Health and Health Policy

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1 SP3eC14 11/14/06 13:29 Page Heath and Heath Poicy Giian Pasca Contents n Introduction: heath, society, and socia poicy 408 Learning outcomes 408 n Heath and heath inequaities 409 Why study heath inequaities? 409 What are the key socia features of heath? 409 How can heath inequaities best be expained? 412 Medica care and heath 414 Individua behaviour v. socia circumstances? 415 Psycho-socia v. materia expanations 416 Poicies for heath and to reduce heath inequaities 417 n Heath poicy 418 The NHS in The NHS in the twenty-first century: contesting medica dominance? 419 The NHS in the twenty-first century: comprehensive care? 423 The NHS in the twenty-first century: from state finance to mixed economy? 424 The NHS in the twenty-first century: managing heathcare top down or bottom up? 430 A universa NHS in the twenty-first century: do other systems work better? 432 n Concusion 434 KEY LEGISLATION AND POLICY DOCUMENTS 435 REFERENCES 436 FURTHER READING 437 USEFUL WEBSITES 438 GLOSSARY 438 ESSAY QUESTIONS 440

2 SP3eC14 11/14/06 13:29 Page HEALTH AND HEALTH POLICY Introduction: heath, society, and socia poicy Heath is very unequa in Britain, reated to key variabes such as gender and race, and deepy patterned in particuar by socia cass. What ies behind these patterns of heath and disease in society? It is widey assumed that the Nationa Heath Service (NHS) produces heath, and that improving heath is a resut of improving medica care. But what impact does the Nationa Heath Service have on heath? The chapter wi start with a discussion of heath, to examine its socia features, and to underpin thinking about heath services and the needs they may be thought to address. By contrast to these patterns of inequaity in heath, the NHS appears to offer a mode of heathcare that is very egaitarian, offering care broady on the basis of need rather than abiity to pay, membership of scheme, or contribution record. Heath poicy in the UK rests on the Nationa Heath Service Act of 1946, the key pariamentary Act of the postwar Labour government. The NHS itsef began in Juy Heath debates even now revove around the decisions made at that time (see Box 14.1). These were to provide Box 14.1 The Nationa Heath Service 1948 Was set up to provide: a system of medica care to individuas; with ideas of comprehensive service covering a heath needs; free at the point of use, paid for by genera taxation; nationay owned and panned from the centre, through regiona and oca bodies; on a universa basis, equay to citizens. Socia, economic, and poitica change since 1948 has chaenged a these ideas and ideas. After its review of heath, the chapter wi take each of the key poicy decisions embedded in the 1946 Nationa Heath Service Act and ask how it has stood up to these changes. How fit is the NHS for the twenty-first century? And how does it compare with other systems of heath provision? Learning outcomes This chapter wi aow readers to: 1. outine the history of the NHS and the key principes that have informed its deveopment; 2. describe the broad patterns of heath and access to heath care in Britain and inequaities invoved; 3. outine a variety of theories that expain difference in heath and heath outcomes in Britain; 4. distinguish and evauate the main issues and positions in current debates about the finance and management of the Heath Service; 5. access key sources of information about the performance of the NHS.

3 SP3eC14 11/14/06 13:29 Page 409 HEALTH AND HEALTH POLICY 409 Heath and heath inequaities Instead of exposures to toxic materias and mechanica dangers, we are discovering the toxicity of socia circumstances and patterns of socia organisation (Wikinson 1996: 23). Why study heath inequaities? Why do heath inequaities matter? Three reasons can be put forward for making these a priority in an understanding of heath that is reevant to socia poicy: 1. The intrinsic significance of issues of ife and death, heath and disabiity, and how these are distributed in society. 2. Reationships of heath with socia variabes such as socia cass and race give cear evidence of the significance of society, socia science, and socia poicy to heath: heath does not beong whoy to medicine, however appropriate medicine might be to peope who are i. 3. A better understanding of the ways that heath reates to socia disadvantage may provide a basis for better poicy. Perhaps the most promising strategy for improving the nationa heath is to improve the heath of the most disadvantaged. What are the key socia features of heath? Socia cass, gender, and ethnicity can a be reated to peope s experience of heath, sickness, and disabiity. Powerfu evidence of these inequaities has been coected in the UK. A government-commissioned report by Sir Dougas Back (DHSS 1980) was particuary infuentia in coating, anaysing, and pubicizing evidence of heath inequaities. The Back report aso stimuated new research that has subsequenty eaborated the picture it drew of socia cass as a key determinant of peope s ife chances. More recenty, another government-commissioned report, Sir Dougas Acheson s Independent Inquiry into Inequaities in Heath, gathered and anaysed the data anew, for a New Labour government, in 1998 (Acheson 1998). Some measures of heath have improved dramaticay during the twentieth and twenty-first centuries. For exampe, ife expectancy has increased from around 45 years for men and 49 years for women in 1901 to over 76 and 80 years respectivey in 2003 (ONS 2002: chart 7.1, 2005: tabe 7.1). Infant mortaity rates have decined too: the chances of surviving the first year of ife have become much greater (Fig. 14.1). But peope have not shared equay in this improvement. For exampe, ife expectancy at birth for socia cass I, the professiona cass, increased amost six years over the ast quarter of the twentieth century, whie the rise for socia cass V, unskied manua workers, was ess than two years. The gap between these two casses stood at amost ten years by the end of the century (ONS 2002: 120). There is a wide gap in infant mortaity too, with the rate for socia cass V now doube that for socia cass I (Department of Heath 2002). These measures suggest that improving heath over the popuation as a whoe has been accompanied by widening differences between experience of heath, ife, and death in different socia groups. Very different sources of data, using very different concepts of heath and inequaity, show very simiar pictures of socia cass differences in heath, iness, and death. Tabe 14.1 shows

4 SP3eC14 11/14/06 13:29 Page HEALTH AND HEALTH POLICY Figure 14.1 The decine in infant mortaity, UK Source: Office for Nationa Statistics Socia Trends 2005: p 98, fig. 7.5 the socia cass differences in standardized mortaity rates, which are the measures generay used to compare death in different popuation groups. These show that for a causes of death, mortaity rates for unskied manua workers in were 806 per 100,000, compared with 280 for professiona workers, around two and a haf times higher. They aso show broady that each decrease in socia cass brings an increase in mortaity: a socia gradient that is widey found in data about heath and inequaity (Bartey 2004). The patterns are repicated across different diseases, with accidents, poisoning, and vioence showing the sharpest differences between socia casses. These figures aso show the sharpening of differences between socia casses over time, in every category of disease. A very different concept of heath is found in data from the Genera Househod Survey. This is a government-sponsored survey in which peope are asked about their experience of ong-standing iness and how much it imits their capacities in comparison with peope of their own age. These data show men cassified as routine manua reporting neary twice as much imiting ong-standing iness as men cassified as higher manageria or professiona or as arge empoyers, with a simiar pattern between women in different socia casses (ONS 2005: tabe 7.4). Gender differences in heath and death can be shown too. But they are ess marked than socia cass differences. Women tend to ive onger than men: there is currenty a four-year gap in ife expectancy (ONS 2005: tabe 7.1). But women experience poorer heath: onger ife brings a heavy burden of chronic sickness and disabiity in ater years, with 48 per cent of women of 75 and over experiencing imiting ong-standing iness according to current Genera Househod Survey data (ONS 2001: tabe 7.1). Ethnic differences have been ess we documented than cass or gender differences. Heath and mortaity differences between ethnic minority and white groups are strongy connected with their experience in Britain. Differences in socio-economic status of different ethnic minority groups, rather than bioogica or cutura differences, are the key to their different experiences of heath and death (ONS 1996).

5 SP3eC14 11/14/06 13:29 Page 411 HEALTH AND HEALTH POLICY 411 Tabe 14.1 European standardized mortaity rates, by socia cass, seected causes, men aged 20 64, Engand and Waes, seected years A causes Lung cancer rates per 100,000 rates per 100,000 Socia cass Year Socia cass Year I Professiona I Professiona II Manageria & Technica II Manageria & Technica III(N) Skied (non-manua) III(N) Skied (non-manua) III(M) Skied (manua) III(M) Skied (manua) IV Party skied IV Party skied V Unskied V Unskied Engand and Waes Engand and Waes Coronary heart disease Stroke rates per 100,000 rates per 100,000 Socia cass Year Socia cass Year I Professiona I Professiona II Manageria & Technica II Manageria & Technica III(N) Skied (non-manua) III(N) Skied (non-manua) III(M) Skied (manua) III(M) Skied (manua) IV Party skied IV Party skied V Unskied V Unskied Engand and Waes Engand and Waes Accidents, poisoning, vioence Suicide and undetermined injury rates per 100,000 rates per 100,000 Socia cass Year Socia cass Year I Professiona I Professiona II Manageria & Technica II Manageria & Technica III(N) Skied (non-manua) III(N) Skied (non-manua) III(M) Skied (manua) III(M) Skied (manua) IV Party skied IV Party skied V Unskied V Unskied Engand and Waes Engand and Waes Note: Socia Cass I Professiona (doctors, awyers) II Manageria and technica/intermediate (nurses, teachers), III Non-manua skied (cerks, cashiers), III Manua skied (carpenters, cooks), IV Party skied (guards, farm workers), V Unskied (buiding abourers, ceaners). Source: Acheson (1998) Independent Inquiry into Inequaities in Heath Report Tabes 1 and 2.

6 SP3eC14 11/14/06 13:29 Page HEALTH AND HEALTH POLICY Socia cass does not encapsuate a variations in heath. There are differences between men and women, between different ethnic groups, and even between areas the north south divide which cannot be whoy understood in terms of cass. But socia cass is a strong component of heath variations. This can be iustrated by thinking about the reationships between cass, gender, and race. For exampe, married women s heath varies according to their partners occupations. Despite a the changes in work and famiy, women s ifetime earnings are about haf men s, on average. Their iving standards are sti determined more by their partner or ack of one and by the househod income rather than their individua earnings: women s heath is thus ceary patterned by socia cass. Ethnic minorities heath fits socio-economic patterns, with those highest in socio-economic terms Chinese and African-Asian having the best heath experience, and poorer groups Pakistani, Bangadeshi, Caribbean having the worst experience of heath. Socia cass is the most powerfu predictor of heath. The environmenta movement has made us more aware of man-made risks, produced by nucear energy, pesticides, geneticay modified food. Such risks may appear to threaten us a. Do these deveoping environmenta threats change the traditiona reationship between poverty, i heath, and eary death, making us equay vunerabe? The evidence offered so far suggests not. Patterns of inequaity associated with socia cass are persistent, even increasing. The Department of Heath is targeting heath inequaity, and measuring progress since It recenty admitted no progress on its chosen heath inequaity measures infant mortaity and ife expectancy rather that the gaps between socia casses were sti widening up to 2004 (Department of Heath 2005: 8 9). How can heath inequaities best be expained? It is easy to think of reasons for socia inequaities in heath: perhaps peope have different patterns of smoking, eating, exercise, and these ead to socia cass differences? Perhaps heath services are unequay distributed? Perhaps the tobacco companies are too free to se damaging products? Perhaps unempoyment or ow benefits are the probem? It is much easier to propose theories than to decide which theories offer the most powerfu expanation. And expanation is a crucia foundation for understanding poicy and the faiure of poicy. Mapping factors that affect heath and may produce heath inequaities is a first step to unraveing a compex picture. Figure 14.2 offers a usefu aid to figuring out how different factors may fit into the picture. It fits individuas into their socia and environmenta context. In this figure, individuas with their age, sex, and genetic makeup are in the centre of the picture. A biomedica mode of heath and disease starts in the midde, with understanding disease processes in individuas. But individuas affect their own heath by their ifestye choices: asking why disease processes start might ead us to behavioura factors such as smoking and food choices. Asking why peope smoke or eat unheathy food might ead us to socia and community infuences. Asking why some socia groups are more ikey to smoke or eat unheathiy might ead us to ask about their iving and working conditions. But what ies behind iving and working conditions? Wider economic and poitica factors, such as nationa government poicies on benefits and asyum seekers, tobacco companies and markets, internationa agencies such as the Word Bank and Internationa Monetary Fund, are important in the distribution of resources that are significant to heath.

7 SP3eC14 11/14/06 13:29 Page 413 HEALTH AND HEALTH POLICY 413 Living and working conditions Genera Education socioeconomic, cutura, and environmenta conditions Work environment Socia and Individua community networks ifestye factors Unempoyment Water and sanitation Heath care services Agricuture and food production Age, sex, and constitutiona factors Housing Figure 14.2 The main determinants of heath Source: Acheson (1998), citing Dahgren and Whitehead (1991). The growing body of research has provided answers to some questions, but has aso raised new ones. Me Bartey cassifies current theories expaining the reationship between socia inequaity and heath into five broad categories. First is the materia expanation: individua income affects diet, housing quaity, exposure to poution, and work hazards. Second is the cutura/behavioura expanation, with differences in norms, beiefs, and vaues bringing different patterns of diet, smoking, and drinking. Third, the psycho-socia expanation proposes that differences in status, contro, and socia support at work or at home impact on physica heath. Fourth, a ife-course expanation proposes that heath and socia circumstances may affect each other over the ifespan: events in crucia periods before birth and in eary chidhood affect peope s abiity to maintain heath. Finay, a poitica economy expanation focuses on poitica processes and the distribution of power, which affect provision of services, the quaity of the environment, and socia reationships (Bartey 2004: 16). Four of the most important questions to arise out of the debates and research on heath and heath inequaities are addressed beow. The first question is about the reationship between heath and medica care. How important is unequa access to medica care and heath services in expaining differences in heath? But more debates in the heath iterature are about how much peope can choose better heath by improving their ifestyes or whether heath is argey determined by socia and economic circumstances. Coud we a equay improve our

8 SP3eC14 11/14/06 13:29 Page HEALTH AND HEALTH POLICY ife chances by foowing heath advice about smoking, exercise, and diet? How much are the choices and heath of peope in poorer socia circumstances constrained by factors over which they have no contro? A third set of questions in this next section is about the routes through which socia inequaity affects heath: shoud we see these as primariy materia or as psychosocia, mediated through peope s experience of reative deprivation? Finay are questions about poicy, about the poicies of UK governments and other nationa governments, and about what approaches to heath and heath inequaities may work best to improve heath and reduce heath inequaities. Medica care and heath First, how important is access to medica care in determining heath? McKeown s thesis is a focus for debates here (McKeown 1976). McKeown argued that the biggest improvements in heath in the UK took pace before there were effective medica interventions to address them. He investigated popuation data from the beginning of the registration of deaths in the 1830s, and examined the trends for the various causes of death that contributed to the major trend of decining mortaity over the nineteenth century. The exampe of TB is given in Fig The graph suggests that TB was aready in decine when records started to be coected, and shows a great reduction in deaths during the nineteenth and twentieth centuries, when no effective medica or pubic heath interventions were avaiabe. The first scientific understanding of TB came with the identification of the tuberce bacius in Effective drug Death rate (per miion) Tuberce bacius identified Chemotherapy B.C.G. vaccination Year Figure 14.3 Respiratory tubercuosis: death rates, Engand and Waes Source: McKeown (1976: 93). Reproduced by permission of Hodder Arnod.

9 SP3eC14 11/14/06 13:29 Page 415 HEALTH AND HEALTH POLICY 415 treatment came in the 1940s, and BCG vaccination in the 1950s. Thus, medica treatment and prevention have come rather ate to give assistance to a trend that was aready we estabished. McKeown showed that this pattern was repicated for most of the key diseases, and argued that improving heath had more to do with improving nutrition and iving standards than with medica interventions. McKeown may have understated the importance of pubic heath measures in the nation s improving heath measures such as improving water suppy and sanitation which were brought to Britain by the nineteenth-century pubic heath movements (these debates are discussed in more detai in Gray 2001b: ). We cannot read directy from this account of medicine in the nineteenth and twentieth centuries to the uses of medicine in the twenty-first. But these debates suggest that we shoud not take the importance of medicine to heath for granted. Access to medica care in the UK has not been entirey equaized, despite the NHS aim of deivering care in reation to need rather than abiity to pay (Department of Heath 1980). Access is more equa than in the more market-oriented service in the US no payment at the time of use, free prescriptions for ower-income groups and the more obvious obstaces to equa treatment are thus removed. There are ess obvious obstaces the cost of journeys and time off work. But if equa medica care coud produce equa heath we might expect to see greater equaity of heath in the UK than the statistics (Tabe 14.1) show at present. We might aso see more differences between different diseases. The same patterns of inequaity show for cancer, heart disease, and accidents: these suggest that something perhaps to do with iving conditions or socia inequaity ies behind the medica situation of peope dying from these diseases. These debates suggest that medicine shoud take its pace as one among many factors that infuence heath and surviva. Individua behaviour v. socia circumstances? Figure 14.2 may hep us to make sense of a compex set of factors and expanations and how they may fit together. But how can we assess the importance of individua behaviour and how do individua choices reate to socia circumstances? There is evidence for the impact of individua behaviour on heath, and on inequaities in heath. The cearest exampe is smoking, which brings risks of heart disease and cancer and is reated to socia circumstances, with peope in poorer circumstances more ikey to smoke. Exercise and heathy eating are aso reated to socioeconomic patterns, with betteroff peope more ikey to do reguar exercise and to eat a diet rich in fibre, fruit, and vegetabes that conforms to the government s heath advice. Shoud we bame poor peope s heath on their smoking and food choices? If so, how much of the bame for heath inequaities ies here? The Whiteha study has been tracking 18,000 government empoyees in London from top civi servants to caretakers and other manua workers since It offers evidence that smoking pays a part in differences between peope in different positions. But it aso shows that smoking and other known risk factors can ony account for a third of the difference in mortaity between the highest and owest grades (a more detaied account of this study and other studies on the expanation of heath inequaities is given in Gray 2001a: 240). Have poorer peope not understood the officia messages? There is research on peope s knowedge of heath advice. But studies have faied to show major differences in knowedge

10 SP3eC14 11/14/06 13:29 Page HEALTH AND HEALTH POLICY about food between different socio-economic groups. They do indicate that poor mothers have as much desire as better-off ones for heathy food for their chidren. And why have better-off peope responded more and more quicky to heath warnings? One key to these differences ies in the socia context. Peope cannot make choices that are whoy divorced from their environment. There are many obvious materia constraints on choices when peope ive in poor environments. Budgeting studies showing the difficuty of affording heathy food are reviewed by Spencer: Far from being abe to afford a heathy diet, many members of ow income famiies frequenty go without any food, heathy or unheathy. Chidren are ess ikey to go without food because they are protected by their mothers, but per cent of chidren said they had gone hungry in the preceding month because of ack of money (Spencer 1996: 156). Access to fresh food may be improving for those with cars, but car-based out-of-town shopping diminishes access for those who have to add bus fares to the price of food. Food choice may be hampered by the inabiity to risk waste. Low incomes may aso ead to disconnections of essentia services of water, gas, and eectricity, especiay since privatization, making peope vunerabe to cod, respiratory infections, and gastro-intestina infections. Damp housing, poor heating/insuation, traffic poution, and unsafe pay spaces for chidren are among the probems peope face trying to make a heathy environment for their chidren on ow incomes. These add up to formidabe materia imitations which are the socia and economic context for peope s heath choices. Higher incomes bring the choice of housing, avoiding many kinds of environmenta threat: traffic poution, nucear power stations, eectricity pyons, and agricutura chemicas. A major study of heath and socia circumstances aimed to compare the impact of heathy iving behaviours ifestyes over which peope have some contro and socia circumstances, over which they do not. Generay socia circumstances were found to be more powerfu expanations than persona behaviours. But the study aso found differences in what different socia groups coud achieve by heathy iving. Peope in good socia circumstances coud improve their heath by exercise, non-smoking, good diet. But peope in poor socia circumstances who made heathy choices did not gain as much benefit. There was a ower return from heathy choices, with heath overwhemed by factors they coud not contro. These findings may hep to expain why poorer peope are ess ikey to make heathy choices. If there is ess heath gain to be had from giving up smoking whie iving in a pouted area, then the rationa choice may be to make ess effort (Baxter 1990). Psycho-socia v. materia expanations Materia imitations have been a dominant part of accounts of heath inequaities in Britain, seen especiay by the Back report as the key expanation for unequa heath. But Wikinson argues that in deveoped societies such as Britain and the US, increasing iving standards have not increased heath: materia needs have been met, even for those in reative deprivation. But income reative to others marks socia status and position in society: the damage ies in unequa access to society more than in unequa access to materia resources. It is socia circumstances that are toxic, rather than materia ones. The damage of socia excusion creates psychoogica damage; smoking, acoho, drugs may be used as a damaging refuge from socia stress. Excusion from choice in a consumer society is damaging to sef-esteem. Comparisons with other societies, and between different states in the US, suggest that more equa societies and areas have ower death rates. If it is equaity

11 SP3eC14 11/14/06 13:29 Page 417 HEALTH AND HEALTH POLICY 417 that makes the difference, then it wi not be enough to wait for economic growth to improve the materia circumstances of peope in poverty: we woud need to redistribute resources, not simpy ift socio-economic eves for everyone (Wikinson 1996, 2005). In response, other researchers stress the continuing importance of objective materia factors in understanding heath inequaity in Britain and other deveoped societies: peope with ower incomes have to choose between socia and consumer spending, heathy diet and heathy accommodation (Bartey 2004). Poicies for heath and to reduce heath inequaities Approaches to understanding heath and heath inequaities are ceary connected to approaches to poicy. From the midde of the twentieth century, UK governments have tended to adopt strategies that first emphasize the distribution of medica care and second persuade peope to adopt heathy ifestyes. So the NHS was deveoped in the 1940s to give everyone access to treatment when they became sick. When ministers of heath argued for preventing i heath, they pubished Prevention and Heath: Everybody s Business (DHSS 1976), stressing peope s abiity to ook after themseves rather than the conditions that might damage heath and make heathy iving difficut. Research at the end of the twentieth century found that advice about heathy iving tended to increase heath inequaities: it was more readiy adopted by advantaged peope than by disadvantaged. These studies preferred poicies to improve the conditions under which peope ived, which woud improve heath directy and materiay and woud aso make it easier to adopt heathy ifestyes and to ower psychoogica stress. The recommendations from this iterature were, for exampe, for changes in housing poicy to produce quaity socia housing and reduce homeessness, raising chid benefits, and contro over tobacco advertising and sponsorship (Benzeva et a. 1995; Acheson 1998). Current UK government poicy is for: striking a new baance...a third way...inking individua and wider action (Department of Heath 1999). The emphasis on individuas improving their own heath remains, but governments now acknowedge the difficuties arising from poverty, poor housing, poution, ow educationa standards, unempoyment, and ow pay, as we as the ink between heath inequaity and socia inequaity. Poicies across this wide agenda have in practice been uneven, but increased chid benefits and chid tax credits are among the most significant poicy deveopments aimed at reducing poverty, socia inequaity, and the roots of heath inequaity. What is to be earnt from comparison with other countries? There is a strong reationship between heath measures such as infant mortaity and socio-economic deveopment. In genera, poverty goes with high infant mortaity rates (IMRs), which are the number of infant deaths during the first year of ife for every 1,000 births. In 1998, industriaized countries had an average IMR of six deaths per 1,000 births, whie ow-income countries had an average of 80 deaths. But there are poor countries with good records as we as rich countries with poor records. Evidence from those poorer countries that have achieved good heath suggests that going for economic growth aone may not be the best way. A UNICEF study chose ten high-achieving countries which had better heath than might be expected given their eves of nationa weath. These incuded Keraa State in India, with an IMR of seventeen, Cuba with seven, and Korea with five. The study emphasized the roe of pubic action and baanced economic growth, spending on basic services and on education, especiay women s education, and fairness

12 SP3eC14 11/14/06 13:29 Page HEALTH AND HEALTH POLICY in pubic spending. The overarching principe was that these countries did not give priority to achieving economic growth first, whie postponing socia deveopment (Mehrotra 2001). Comparison with countries more simiar to the UK in economic deveopment shows that the high-achieving countries in the European Union in terms of infant mortaity are Sweden and Finand, where deaths of chidren in the first year of ife in 2002 were 2.8 and 3 per 1,000 compared with an EU average of 4.5 (Eurostat 2004: 83). The poicy regimes of these highest achievers in Europe emphasize high eves of government intervention to reduce poverty and socia inequaity and to increase socia cohesion. The socia democratic regimes of Finand and Sweden may be contrasted with the US, where governments promote a ibera, freemarket-based approach to socia poicy. Here infant mortaity rates are higher, at seven per 1,000, despite high eves of economic deveopment and spending on heathcare. Heath poicy The NHS in 1948 Governments had aready intervened in heath and heath poicy, with pubic heath egisation in the nineteenth century, hospitas under the Poor Law, Nationa Heath Insurance eary in the twentieth century, and the Emergency Medica Service during the war. But the Second Word War brought a quaitative difference in assumptions about what governments coud and shoud do. It aso brought experience of the confusion of existing heath services and their inadequacy. Wiiam Beveridge was commissioned to make pans for socia security after the war. His pan for the nation s socia security assumed that there woud be comprehensive heath and rehabiitation services. The wartime government did indeed pan for a major extension of heath and medica services. But the first eection after the war brought a Labour government to power and Aneurin Bevan to the Ministry of Heath. The pans for reform acquired a more radica twist. It was aready assumed in the wartime pans that the new heath service woud be universa (avaiabe to a), comprehensive (incuding a services, both preventative and curative), and free (invoving no payment at the point of deivery) (Webster 1998: 22). Bevan s pan aso nationaized the hospitas and reorganized them into a system that woud be managed on a regiona basis. He aimed to universaize the best heath care, in contrast to a Poor Law, minimum-eve approach which favoured means-tested services for the poor, and which stigmatized those who used it. The service woud not ony be free at the point of use; it woud aso be funded mainy through genera taxation, rather than through insurance contributions. This meant that peope woud pay according to how much they coud afford, through taxes which Bevan beieved shoud be progressive, taking a higher proportion from higher earnings. Thus the NHS was buit on expicity egaitarian and redistributive principes. The NHS Act was passed in 1946 and the service inaugurated in 1948, with a eafet, The New Nationa Heath Service, on everyone s doormat at the start of the NHS, decaring: It wi provide you with a medica, denta, and nursing care. Everyone rich or poor, man, woman or chid can use it or any part of it. There are no charges, except for a few specia items. There are no insurance quaifications. But it is not a charity. You are a paying for it, mainy as taxpayers, and it wi reieve your money worries in time of iness. (quoted in Webster 1998: 24)

13 SP3eC14 11/14/06 13:29 Page 419 HEALTH AND HEALTH POLICY 419 Whie the egisation and estabishment of the NHS evoked fierce opposition, the service did in fact become popuar, for the freedom from medica bis and the anxiety that surrounded them. Not ony was the NHS popuar with the pubic, it aso gained oyaty and support from those who worked in it. More surprising, perhaps, is the degree of support it commanded from poiticians of different poitica coours, incuding Conservative governments with very different ideas from those of Bevan and the postwar Labour government. There have been many opportunities to move from the principes of the NHS, to introduce market-oriented systems of heathcare, but poiticians incuding Thatcher and Bair have continued to express broad oyaty to NHS ideas, if they have sometimes undermined them in practice. Bevan s proposas for the NHS can be seen as a mixture of audacity and prudence (Webster 1998: 15). If nationaizing the hospitas, universaizing the best, and funding through taxation were the audacious part, there were prudent eements in the NHS mixture. The NHS hed onto systems of administration that aready existed, making a tripartite system whose ack of coherent panning structure revisited ater heath ministers. The system was aso conservative in the services that it offered. The system took over hospitas and genera practitioner services and drew oca authority pubic heath services under its umbrea. The appointed day for starting the NHS brought no chaos of new systems, rather the same services as deivered the previous week, abeit to far more peope. Comprehensive heath and rehabiitation services dominated by medica services to individuas ay at the centre of this most coectivist system of heath service deivery. The next sections discuss what has become of these NHS principes (See Box 14.1) in practice over the neary sixty years since the service began. Socia, poitica, and economic changes during this period have made in many ways a different word. Famiy change has changed the assumptions we can make about how much we care for each other. Demographic change has brought a much oder popuation, with much heavier needs for heathcare. Consumerism brings patients who have more expectations and make more demands than their predecessors. Economic growth brings new resources. Gobaization brings more aggressive markets and ess confidence in interventions by nationa governments. Technoogica deveopment brings new possibiities, mainy more expensive possibiities, for a kinds of therapeutic intervention. How has the NHS responded to a these changes? And how we is it paced to adapt to the twenty-first century? Each of the foowing sections takes a key eement of the decisions that estabished the NHS and asks how it has fared and whether the principes of 1948 are sti recognizabe in the service that exists today. The chapter aso discusses the extent to which the principes of the NHS are reevant to heath and heathcare today. The NHS in the twenty-first century: contesting medica dominance? A biomedica mode of heath was the dominant mode at the beginning of the NHS, rooted in assumptions about the vaue of medica science in the treatment of individuas. Doctors authority was centra to the operation and management of hospitas, primary care, and community heath, incuding authority over other professionas and heath workers. Patients had itte roe in NHS decision-making, and were seen as having itte roe in their own heathcare. Aternative practices such as chiropractic or acupuncture were not avaiabe on every high street. As we have seen in earier sections, medicine s roe in heath has been chaenged by socia science. The dominance of medicine in the NHS has aso been contested from severa

14 SP3eC14 11/14/06 13:29 Page HEALTH AND HEALTH POLICY Box 14.2 The NHS now: a snapshot On a typica day in the NHS: Amost a miion peope visit their famiy doctor 130,000 go to the dentist for a check up 33,000 peope get the care they need in accident and emergency 8,000 peope are carried by NHS ambuances 1.5 miion prescriptions are dispensed 2,000 babies are deivered 25,000 operations are carried out incuding 320 heart operations and 125 kidney operations 30,000 peope receive a free eye test District nurses make 100,000 visits On a typica day in the NHS, there are: 90,000 doctors 300,000 nurses 150,000 heathcare assistants 22,000 midwives 13,500 radiographers 15,000 occupationa therapists 7,500 opticians 10,000 heath visitors 6,500 paramedics 90,000 porters, ceaners, and other support staff 11,000 pharmacists 19,000 physiotherapists 24,000 managers 105,000 practice staff in GP surgeries (Department of Heath 2000: 23) directions. We may ask whether patients have been turned into consumers, how much doctors authority has been contested by other professionas in the NHS as we as outside awyers for exampe and whether a more socia or environmenta mode has gained ground over the medica perspective. The deveopment of consumerism is a key socia change. If peope using heath services were once assumed to be patients, they may now have greater expectations of choice and contro as consumers of services. Patients groups have deveoped around chronic heath conditions, such as Parkinson s disease; and carers groups estabished to support those who have responsibiity in the community. These operate as foci of information for the many NHS users who have ong-term iness or impairment. The internet enhances the sharing of information

15 SP3eC14 11/14/06 13:29 Page 421 HEALTH AND HEALTH POLICY 421 for such groups and for individuas. Peope now frequenty choose aternative therapies rather than medicine or as we as medicine. The transformation of peope from patients into medica consumers is partia: iness makes peope vunerabe, and they may sti be seen as patients needing expertise and services. But these socia changes may be seen as bringing some eements of consumerism into reationships between doctors and patients, making the authority of medica decisions ess taken for granted. They have aso brought a new government agenda to the fore, with governments increasingy assuming that they can and shoud reform the NHS through patient choice. The deveopment of new socia movements has aso chaenged the assumptions on which medica authority rested. The women s movement and environmenta movement both deveoped during the ast quarter of the twentieth century. The green movement has drawn attention to the environmenta aspects of heath in contrast to the medica ones. The women s heath movement chaenged medicine s mascuinity and its reation to other professions, in particuar nursing and midwifery. Women were denied access to medica schoos in the nineteenth century, and not admitted equay with men unti neary the end of the twentieth. Nursing and midwifery were estabished as femae professions under medica authority. Gender divisions and power reations in heath work have been changed though not whoy transformed by the chaenges of the women s movement and egisation such as the Sex Discrimination Act (1975). Whie medicine s reation to other professions was under scrutiny, so was its reation to women as patients. Contraception, abortion, chidbirth, and new reproductive technoogies such as in vitro fertiization bring issues of persona autonomy into sharp focus. In the ast quarter of the twentieth century the women s movement fought for and to some extent achieved more autonomy for women in making decisions about whether, when, and how to have babies (Doya 1995; 1998). Medica authority has aso increasingy been chaenged in the courts, and in pubic inquiries. Litigation is increasingy seen as a way for individuas to gain redress when they are dissatisfied with the quaity of care. An increasingy open environment in which the media pay a key roe makes pubic issues of medica decisions which might earier have remained within the privacy of doctor patient reationships. Trust in medicine has been the subject of high-profie investigations into poor-quaity care, the abiity of individuas to expose it, and of heath systems to dea with it. The Kennedy Report into the Bristo Roya Infirmary and the case of Harod Shipman, a GP who is thought to have murdered over 200 patients, reveaed faiures of professiona sef-reguation. Changes in medica governance have foowed, bringing more reguation to NHS professionas (See Box 14.3, Ham 2004: 246). But whie medica authority has increasingy been chaenged, it has not died. The description of the Nationa Heath Service as a Nationa Iness Service or a Nationa Medica Service appears in every textbook. NHS spending has aways been dominated by spending on hospitas, with primary care and pubic heath agging behind. Heath ministers are aways centray concerned with hospita beds, waiting ists, and standards of care. If these concerns fitted with the 1948 ideas about the roe of medica science and treatment in heath, they may be seen as increasingy at odds with research and debates about the sources of heath and i heath at the end of the twentieth century. There have been attempts by recent governments to push pubic heath up the agenda. For exampe, the Word Heath Organization has encouraged governments to work on strategies to bring heath rather than treat disease. The UK government

16 SP3eC14 11/14/06 13:29 Page HEALTH AND HEALTH POLICY Box 14.3 Evidence-based medicine Growing interest in evidence-based medicine (EBM) can be seen as one response to these chaenges to medica science. Doctors and medica researchers want to ensure that cinica practice is informed by up-to-date research findings in order to preserve the credibiity of medicine. Managers have an interest in eiminating ineffective treatments, in order to make the budget go further and raise the quaity of care. Variations in the introduction and use of effective treatments are aso seen as inequitabe by patients and organizations representing patients. Systems to make sure that new research findings are impemented in cinica practice have deveoped from within cinica professions as we as from managers and governments. Cinica guideines have been produced by the professiona bodies, such as the Roya Coeges, setting out agreed standards. Government initiatives incude the Nationa Institute of Cinica Exceence, to produce guideines on cinica and cost effectiveness of services (Baggott 1998: 56 7). Box 14.4 NHS core principes, The NHS wi provide a universa service for a based on cinica need, not abiity to pay 2. The NHS wi provide a comprehensive range of services 3. The NHS wi shape its services around the needs and preferences of individua patients, their famiies, and their carers 4. The NHS wi respond to different needs of different popuations 5. The NHS wi work continuousy to improve quaity services and to minimize errors 6. The NHS wi support and vaue its staff 7. Pubic funds for heath care wi be devoted soey to NHS patients 8. The NHS wi work together with others to ensure a seamess service for patients 9. The NHS wi hep keep peope heathy and work to reduce heath inequaities 10. The NHS wi respect the confidentiaity of individua patients and provide open access to information about services, treatment and performance (Department of Heath 2000: 3 5) has responded with White Papers such as Saving Lives: Our Heathier Nation (DoH 1999) and a Minister with responsibiity for Pubic Heath. Ministers of Heath and government documents, even HM Treasury, now express the need for prevention and the need to reduce heath inequaities. The agenda has changed and broadened to incude a heath perspective as we as a medica one. The priorities in practice are more persistent. The NHS Pan set out ten core principes for the NHS (see Box 14.4) These incude providing a universa service based on cinica need (1), shaping the services around the needs and preferences of individua patients, their famiies, and their carers (3), and working to improve quaity services and minimize

17 SP3eC14 11/14/06 13:29 Page 423 HEALTH AND HEALTH POLICY 423 errors (5). The ninth principe is that The NHS wi hep keep peope heathy and work to reduce heath inequaities. But it is the ony principe that refects the agenda of socia change rather than the agenda of medica care (Department of Heath 2000: 3 5). The medica mode of heath may no onger be unchaenged. Consumerism, new socia movements, especiay the women s movement and the environmenta movement, growing itigation and pubic inquiries, socia science research: these diverse changes in society make medicine s authority and dominance now much more open to question than it was at the start of the NHS. But perhaps the statement of ideas in the NHS Pan, as we as practice on the ground, in particuar spending, suggest these have undermined trust in medicine and trust in doctors ess than may at first appear. The NHS in the twenty-first century: comprehensive care? If comprehensive care was part of the 1946 promise, deivering comprehensive heath services brings diemmas. The possibiities of medica intervention aready seem imitess, yet they grow a the time. We have not, as a society, decided to spend more than a fraction of our resources on heathcare, and few woud wish for a society and economy consumed by meeting heath needs. Increasing the resources spent on heathcare woud sove some probems, meet more needs, but woud not meet them a. Comprehensive care, meeting a heath needs, whether defined by professionas or by peope as patients, parents, sons or daughters of patients, may best be seen as an idea that cannot be reaized in practice. This idea may aso be seen as a measure against which to assess what the heath system does achieve and to compare it with others. These probems emerge internationay in different heath systems. The NHS commitment to comprehensive care, free at the time of use, poses the diemma in a particuar form in the UK, but every heath system generates debates about rationing and priorities. Prioritizing or rationing in fact takes pace. Some services have been withdrawn from the NHS in some areas cosmetic operations, infertiity treatment, ong-term care of the edery. Some groups of patients are ess ikey to receive services than others. There is evidence of discrimination against oder patients, or smokers may be deemed ess ikey to benefit from treatment. Mechanisms for rationing incude those set out in Box More demanding heath consumers make these issues more contentious. There was never a goden age in which a possibe heath needs were met, but patient questioning about priorities defined by professionas has probaby grown, as patients have become more ready to compain (Powe 1997: 107). The more overt debates about rationing that have ensued have Box 14.5 Rationing mechanisms waiting ists deterrence through charges defecting demand to other services diuting (e.g. using cheaper drugs) denia of some services (Hunter 1997: 22).

18 SP3eC14 11/14/06 13:29 Page HEALTH AND HEALTH POLICY raised the question about who shoud take such decisions and how. Community participation in deveoping priorities is one kind of soution, scientific cacuation of cost benefit or cost effectiveness another. Pubic participation in decision-making may bring advantages, but may aso tend to excude unpopuar groups/needs from heath treatment. The scientific approach cacuating costs and benefits is more defensibe in comparing different treatments for the same probem than in the infinitey compex probem of making systematic comparisons of costs and benefits across different heath needs. The question of which different treatment is most cost-effective for kidney disease can be addressed by accounting the costs of each in reation to the effectiveness of the treatment. But more fundamenta difficuties are raised by attempting to count the costs and benefits of drugs to ease mutipe scerosis against those of, say, infertiity treatments. Centra governments have aimed to diffuse the bame attaching to hard decisions, with professionas and heath authorities having in practice to decide questions such as whom to treat and how much, how much to spend, what to eave out. There is therefore variation around the country in these decisions and how they are made. The accusation of postcode ottery, in which treatment depends on where you ive, has brought efforts to bring more coherence to these decisions. NICE, the Nationa Institute for Cinica Exceence, was estabished in 1999 to provide patients, heath professionas and pubic with authoritative, robust and reiabe guidance on current best practice. Advice covers specific treatments, such as drugs, techniques and procedures, and cinica management of specific conditions (NICE 2002). NICE has reported on many contentious issues, such as the vaue of drug treatments for Azheimer s disease or mutipe scerosis. At first, guidance from NICE did not give patients the right to receive particuar treatments and was therefore an aid to more coherence in the professiona decision-making process rather than a new rationing agency. But in 2003 a decision to make NICE guidance mandatory reduced the discretion of Primary Care Trusts. Centra government aimed to increase consistency of decision-making, whie keeping responsibiity for decisions at oca eve (Ham 2004: 258). Pubic participation in NICE decisions has been joined through a Citizens Counci, with members of the genera pubic invited to discuss the questions on which NICE wi report. Box 14.6 on ong-term care offers iustration of these issues too. It shows a shift of care from heath authorities to socia care agencies and famiies which represents a shift in what is defined as heathcare. Whie the coverage of the NHS has in many ways widened over time to incude contraceptive services, and many drug treatments as they have become avaiabe there are some instances of a narrowing NHS remit. Routine eye examinations were no onger provided free from Termina care in hospices has deveoped party within the NHS, but depends for haf its cost on charitabe contributions (Poock 2005: 41). Dentistry has disappeared from the NHS in some areas, as dentists have refused to work under NHS contracts. In Engand and Waes, ong-term persona care has been excuded from the NHS, whie nursing needs are in principe covered. In Scotand both are treated as heath needs. The NHS in the twenty-first century: from state finance to mixed economy? One idea of the transformation of socia wefare provision in the UK during the atter part of the twentieth century is that it went from domination by the state to a more variegated mix of pubic, private, vountary, informa care a mixed economy of wefare. This section

19 SP3eC14 11/14/06 13:29 Page 425 HEALTH AND HEALTH POLICY 425 Box 14.6 Long-term care The poicy thread that binds a these officia attempts to promote community care has been a concern to shift the responsibiity for care from one agency to another from the NHS to oca authorities, from oca authorities to famiies (Lewis and Gennerster 1996: 2). The issue of ong-term care gives an exampe of changing poicy over what shoud be deemed to be heath needs and incuded as part of the heath service. Poicy has, in effect, changed, so that peope who might once have occupied hospita beds are now more ikey to be in nursing homes or residentia care, or in their own homes with support from community services. Care that woud have been free at the point of need within the NHS may be charged by socia services or nursing homes, or may be deivered by reatives without charge or count. The NHS inherited many ong-term beds from the Poor Law, warehouses for oder peope, some of whom needed hospita or nursing care, but many whose need was for an aternative pace to go. Movements in menta heath and geriatric medicine towards enabing peope to support themseves in their own homes as ong as possibe have contributed to this decine in ong-stay hospita beds. These deveopments have produced a wider range of community and smaer home provision and enriched the choice for peope needing ong-term care. But the desire to move costs, from fuy funded NHS beds to means-tested oca authority responsibiity, and from oca authority to unpaid care at home, has been a major power behind these changes. An eement of privatization has been invoved, as the government has fostered deveopment of an industry of care homes, as we as pushing costs onto famiies and unpaid carers. At the start of the NHS there were eeven hospita beds per 1,000 popuation. By 1989/1990 this had dropped to 6.2 per 1,000 and by 1999/2000 to 4.1 per 1,000 (Office of Heath Economics 2002). There are many reasons for this decine, which affects acute hospita beds as we as ongterm ones: the remaining beds are used much more intensivey, with quicker patient turnover, shorter hospita stay, and keyhoe surgery aowing patients home. But this huge decine in hospita beds, at a time of ageing popuation, gives some indication of the shift from NHS to oca authorities, and from oca authorities to famiies, described above by Lewis and Gennerster. A Roya Commission Long Term Care for the Edery was estabished by the new Labour government in 1997, and pubished a report in Scotand decided to foow its recommendations for a comprehensive package of care for peope with ong-term needs. But peope in Engand and Waes have been offered ess. There is a new agreement to incude the costs of nursing care within the NHS. But a new boundary has been created, which may be difficut to defend, between those whose needs are deemed to be for nursing and those whose needs are for persona care. Persona care remains outside the NHS. examines the mix of state and private finance in the UK, as we as the mix of state and famiy care, to ask how true this picture is in reation to heathcare. The question of the mixture of state and private finance has been entwined with the question of whether we spend too much or too itte on heath. Freedom from payment at the point of use gives rise to fears that peope wi demand too much. Right-wing critics have argued the need for a price mechanism to reguate demand: peope may want more at the

20 SP3eC14 11/14/06 13:29 Page HEALTH AND HEALTH POLICY point of need than they are prepared to pay for in taxes. Defenders of the NHS have argued for its efficiency in keeping costs down as we as its humanity in meeting needs. As an experimenta system, the NHS did overspend in its first two years, an experience which brought a ong period of stringency and constraint, with spending setting at around 3.5 per cent to 4.1 per cent of GDP during the first 25 years (Webster 1998: 30 4). Currenty, both pubic and poicy anaysts are more concerned about the ow eves of NHS spending and ow eves of service in comparison with other European countries (Fig 14.4). After ong periods in which governments have argued for sma government and ow taxation, United States Germany Switzerand France Canada Norway Begium Netherands EU15 Austraia Itay Sweden Denmark Iceand Greece Austria New Zeaand Portuga Japan Czech Repubic Spain Finand Hungary United Kingdom Poand Ireand Luxembourg (1997) Korea Mexico (1997) Turkey (1997) Pubic heath expenditure as % of GDP a Tota heath expenditure as % of GDP a 0% 2% 4% 6% 8% 10% 12% 14% 16% a Gross domestic product at market prices Figure 14.4 Tota heath expenditure as a percentage of GDP* in OECD countries Source: Office of Heath Economics (2002).

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