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Education And Debate

Threat to social justice

BMJ 1997; 314 doi: (Published 22 February 1997) Cite this as: BMJ 1997;314:598
  1. Iona Heatha
  1. a Caversham Group Practice Kentish Town Health Centre London NW5 2AJ


    The speed of change in the NHS since 1990 has been furious and, with the recent spate of three white papers1 2 3 and a bill,4 there is no let up in sight. It is essential to continue to ask whether this change has been, and will be, for the better. This does not imply a facile assumption that all is well.5 We need always to be striving for improvement, and yet in the laudable desire to improve it is easy to lose sight of the fundamental aims of the health service and of its purpose within society. It is time to take stock of the current changes and analyse how far they take Britain towards the NHS to which it aspires.


    Health as a social goal

    At its inception the NHS was designed to provide personal health care as a publicly organised service. It was to include all citizens and was a deliberate move towards social justice.6 Despite all the recent changes the NHS remains explicitly committed to equity.7 However, it is now expected to operate in the context of a wider society which apparently has no such commitment. Increasing socioeconomic polarisation has let the rich become richer and more complacent and the poor become poorer and more marginalised. Homelessness, unemployment, and the prison population have all risen.8 Poverty, marginalisation, loss of autonomy, unemployment, and homelessness are all destructive of health and so make the task of the NHS more difficult. During the 1980s social divisions in Britain accelerated at a rate not matched for a sustained period by any other rich industrialised country.9 Yet responsibility for health has been shifted from society to the individual10 and we seem to have lost any notion of the pursuit of health as a social goal. …

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