P1:OSO/OVY P2:OSO/OVY QC:OSO/OVY T1:OSO MHBK011-FM MHBK011-Taylor December30,2009 13:24 Key Debates in Health Care i P1:OSO/OVY P2:OSO/OVY QC:OSO/OVY T1:OSO MHBK011-FM MHBK011-Taylor December30,2009 13:24 ii P1:OSO/OVY P2:OSO/OVY QC:OSO/OVY T1:OSO MHBK011-FM MHBK011-Taylor December30,2009 13:24 Key Debates in Health Care Gary Taylor and Helen Hawley Open University Press iii P1:OSO/OVY P2:OSO/OVY QC:OSO/OVY T1:OSO MHBK011-FM MHBK011-Taylor December30,2009 13:24 OpenUniversityPress McGraw-HillEducation McGraw-HillHouse ShoppenhangersRoad Maidenhead Berkshire England SL62QL email:[email protected] worldwideweb:www.openup.co.uk andTwoPennPlaza,NewYork,NY10121-2289,USA Firstpublished2010 Copyright(cid:2)C GaryTaylorandHelenHawley2010 Allrightsreserved.Exceptforthequotationofshortpassagesforthepurposesof criticismandreview,nopartofthispublicationmaybereproduced,storedina retrievalsystem,ortransmitted,inanyformorbyanymeans,electronic, mechanical,photocopying,recordingorotherwise,withoutthepriorwritten permissionofthepublisheroralicencefromtheCopyrightLicensingAgency Limited.Detailsofsuchlicences(forreprographicreproduction)maybeobtained fromtheCopyrightLicensingAgencyLtdofSaffronHouse,6–10KirbyStreet, London,EC1N8TS. AcataloguerecordofthisbookisavailablefromtheBritishLibrary ISBN13:9780335223947(pb) 9780335223930(hb) ISBN10:033522394X(pb) 0335223931(hb) LibraryofCongressCataloging-in-PublicationData CIPdatahasbeenappliedfor Fictitousnamesofcompanies,products,people,charactersand/ordatathat maybeusedherein(incasestudiesorinexamples)arenotintendedto representanyrealindividual,company,product,orevent. TypesetbyAptaraInc.,India PrintedintheUKbyBellandBainLtd.,Glasgow. iv P1:OSO/OVY P2:OSO/OVY QC:OSO/OVY T1:OSO MHBK011-FM MHBK011-Taylor December30,2009 13:24 Contents Acknowledgements vii Introduction 1 1 Healthandhealthpolicy 7 PART1 THEPOLITICSOFPROVISION 2 Thestate 23 3 Theprivatesector 45 4 Thevoluntarysector 67 PART2 SETTINGPRIORITIES 5 Healthinequalities 85 6 Healthpromotion 103 7 Rationing 119 PART3 PATIENTSANDHEALTHPROFESSIONALS 8 Patients’rights 135 9 Professionalism 150 10 Conclusion 160 Bibliography 166 Index 187 v P1:OSO/OVY P2:OSO/OVY QC:OSO/OVY T1:OSO MHBK011-FM MHBK011-Taylor December30,2009 13:24 vi P1:OSO/OVY P2:OSO/OVY QC:OSO/OVY T1:OSO MHBK011-FM MHBK011-Taylor December30,2009 13:24 Acknowledgements Without the support and encouragement from friends, colleagues and our familiesthisbookwouldhavebeenimpossibletocomplete.Ourthanksgoin particular to Mike McManus for showing us the way to make the politics of healthaccessibleandrelevanttostudentstrainingtobehealthprofessionals. AlisonMcCamleyhasbeensupportivethroughoutandwebenefitdailyfrom herfriendship.WewouldalsoliketothankRachelCrookesatOpenUniversity Pressforstayingwithusthroughouttheprocessofwritingthebookandfor her sound advice, guidance and good humour. Our reviewers also made a significant contribution to the final shape of this book and we thank them for their comments. Some of the material contained in the book we have previouslyhadpublishedasjournalarticles.Wewouldliketothanktheeditor ofSocialPolicyJournalforpermissiontodrawuponmaterialfromTaylor,G.and Hawley,H.(2004)‘Theconstructionofargumentsontherationingofhealth care:perspectivesfromtheBritishbroadsheets’,SocialPolicyJournal,Volume3, Number3,pp.45–62.MaterialfromTaylor,G.andHawley,H.(2006)‘Health promotionandthefreedom oftheindividual’, HealthCare Analysis, Volume 14, Number 1, pp. 15–24 has been used with kind permission from Springer ScienceandBusinessMedia. Personal thanks and dedications MythanksgotoKarenfordiscussingmanyoftheissues,commentingupon thedraftchaptersandforkeepingourchildrenhappyandwell.Iwouldliketo dedicatemyworkinthisbooktomyoldfamilyGPDrCranstonofKingshurst Birmingham,whostayedupwithmenightafternightinthewinterof1963 andkeptmesafe. GaryTaylor My thanks go to Gavin for his support and understanding during my many hours at the computer and also my parents for their constant faith in my abilities.ThanksalsotothePublicHealthdepartmentofNHSRotherhamfor givingmeagoodgroundingandfrontlineexperienceofaholisticapproach tohealth. HelenHawley vii P1:OSO/OVY P2:OSO/OVY QC:OSO/OVY T1:OSO MHBK011-FM MHBK011-Taylor December30,2009 13:24 viii P1:OSO MHBK011-Intro MHBK011-Taylor December30,2009 13:25 Introduction Chapter Contents Keyquestions Thestructureofthechapters Thestructureofthebook Conclusion Thisbookisconcernedprimarilywithexploringkeydebatesontheroleofthe stateinthedirectionandprovisionofhealthcareandhowthesedebatesare reflected in the framing of health policy in a variety of countries. Although its main focus is on the development of health policy in Britain and in the UnitedStates,thebookalsotapsintoabroaderrangeofinternationalexam- ples.Inapproachingthesedebates,wehaveattemptedtocapturetheflavour ofatleastsomeoftheconflictandcontroversyoverhealthcareissues.Rather thanconcentrateuponstatisticalmaterialontheneedsofthevariouspopu- lationsortheextentofhealthcareprovisionindifferentcountries,wehave chosentoviewthedebatesinapoliticalcontextinthebeliefthatrecording conflictingviewsovertheaimsandprocessesofhealthcarewillhelpreadersto locatethemselvesinpoliticaltermsandtothinktheirwaythroughalternative approachestohealthcare.Whenwetalkaboutpolitics,however,wemeanit in the broadest of senses. We are interested in capturing and illustrating the importanceofdifferentworldviews.Althoughpoliticalpartiesandinfluential politicians will sometimes express these views, they are fortunately not the onlysourceofpoliticalin sight.Eachofushaswithinourverycoresomething thatcouldbedescribedaspolitical.Consider,forexample,theviewsthatwe have of each other. Can we trust each other to do what is right? Should the government help those who are unable to help themselves or should every personberesponsiblefortheirownwelfare?Thesearepoliticalquestions.In ordertoanswerthesequestions,itisnotnecessarytohaveadetailedknowl- edgeofpoliticalpartiesorthelatestgovernmentinitiative.Farmoreimportant is that we see ourselves in relation to others, as members of the community andascitizenswitharangeofrightsandresponsibilities. Key questions Sowhatkindofquestionsshouldweconcernourselveswith?Theanswerto this depends upon who are the main participants, stakeholders or actors. If 1 P1:OSO MHBK011-Intro MHBK011-Taylor December30,2009 13:25 2 KEYDEBATESINHEALTHCARE we were interested in the internal workings of the National Health Service (NHS) then we would need to identify where power resides in the service, whichgroupsmakethedecisionsandhowthesedecisionsareimplemented. Wehavechosen,however,tolookintheoppositedirection.Ratherthanlook- inginwardsatanorganizationliketheNHS,wehavechosentolookatsociety. Thequestionsweaskareframedsothatwecanexplorewaystounderstand, manageandimprovethehealthofeachofus.Inthisbook,wewillbelooking atsuchquestionsas: (cid:2) Whoisresponsibleforthehealthofthenation? (cid:2) Doesthisresponsibilityliewitheachindividualorishealthasocial conditionforwhichgovernmentsshouldassumesomeresponsibility? (cid:2) Should the state play a major role in the direction and provision of healthcareorshouldwerelyrathermoreupontheprivatesectorand upontheincreasinglyinfluentialvoluntarysector? (cid:2) Isthereafairwaytorationhealthcare? (cid:2) Towhatextentshouldthestatetacklehealthinequalities? (cid:2) Ispreventionbetterthancure? (cid:2) Whatkindofrightsshouldpatientshave? (cid:2) Whatistheimpactofprofessionalismupontherelationshipsbetween differentsectionsofthehealthcaresystem? Thesekeyquestionswillprovideuswithaseriesofwindowsintothepolitics ofhealthpolicy. The structure of the book This book is intended not as a history of health care but as an exploration of ideas and policies on key problems facing modern health care systems. It beginswithanexaminationofdifferentmodelsofhealthandthenmoveson toconsidereightmaindebatesonissuesrangingfromtheroleofthestatein theprovisionofhealthcaretotherightsofpatients.Thesedebateshavebeen selectedinthehopethattheywillbeofsomerelevancetopeopletrainingfor workinhealthcare.Ratherthangointodetailonsomeoftheissuesthatmight concernhealthcaremanagers(suchasthemechanismsusedtoauditquality ofprovision)wehaveconcentratedonthoseissuesthatmightresonatemore withfront-linehealthcareworkers.Thesedebatesinturnaredividedintothe threemainpartsofthebook: (cid:2) thepoliticsofprovision; (cid:2) settingpriorities; (cid:2) patientsandhealthprofessionals.