Modern public health

Model answer

Older people are more likely to have long-term conditions such as heart disease, diabetes and dementia, often several at once, which need continuing treatment and expensive medicines. They also need more operations, such as hip replacements, and longer stays in hospital, and beds are blocked when there is not enough social care for them to go home.

Model answer

One similarity is that both were government responses to investigations that showed a link between poverty and ill-health. The 1848 Public Health Act followed Edwin Chadwick's Report on the Sanitary Condition of the Labouring Population of 1842, which showed that poor people in industrial towns died far younger than the rich - in Liverpool, labourers died on average at about 15 and the gentry at about 35 - and argued that preventing disease would reduce the cost of poor relief. The cholera epidemic of 1848 added urgency. In the same way, the Liberal reforms followed Booth's and Rowntree's surveys, which showed that about 30% of people in London and York lived in poverty, mainly because of low wages, sickness and old age, and the Boer War, which revealed that many recruits were unfit. In both cases evidence gathered by investigators made it harder for governments to argue that health was a purely private matter.

A second similarity is that both were limited, because of laissez-faire beliefs, cost and opposition. The 1848 Act created a General Board of Health, but towns only had to set up local boards of health if their death rate was above 23 per 1,000; many did nothing, and the Board was abolished in 1858. Opponents, nicknamed the 'dirty party', disliked central interference and higher rates. Similarly, the 1906 Act allowed councils to provide free school meals but did not force them to, old age pensions of 1908 went only to the over-70s on low incomes, and the National Insurance Act of 1911 did not cover workers' families or hospital treatment. The Liberals also faced opposition, from the House of Lords, which rejected the People's Budget in 1909, and from doctors who disliked National Insurance. In both cases the government took a step away from laissez-faire, but only a cautious one.

Model answer

Source A is useful because it sets out the founding principles of the NHS in the government's own words. It promises 'all medical, dental, and nursing care' - a comprehensive service - for 'everyone - rich or poor, man, woman or child', with 'no charges' and 'no insurance qualifications'. This was a huge change. Under the 1911 National Insurance scheme only insured workers had free GP treatment, not their wives and children, and many people avoided doctors because they could not afford the fees. The statement that it is paid for 'mainly as taxpayers' shows that the NHS was funded through taxation, and the insistence that it was 'not a charity' shows the government's wish to remove the shame associated with the Poor Law and charity hospitals.

The provenance adds to its usefulness. It is an official leaflet sent to every household, so it shows exactly what the government promised and how it wanted people to understand the new service. Its purpose was to explain how to use the NHS and to encourage people to register with a family doctor before 5 July 1948.

However, because it is government publicity designed to reassure, it presents only a positive picture. It says nothing about the strong opposition from the British Medical Association - in a 1948 poll most doctors voted against the scheme - or about the concessions Aneurin Bevan made to win them over, such as allowing consultants to keep private patients. It also cannot show what happened next: demand was enormous, with millions receiving dental treatment and glasses in the first year, costs were far higher than expected, and charges were soon introduced for dentures and spectacles in 1951 and prescriptions in 1952. The phrase 'except for a few special items' hints that the service was never entirely free.

Overall, Source A is very useful for the principles and public presentation of the NHS, but less useful for the political struggle behind its creation and its early problems.

Model answer

Individuals have played a vital role in improving public health, providing the evidence, ideas and leadership behind almost every major reform. However, individuals could rarely make a lasting difference on their own: their ideas only improved public health when government acted on them, often after war, crisis or new science had made action unavoidable.

In the medieval and early modern periods individuals had a limited impact. Abbots organised clean water supplies and drains in monasteries, and Edward III ordered London's streets to be cleaned during the Black Death in 1349, but these were isolated actions based on the belief that bad air caused disease. In 1662 John Graunt used the weekly Bills of Mortality to study patterns of death, an early example of using statistics, but this did not change public health at the time. Edward Jenner's smallpox vaccination of 1796 was a major breakthrough by one man, yet it only became universal when Parliament made it compulsory in 1853.

In the nineteenth century individuals were crucial in providing evidence. Edwin Chadwick's report of 1842 showed that the poor in towns died much younger than the rich and blamed filth and bad drainage. John Snow's investigation of the Broad Street pump in 1854 showed that cholera spread through contaminated water, and Joseph Bazalgette designed the sewers that cleaned up London. However, their limits show the importance of other factors. Chadwick's 1848 Act was weak and permissive, and he was removed from the Board of Health in 1854. Snow's ideas were not widely accepted in his lifetime, and it took Pasteur's germ theory and Koch's identification of the cholera germ in 1883 to prove him right. Bazalgette's sewers were only built because the Great Stink of 1858 forced Parliament to pay for them.

In the twentieth century individuals again provided ideas and leadership. Booth and Rowntree measured poverty, Lloyd George drove the Liberal reforms, Beveridge's report of 1942 set out a plan to defeat the five giants, and Aneurin Bevan created the NHS in 1948 despite opposition from doctors. Richard Doll and Austin Bradford Hill showed in 1950 that smoking caused lung cancer. Yet war created the conditions in which Beveridge's ideas became popular, Labour's victory in 1945 gave Bevan the power to act, and government provided the money and laws. Communication also mattered: Beveridge's report became a best-seller, and Snow's map and Chadwick's report persuaded others.

In conclusion, individuals have been very important, because without people like Chadwick, Snow, Beveridge and Bevan many reforms would have been delayed. But they were not the main factor. Their ideas only improved public health when government turned them into laws and paid for them, and government usually acted only when war, crisis, science or the votes of ordinary people pushed it. The greatest improvements came when determined individuals and government worked together.