anddisadvantages of an equal society?

2 The government has identified that peoplevulnerable to social exclusion include thehomeless and people in poor housing, theunemployed, people with poor educationalqualifications and people on low incomes.

Find out more statistics on these areas ofpeople’s lives. Try to establish whethertrends are improving or not. Discuss withother members of your group how youwould address the problems.


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Getting you thinking1 Write a list of items that you think are essential – and without which you would be in poverty.

2 Compare this with your friends’ lists.

3 In your own words, write a definition of poverty.

4 Which groups in our society do you think are most likely to be in poverty?

5 What are the main consequences of poverty in the United Kingdom?

Absolute povertyA level of income below that which will sustain goodhealth.

Culture of povertyA view that poverty is associated with a particular (andseparate) way of life that is passed on from generation togeneration.

Means-tested benefitsWelfare benefits that are only available to people if theirincome and savings are below a certain level, decided bythe government.

Poverty line A term, introduced by Seebohm Rowntree, which set a levelof income below which people were said to be in poverty.

Relative povertyRelative poverty occurs when people live below thestandard of living normally accepted in a particular society.

Universal benefitsWelfare benefits to which people are entitled, regardless oftheir income or savings.

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Topic 6 Poverty and welfaresupport


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What do we mean bypoverty?In this topic we will discuss what we mean by poverty,and how difficult it is to measure poverty. We willthen consider why, in a wealthy nation like ours,poverty still persists and, finally, how governmentshave responded to the identified needs of the poorestin our society.

It will be no doubt be clear when comparing yourlists of ‘essentials’ that it is difficult to agree on whatwe mean by ‘poverty’. And if we cannot easily definea term, we will have great difficulty in measuring theextent of the problem – or even if the problem exists.

The first systematic studies of poverty in Englandwere conducted by social reformers at the turn of thenineteenth century. Charles Booth (1840–1916) in hisstudy, Life and Labour of the London Poor, and theQuaker Seebohm Rowntree (1871–1954) in his studyof York, Poverty: A study of town life, exposed theexistence of widespread poverty in these two cities.These studies were important, not only in their ownright, but also in their continuing influence. Theyprovided evidence and an approach to understandingpoverty, which has influenced government policies,and also provided an approach to defining andmeasuring poverty which has influenced thesubsequent research in this area.

Booth covered a wide range of issues which havebecome central themes in studies of poverty, includingemployment, health, housing, religion and the level ofwages. He was probably the first to identify the closelinks between poor health, disability, poverty, poorhousing, unemployment and bad working conditions.

Rowntree (probably better known for his chocolatefactory which was a main employer in York at thetime) developed a vocabulary for discussing povertywhich has informed discussion since. He introducedthe idea of a poverty line – a concept that is stillused by governments, and informs our benefit systemtoday. It identifies a level of income below whichpeople are regarded as living in poverty.

Rowntree defined people as poor if their incomewas such that the resulting deprivation had adetrimental effect on their health. With the assistanceof the British Medical Association, he calculated theincome that was necessary for the members of ahousehold to maintain ‘physical efficiency’. If theirincome was below this level they were regarded as inabsolute poverty. The income allowed a basic dietthat would be adequate, but no more. There was noallowance for papers or magazines, or alcohol, ortravel. There was no allowance for stamps for writingto children living away from home. Families wereregarded as in ‘primary poverty’ if their income wasbelow the level that would maintain physicalefficiency, and in ‘secondary poverty’ if their incomewould have been sufficient had they not spent moneyon items not on his list. This distinction could be seenas pointing to the idea of the ‘deserving poor’ andthe ‘undeserving poor’.

Rowntree conducted further studies in1936 and1950 where the understanding of poverty suggestedthat there was more to being poor than simply notbeing able to keep the body intact – social andemotional health were significant too. The 1936 studyallowed that, to be above the poverty line, peopleshould have an income sufficient for a radio,newspaper, beer and a holiday.

Later studies of poverty developed further the ideathat poverty could be regarded as a level of incomebelow which people were ‘not able to participate inthe life of the community’. The level, then at which apoverty line may be set would vary from communityto community, and at different times in history. Insome parts of Africa, for example, to have suitableshelter and regular meals would be regarded as richindeed. In modern Britain people would normallyregard this as not enough to count as playing a fullpart in the community. Peter Townsend (1979) waskey in the development of the idea that the idea ofpoverty should be related to the society in whichpeople live. He developed the idea of relativepoverty (relative deprivation), claiming that:

‘Individuals, families and groups in the populationcan be said to be in poverty when they lack theresources to obtain the types of diet, participate in theactivities and have the living conditions and amenitieswhich are customary, or at least widely encouraged orapproved in the societies to which they belong . . .they are in effect excluded from ordinary livingpatterns, customs and activities.‘

Townsend P. (ed.) (1979) Poverty in the United Kingdom

This approach to poverty was taken further by Mackand Lansley (1985, 1991) in their major studiesBreadline Britain, defining poverty in relative terms.

Loneparents

Olderpeople

Peoplewith

disabilities

People onlow wages

Theunemployed

Thosevulnerableto povertyinclude…

Figure 14


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They attempted to define poverty by asking theirrespondents what they considered to be necessities inmodern Britain. An item was considered a necessity ifmore than half the respondents classified it as such.On the basis of this list of ‘perceived necessities’,Mack and Lansley measured the extent of poverty. Inthese, they took account of personal choices, askingrespondents whether they lacked an item out of‘choice’ or ‘necessity’. Some people, for example,might choose to not have a television or a telephonein their home. Mack and Lansley found that generally,where people lacked three or more ‘necessities’ it hadlittle to do with choice. It was unavoidable – they justcouldn’t afford them. This approach has been usedsince.

The most recent attempt to update the BreadlineBritain studies was the1999 ‘Poverty and SocialExclusion Survey of Britain’ produced by the Office ofNational Statistics, supported by the Joseph RowntreeTrust. The aim of this study was to:

• Update the Breadline Britain surveys.

• Estimate the size of groups of households indifferent circumstances.

• Explore movements in and out of poverty.

• Look at age and gender differences in experiencesand responses to poverty.

Over 90% of the population in this survey regarded abed and bedding for everyone, warm living areas ofthe home, a damp-free home, the ability to visitfamily and friends in hospital, two meals a day, andmedicines prescribed by the doctor as necessities.

The researchers found that a quarter (26%) of theBritish population was living in poverty measured interms of low income and multiple deprivation of theagreed necessities.

(Adapted from www.bris.ac.uk/poverty/pse.)

A ‘working definition’ of poverty is still necessary toidentify the extent of need, and then to address theissues. Some nations, including the United States, usea ‘budget standard’, based on the cost of a minimumbasket of food (following Rowntree’s idea). The UKand other members of the European Union set apoverty line at 50% of the median income. (Themedian is the mid-point of the full range of incomesin the population.) Those with an income of less than50% of this amount are deemed to be in poverty.

Despite all these differences in definition, for thosepeople on low incomes – perhaps having to choosebetween eating well and keeping warm – poverty isall too present.

Culture of povertyOscar Lewis, an American writer, is identified as theauthor most closely associated with the idea of aculture of poverty. He thought that poverty wasassociated with a particular, separate, way of life thatwas passed on from generation to generation. Hethought that in order to cope with their stressfulcircumstances the poor were unlikely to plan for thefuture – they rarely saved, they had a less wellordered life, and a more fatalistic attitude to thefuture. Their culture and way of life was different tothe mainstream in the society. A similar idea wasdeveloped in the 1970s through the concept of the‘cycle of deprivation’ in which it is said that thelifestyle of the poor was passed on from onegeneration to the next. There is, however, littleevidence to suggest that the poor have values andaspirations that are significantly different from the restof society. They shop largely in the same high street,they are subject to the same advertisements, andsimilar demands are made by their children. As aresult, they have a keen sense of being amongst theleast well off in modern Britain.

Welfare benefitsconcerned with povertyThis section considers the benefit system aimed atsupporting those identified as being in financial poverty.The structure of the benefit system can be traced backto the system set up following the Beveridge Report,and specifically to addressing issues of ‘want’. Writing ata time of almost full employment, he saw poverty asgenerally caused by two things – first, the loss of incomecaused by the old age, unemployment, ill-health, ordeath of the family’s main wage earner (at that timealmost always the man) and, secondly, the cost ofchildren.

The benefit system was to be largely financed by anew ‘National Insurance’ scheme to which people wouldcontribute when they were in work and from which theywere able to claim when they were unable to work. Thismeant that they would claim retirement pension whenthey were too old to work, sickness benefit when theywere too ill to work, and unemployment benefit (nowJob Seekers Allowance) when unemployed. They wouldbe entitled to these benefits because they had paid intothe National Insurance scheme and they met the lifecircumstances criteria – they had reached retirement age,for example. These benefits were not related to aperson’s income, neither were they charity – they werean entitlement. They were universal benefits, available


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to all who had paid into the scheme and met the lifecircumstances criteria.

In addition to the National Insurance benefits (oftencalled ‘contributory’ benefits, because they depended onpayment of National Insurance contributions) there weremeans-tested benefits for people who had not paidinto the scheme, normally because they had not been inconsistent employment – and, of course, there wouldalways be people who had never worked. Eligibility formeans-tested benefits depended on people’s level ofincome and their level of savings. Those unable to work,who had not paid into the scheme, would be entitled tobenefit only if their own resources fell below a certainlevel – the level that the government thought adequateto keep them out of poverty. This approach, thereforedrew on Rowntree’s concept of a poverty line. Thebenefits today that are means tested include IncomeSupport, Housing Benefit, Educational MaintenanceAllowance, and the non-contributory Jobs SeekersAllowance – paid to the unemployed who have not paidsufficient contributions to the National Insurancescheme.

The take-up of benefits Of particular interest (and concern) to social workersis why, despite poverty, a significant proportion of thebenefits aimed at the poorest in society is notclaimed, including benefits aimed specifically at olderpeople. The benefits with the lowest take-up rates arethe means-tested benefits. There are many possiblereasons why this might be the case:

• The benefit system is very complicated, and peopleare often not clear of their entitlements.

• The forms that need to be completed are long andoften complex.

• The questions asked and the information requiredcan be seen as an invasion into privacy, and toomuch of an intrusion into personal circumstances.

• Some claimants are too proud to claim theirbenefit, particularly the means-tested benefits.Some older people in particular still see this ascharity rather than an entitlement.

• Some people feel that there is a stigma attached toclaiming their benefit.

• Claiming means-tested benefits often requiresvisiting the Benefits Office, and some feel thatthere is a stigma attached to this as well.

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Define the terms ‘primary poverty’ and‘secondary poverty’, as introduced bySeebohm Rowntree.

Explain the difference betweenuniversal benefits and means-testedbenefits.

Which groups in our society are mostvulnerable to poverty?

Identify the likely reasons why there isa lower take-up rate for means-testedbenefits than for universal benefits.

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1 Using the internet, your local library,Citizen’s Advice Bureau, or Benefits Office,list and briefly describe five universalbenefits and five means-tested benefits.

2 Universal benefits are available to the mostwealthy members of the community – whocould quite well manage without them. Isthis a good use of taxpayers’ money?Discuss this with reference to Child Benefit.

Poor take-up of benefits

Martha is seventy five years of age. She lives on herstate retirement pension and is finding it difficult tomanage. An advice worker who visited the day centreshe attends explained to Martha that she could alsoclaim Income Support and additional Housing Benefit.Both of these are means-tested benefits. Marthabecame quite annoyed and impatient at this advice.She said “I don’t want the social prying into myprivate business. I haven’t claimed anything in my lifebefore and I’m not going to start now. Anyway it’s socomplicated. They want to know everything. Andwhat if I get it wrong? I could be all over thenewspapers if I claim too much”.

In the mean time Martha is depressed and worried.She is frightened to put on the heating in thewinter because she cannot afford the bills. Her dietis poor and her general quality of life declining.


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Getting you thinkingYour local health authority is planning to open a hostel in your area for people with mental healthproblems.

1 Write down your initial feelings about this plan.

2 Compare your thoughts with other people in your class

3 How do you think the people who live nearby will feel?

4 Try to identify two reasons in favour of this plan, and two reasons against it.

InstitutionalisationThe process of becoming dependent on the rules androutines of large organisations.

LabellingThe process of attaching stigmatising stereotypes toparticular groups of people who are then seen as all sharingnegative characteristics.

Multi-disciplinary teamA team of care workers from a range of professionalbackgrounds. The team may include doctors, nurses, socialworkers and occupational therapists, for example.

StigmaA term closely related to labelling which refers to theimpact of negative attitudes and behaviour on the healthand well-being of marginalised groups, e.g. offenders, thementally ill or travelling families.

Total institutionA large, highly organised residential establishment wherepeople live their lives completely separately from the widersociety, e.g. a prison or an army barracks or a large mentalhospital.

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Topic 7 Mental health


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How do we measure thehealth of the nation?In Unit 9 there is a fuller discussion of what we meanwhen we describe somebody as ‘healthy’. A favoureddefinition by health and care workers is the WorldHealth Organization’s view that health is ‘a state ofcomplete physical, mental and social well-being, andnot the absence of disease or infirmity’.

Measuring how far this has been achieved acrossall sections of the population, however, and how thatcompares with other societies and across otherhistorical periods, is a challenge. In order to measurewell-being statistically there has to be a cleardefinition that is, in itself, measurable – a challengeindeed.

Most research – and hence most statisticalinformation – on the healthiness of nations describeslevels of ill-health. There is, for example, detailed dataavailable on the numbers of GP and hospitalappointments, the take-up of immunisationprogrammes, the incidence of diagnosed mentalillness, levels of morbidity and mortality, includingsuicide rates. All this data has been analysed by socialclass, occupation, geographical region, ethnicity, age,sex and occupation – variables that are far easier todefine and measure than levels of well-being. Tomeasure our own level of well-being is challengeenough, so comparisons with others are not easilyopen to objective study or statistical analysis.

What is mental illness?Mental illness is very common (and we will discuss thestatistics that support this claim later) but there is agreat deal of controversy, discussion and uncertaintyabout what we mean by a mental illness, what arethe causes and how people can be helped to recover.There are difficulties of definition. What is seen as‘normal’ and ‘abnormal’ behaviour varies betweensocieties, and at different times in history. Further,there can be considerable difficulties in diagnosis andappropriate support when doctors, carers and clientsare from different cultural or religious backgrounds.

Psychiatrists have, however, categorised differentforms of mental illness. Amongst the most commonare depression, anxiety, panic attacks, phobias,obsessive–compulsive disorders and schizophrenia.Identifying a condition helps, of course, with decisionson forms of treatment and the ongoing care needed.Doctors, however, may disagree on the diagnosis.Giving a specific diagnosis can lead to some negativeconsequences – sometimes referred to as labelling.

Labelling someone as ‘a depressive’ can lead to thisbecoming the defining characteristic of that person. Itis seen as their main characteristic, and other aspectsof their life – as a parent, teacher, lover and friend –are overlooked. The condition becomes a label thatthey have great difficulty leaving behind, even whenthe symptoms have gone.

This lack of clear definition and certain diagnosiscould be seen to underpin the ignorance, fear andanxiety about issues of mental health, and theprejudice faced by many people with mental healthproblems.

The causes of mental illnessesThe causes of mental illness and distress are also notfully understood. They are part of a wider discussionof the link between nature and nurture – that is,whether our personalities are shaped by our geneticmake-up or the result of our life experiences. It islikely that mental distress is the result of acombination of factors drawn from our inheritedcharacteristics (our genes), ongoing changes in ourbiochemistry (e.g. hormonal changes) and lifeexperiences, including our family background and theconsequences of stressful life events. It is possible thatsome people, because of their genetic make-up, aremore vulnerable to mental illness than others, andthat the illness is triggered by stressful or traumaticlife events, such as divorce, redundancy or the deathof a partner.

How common is mental illness?It is very difficult to accurately calculate the levels andincidence of mental illness. There are readily availablestatistics on the frequency of mental health problemsin the UK, but these statistics need to be treated withcaution.

The number of people identified as suffering froma mental illness will often be based on the number ofpeople presenting themselves for treatment. But thereare many people with mental health problems who donot seek professional help – for a range of reasons.They may not realise that they are ill. They may

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Stressfullife events

Braininjury

Familyand relationship

problems

Geneticfactors

Changes inbio-chemistry

Possiblecauses ofmentalillness

Figure 15


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explain their feelings in all sorts of ways – ‘life can behard’, ‘everybody feels low sometimes’, ‘perhaps thisis normal’. Furthermore, attitudes to mental illness arecomplex, and people are often quite unwilling toaccept that they or their family have a mental healthproblem. There is often a stigma linked with mentalillness which doesn’t apply to people presenting withmost physical conditions. This might lead to adisadvantage when applying for jobs, places oneducational courses and engaging in other areas ofsocial and economic life. Furthermore, psychiatricdiagnosis is complex and often far fromstraightforward. Psychiatrists may differ in theirdiagnoses and sometimes the diagnosis may changeseveral times in the course of treatment.

An alternative method of measuring the levels ofmental illness is to conduct a ‘community survey’ –interviewing a sample of the population and,according to set criteria, identifying whether they havea mental health problem. This is seen as more reliable.The most recent and largest survey of this type wascarried out in by the Office for National Statistics in2000. This survey put the ‘prevalence’ of mental illnessin Great Britain at one in six of the population. (Thatis, at the time of the study, one in six people had amental health problem.) Another study by Goldbergand Huxley, which used a wider definition of mentalillness, put the figure at one in four.

The care of thementally illThe care of people with mental health problems is thestatutory responsibility of the National Health Service andthe local authority social service departments. The largeVictorian mental institutions (often one-time workhousesbut latterly normally called psychiatric hospitals) arelargely a feature of the past. ‘Community care’ as astrategy for psychiatric patients was first mentioned inthe 1954–57 Royal Commission on Mental Illness andDeficiency. It was recommended that there should be a‘general orientation away from institutional care in itspresent form towards community care’. There was somemovement during the 1960s towards increasing care inthe community. A 1975 government white paper, Betterservices for the mentally ill, recommended a movetowards community care and day care provision. Andthis trend became a requirement following the1990 NHSand Community Care Act.

The move towards community support rather thancare in hospitals may have been seen by some as a wayof saving money. It was thought that care in thecommunity would cost significantly less than hospital

care – a view that has subsequently been seen to haveno foundation. Good care in the community is expensiveand, in fact, more expensive than institutional care.There was, however, an increasingly held view that largeinstitutions were not providing the appropriate care formost people with mental health problems. Thearguments for community care were strengthened bythe writings of Erving Goffman. In his book Asylums(1961) he claimed that residents in large institutions –and he used mental hospitals as his main example –became so dependent on the rules and routines of theseinstitutes that they were often unable to functionindependently in the community. He claimed that thisprocess took place, not only in large mental hospitalsbut also in other large and socially separate institutes,which he called total institutions, including prisons,convents and army barracks. He called this process ofincreased dependency institutionalisation.

The vast majority of people with mental healthproblems today are cared for within the community. Thesmall minority who need hospital care are increasinglycared for on a psychiatric ward of a general hospitalrather than in a separate institution. Contrary to theimpression sustained by sensational stories in the media,the number of mental health patients who are either adanger to themselves or to others is very few. People inthis situation are cared for in hospitals under the MentalHealth Act, discussed below.

The Community Mental Health team supports peopleand their carers who have mental health needs and areliving in the community. This is staffed by a multi-disciplinary team consisting of health and social carestaff. The team may consist of community psychiatricnurses, occupational therapists, social workers, apsychologist and counsellors. The government isencouraging closer cooperation between social servicesand the health services, and in some areas the healthand care services are now jointly managed. Thecommunity care services will include day centres, homecare workers, meals on wheels, hostels and shelteredhousing projects, social clubs and befriending schemesto support people with mental health needs who areliving in the community.

The law and mental healthSection 1 of the Mental Health Act 1983 defines amental disorder as ‘mental illness, arrested orincomplete development of mind, psychopathic disorderand any other disorder or disability of the mind’.

The vast majority of people who are receivingtreatment in a psychiatric unit or hospital arevoluntary patients – ‘informal patients’ as defined inthe Mental Health Act. They are legally free todischarge themselves from hospital and they can

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refuse treatment. They have exactly the same rights aspeople in hospital with physical ailments.

Part 2 of the Act concerns ‘formal patients’ whoconstitute approximately 15% of psychiatric patients inhospitals. They are compulsorily detained under theMental Health Act, and lose some of the rights enjoyedby informal patients and other citizens. They are notfree to refuse treatment or to leave the hospital.

Mental Health Review Tribunals hear applicationsfrom patients concerning decisions by psychiatrists andother medical practitioners. The purpose of thehearings is to decide whether and under whatconditions people should be discharged from hospitalunder Part 2 of the Mental Health Act 1983. A tribunalnormally has three members – a doctor, a lawyer and alay person, who would normally have experience inareas of mental health and social services.

The Disability Discrimination Act (1995), discussedin Topic 4, applies equally to mental health as it doesto physical disability. People with mental healthproblems have recourse to the law – and a right tosupport from the Disability Rights Commission incases of perceived discrimination in employment, ineducation and in access to goods and services.

SuicideThere is a statistical link between the incidence ofmental illness and suicide. The suicide rate for men issome three times higher than for women, and has

increased alarmingly for young men over 15 – andparticularly for men between 25 and 44.

As with all statistics, suicide statistics must be usedwith caution. There may be instances where a verdictof suicide is unrecorded to spare the family additionalgrief – or even for insurance purposes. On occasion,suicides may be recorded erroneously as ‘accidents’.Overdoses of drugs, for example, may be recorded asaccident. Factors that are linked with suicide includebeing male, living alone, being unemployed, alcoholmisuse, and drug misuse.


Why is it difficult to measure the levelof mental illness in our society?

Identify factors that may contribute tomental illness.

What is meant by the term‘institutionalisation’?

Why has there been a movementtowards community care for peoplewith mental health problems?

Explain the difference between a‘formal’ and an ‘informal’ patient,under the Mental Health Act 1983.

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1 Using the internet, your local library, andinformation provided by your local healthand social care services, investigate theservices available in your area for peoplewith mental health problems.

2 A public meeting has been called to discussthe plan to build a hostel locally, for peoplewith depressive illnesses. Working in pairs,prepare two statements – one arguing thecase for the plan, and the other opposing it.

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30

25

20

15

10

5

01971 1979 1987 1995 2003

Suicide rates:1 by sex and age

65 and over

45–64

25–44

15–24

Males

United KingdomRates per 100,000 population

30

25

20

15

10

5

01971 1979 1987 1995 2003

65 and over

45–64

25–44

15–24

Females

1 Includes deaths with a verdict of undetermined intent (open verdicts). Rates from 2002 are coded to ICD-10. Rates are age-standardised to the European standard population.

Figure 16


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Getting you thinking1 How would you define the term ‘disability’? Compare your

definition with those of other people in your group.

2 How easy is it for a person in a wheelchair to go shoppingin the High Street that you normally use?

3 Imagine that you needed to use a wheelchair. How easywould it be for you to attend school or college and followthis course?

Direct paymentsCash payments made to people assessed as needingcommunity care services, so that they can select the specificsupport they need.

Disabling environmentAn environment in which adaptations are not in place toensure that people with impairments can take a full part inday-to-day life.

ImpairmentThe limitations that may be made on an individual due tophysical, mental or sensory dysfunction.

InstitutionalisationThe process of becoming dependent on the rules androutines of large organisations.

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Topic 8 Ability anddisability


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The difficulties ofdefinitionAs in so many areas of social care and social policy,terms relating to people with physical disabilities andimpairments are used in different ways by differentwriters. It is important when considering these issuesto be clear exactly how you are using the terms. Inmany ways there is no clear dividing line betweenpeople with disabilities and the rest of society. Most ofus will suffer disabilities at some point in our lives,and the same condition may create serious problemsin day-to-day life for some people but not for others.Some may therefore regard the condition as adisability, whilst others may not.

Accurate figures of the number of people withdisabilities are not known. This is partly because ofthe difficulties of definition and partly because theregisters of people with disabilities kept by localauthorities are incomplete. There is little agreementover who should be identified as ‘disabled’. In 2005,the definition used in the Disability Discrimination Actwas extended to protect more people with HIV, cancerand multiple sclerosis, and the requirement that amental illness should be clinically ‘well recognised’was removed. The government is currently revising itsguidance on the definition of disability.

The Disability Discrimination Act !995 defines aperson with a disability as ‘someone who has aphysical or mental impairment that has a substantialand long-term adverse effect on his or her ability tocarry out normal day-to-day activities’. ‘Long-term’normally means that the effect of the impairment ‘haslasted or is likely to last for at least 12 months’.Normal day-to-day activities includes things likeeating, washing, walking and going shopping.

A helpful distinction can be made between theterms ‘impairment’ and ‘disability’. Impairment is seenas the limitations that may be made on an individual,due to physical, mental or sensory dysfunction – with afocus on the individual. Disability, on the other hand, isseen as the restricted opportunity to take part in thenormal life of the community, due to physical, social orattitudinal barriers.

The medical model of disability Images of people with disability often show restrictedmobility – people using wheelchairs, for example, orwhite canes. But there are many physical conditions,of course, that may be ‘disabling’ but are not visible –such as back pain, heart conditions or asthma. Themedical model views disability as a dysfunction or animpairment located within the person’s body. Theyhave multiple sclerosis, for example, and their

difficulties in day-to-day living would be seen as aconsequence of their condition. It would thus be seenas the individual’s responsibility to adjust to thelimitations that may follow.

The physical consequences of a medical conditionor impairment, however, will vary. The age andpersonal circumstances of the person will impact onits effect, for example, and people’s attitudes to thecondition will affect its impact on day-to-day life.

The psychological approach todisabilityThe psychological approach to disability also has itsmain focus on the individual, with a particularconcern that individuals should adjust to theircondition. This approach will address the individual’smental response to their impairment and the therapygiven may be concerned with developing copingstrategies.

The social model of disabilityIn contrast to the medical and psychological models,the social model locates disability within society. Ifsomeone is in a wheelchair – but there is 100% accessto all amenities – then proponents of the social modelwould feel that they no longer had a disability. Theywould have an ‘impairment’ but this would not impactnegatively on their day-to-day life. The social modeltherefore locates the problems not with the individual,but in the physical environment, and in people’sattitudes and practices. Here the onus is put on societyto adapt to the needs of people with disabilities. The

Medical model of disability

Aziz became blind as an adult as a result ofdiabetes. He cannot read Braille. He has had verylittle support to develop skills for daily living. He isvery nervous of using kitchen equipment and, infact, cannot even make a cup of tea withconfidence. Aziz is never sure that the house isclean and this bothers him quite a lot. Although hehas a white stick to use outside Aziz is very nervousof going out of the house. The roads are very busywhere he lives and the pavements are uneven. Azizalso feels personally vulnerable. He knows thatanyone could take advantage of him. He’s usuallyquite frightened when he goes out. Aziz hasexplained this situation to his GP. Unfortunately hisGP says that Aziz just has to adapt to his newsituations. He tries to impress on Aziz that he has aserious disability and that he needs to adapt his lifeto this.


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focus of this model is on the disabling environment.It is probably more helpful to consider the valuable

insights of all three models rather than to just see themas three competing ideas. It is necessary to understandthe likely physical impact of a condition in order tomake appropriate environmental changes and organiseappropriate support. It’s helpful to use the insights ofpsychology to support people in their adaptation tochange. However, it could be argued that social careworkers need to particularly embrace the social modelif they are to ensure that people with impairments aregoing to fully participate in their communities.

Government responsesto disabilityThe growth of separate institutions to care for peoplewith disabilities started in the Industrial Revolutionwhen more and more people started working awayfrom their homes – in factories and mills. Most peoplewith disabilities who could not be cared for at homeby their family or friends lived in hospitals and otherinstitutions – some of them one-time workhouses.This system of care had its roots in the medical modelof disability. The people diagnosed as disabled werecared for by medical , nursing and care staff. Theywere separated from the wider society and vulnerableto the institutionalisation discussed in Topic 7.There was no thought that society could or shouldadapt so that they could be included in the social andeconomic life of the time. This approach persistedthrough much of the twentieth century.

The 1944 Disabled Persons (Employment) Actrequired local authorities to establish the number ofpeople with disabilities in their area, and Part 3 of the1948 National Assistance Act placed a duty on localauthorities to arrange services for disabled people.This measure largely resulted in people going intoresidential care rather than living independently in thecommunity. The 1970 Chronically Sick and DisabledPersons Act required local authorities to establish thenumber of people with disabilities in their area,compile a register of people with disabilities andprovide for their needs. The response to thisrequirement, however, varied across the country. Theregister did not clearly guide provision, which was lessthan adequate – and in some areas it was ignored.Further, the services available were not well organisedfrom the point of view of the user. There wasinsufficient coordination of provision, and navigatingthe systems was complex, and often disheartening.This legislation had attempted to address individualcare needs but it did not, in itself, address the widerissues – access to employment, education, publicservices and many public buildings. The existence ofthe ‘disabling environment’ was still largely ignored.Not until the passing of the Disability DiscriminationAct 1995 was there legislation that requiredemployers, public authorities and care workers toorganise and adapt their provision to meet the diverseneeds of the population .

The NHS Community Care Act 1990, as its namesuggests, was a key point in the development anddelivery of care services outside institutions and withincommunities. It required local authorities to assess the

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Providing services through direct payment

Mohammed is sixty-one years of age and hasParkinson’s Disease. Tamsila, his wife is his maincarer. Because she has arthritis, Tamsila is not verystrong, finds walking painful and so she doesn’tget out much. Tamsila feels pessimistic about thefuture and is quite depressed. Neither Mohammednor Tamsila speaks very much English and they feelquite socially isolated.

Mohammed needs considerable help with dailyliving activities. He and his wife have recently beenassessed by the local social services department fora range of community care services. They are goingto receive a direct payment for these services sothat they can choose their own care providers andpay them directly. Tamsila would like to use peoplefrom the Mosque whom she knows and withwhom she fees comfortable.

Social model of disability

Carl, aged 25 is a solicitor’s clerk who has multiplesclerosis. He can now only walk short distances. Healways uses walking sticks and often a wheelchairto get around his home and workplace. His househas been adapted so that he can carry out allnormal day-to-day activities. The doors have beenwidened for his wheelchair, the electricity pointsare now at waist height and he has had a stair lift,adapted bath and shower fitted. Carl’s employerhas also tried to help by providing him with alaptop so that he can often work from home. Carlnow has an adapted car and is able to visit hisfamily and friends quite easily as well as go onholiday and plan an active social life of his choice.He has impairments but the adaptations to hishome and work environment mean that he rarelyfeels ‘disabled’.


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needs of people requesting community care services –and money was made available to the local authoritiesto finance the provision. At the same time, the largerinstitutions were closing. Community care provisioncould include social work support, home care workersproviding practical support with daily living activities,day centres providing social, educational, recreationaland other therapeutic activities, and physicaladaptations to living accommodation. In complexcases, the 1990 Act requires the appointment of a‘care manager’ to plan, monitor and review theprovision for users and their carers. In 1995, theCarers (Recognition of Services) Act gave informalcarers – usually unpaid family and friends – the rightto a separate assessment of their needs too.

The 1996 Community Care (Direct Payments) Actallowed local authorities to make cash payments topeople who have been assessed as needingcommunity care services. This has been in part aresponse to the view that people with disabilitiesshould make their own decisions about how their careneeds are met, who provides them and how theservices are delivered. They use their cash payment topay for their chosen services.

It was not until the passing of the DisabilityDiscrimination Act (1995) that there was a shift inpolicy towards ‘rights’ for disabled people. The Actgives disabled people rights in the areas of:

• Employment

• Access to goods, facilities and services

• Buying or renting land or property.

The proposed Commission for Equality and HumanRights, discussed in more detail in Topic 4, is expectedto replace the Disability Rights Commission in 2007. Itis expected that the work carried out by the DisabilityRights Commission will continue through the newcombined commission.


How does the Disability DiscriminationAct define ‘disability’?

Define the term ‘impairment’.

Describe the three main models ofdisability – the medical model, thepsychological model, and the socialmodel.

During the twentieth century, whymight people with disabilities havebecome institutionalised?

Briefly describe the measuresintroduced by the NHS and CommunityCare Act 1990.

In what areas of economic and sociallife did the Disability Discrimination Act1995 give people rights?

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1 Using your local library, advice bureau orsocial services department, research therange of community care services in yourarea for people with disabilities.

2 Using the internet, find four groups thatsupport people with disabilities andsummarise their aims and activities.

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Topic 1 202 - Collins

Documents

Transcript of Topic 1 202 - Collins