Perspectives in Health Care PDF
Preview Perspectives in Health Care
Perspectives in Health Care Perspectives in Health Care Edited by Nancy North and Yvonne Bradshaw F oreword by Jo an Higgins -- MACMILLAN Selection, editorial matter, Introduction and Conclusion © Nancy North and Yvonne Bradshaw 1997 Chapters (in order) © Yvonne Bradshaw; Nancy North; lan Kendall; lan Kendall and Graham Moon; Rosemary Gillespie; Graham Moon; Nancy North; John Mohan, 1997 Foreword © Joan Higgins 1997 . All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No paragraph of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London WIP 9HE. Any person who does any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages. First published 1997 by MACMILLAN PRESS L TD Houndmills, Basingstoke, Hampshire RG21 6XS and London Companies and representatives throughout the world ISBN 978-0-333-61465-5 ISBN 978-1-349-13469-4 (eBook) DOI 10.1007/978-1-349-13469-4 A catalogue record for this book is available from the British Library. This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. 10 9 8 7 6 5 4 3 2 1 07 06 05 04 03 02 01 00 99 98 Copy-edited and typeset by Povey-Edmondson Tavistock and Rochdale, England For Rebecca, Alice and Ben; Holly and Tom Contents Foreword Vlli List oj Contributors x Introduction Xl Perspectives Yvonne Bradshaw 2 Policy Processes 23 Nancy North 3 Health Care Models and Welfa re Themes 47 Ian Kendall 4 Individual Responsibility or Citizen Rights? 67 Ian Kendall and Graham Moon 5 Managers and Professionals 84 Rosemary Gillespie 6 Markets and Choice 110 Graham Moon 7 Consumers, Service Users or Citizens? 130 Nancy North 8 Market Testing, Market Failure: Health Service Privatisation in Theory and Practice, 1979-96 150 John Mohan 9 Conclusion 170 Nancy North and Yvonne Bradshaw Index 187 Vll Foreword When Iain Macleod observed in 1958 that 'The National Health Service, with the exception of recurring spasms about charges, is out of party politics', few would have disagreed that the debate about principles and values was behind us (quoted in R. Klein, The New Politics oJ the NHS, Longman, 1995, p. 29). After intense struggle to establish the NHS and a decade of structural reform, it did appear, by the late 1950s, that the fundamental questions about how to finance and organise the new national service had all been resolved. A broader analysis of public policies for health over the last century, however, demonstrates that major debates about ideology and prac tice both preceded the relative calm of the 1950s and persist to the present day. Although the foreign observer has co me to see the British NHS as an immovable rock, around which the turbulent waters of social, economic and political change may be swirling, the recent threats to its funding and structure cast doubt upon its stability and future. The chapters in this book illustrate clearly that the NHS, as conceived in 1948, cannot be taken for gran ted and that many critical challenges remain. What is striking, in the discussion which follows, is the endurance in British health policy of some traditional themes and questions. Who should provide health care (families or the state, the individual or the collective, the local authority or the health service)? How should it be organised (through the market or the state, locally or centrally)? Who should determine its character (clinicians, users, managers or politicians)? How can it be funded (through taxation, insurance or charges)? And according to what principles shoul1 it be distributed (eq uity, equality, desert, clinical need, prognosis, ability to pay)? As the authors demonstrate, few, if any, of these questions can be regarded as answered for all time. Although there may be some doubt about the lasting impact ofthe post-1979 NHS 'reforms', over the longer term the real challenges which they posed to post-war social democratic welfa re values cannot be overlooked. Vlll Foreword IX As this book shows, the further we move away from some of the 'great events' in British health poliey (the introduetion of national insuranee, the birth of the NHS, the ereation of an internal market), the more we are able to analyse these developments with darity. Changes whieh were deseribed, in their day, as 'inevitable develop ments' or 'rational responses' to new eireumstanees ean, with hind sight, be understood as the outeome of eomplex soeial proeesses whieh were neither inevitable not rational. The strength of this book lies in its interweaving of theoretieal insight, analytieal perspeetive and historieal fact. All these elements are eentral to our understanding of health policy in the past and its prospeets in the future. ]OAN HIGGINS Professor 01 Health Policy University 01 Manchester List of Contributors Yvonne Bradshaw is Lecturer in Social Policy at the University of Portsmouth. Her main research interests are in so ci al policy and administration and social security policies. Previous publications have focused on the interface between health care and the criminal justice system. RoselDary Gillespie is Lecturer in Sociology at the University of Portsmouth. She has published in the area of women and the body and is currently researching voluntary childlessness and wornen. Ian Kendall is Professor of Social Policy at the University of Ports mouth. He has written on several aspects of health policy with both Graham Moon and John Carrier, including community care, com plaints procedures and mental health services. John Mohan is Reader in Geography, University ofPortsmouth. He is the author of ANational Health Service? The Restructuring of Health Gare in Britain since 1979 (Macmillan), editor of The Political Geography 01 Gontemporary Britain (Macmillan) and the author of numerous articles and book chapters on health care policy. He is currently researching the historie al geography of the British voluntary hospital system and the rise and fall of regionalism and regional planning of the hospital services. GrahalD Moon is Professor of Health Services Research at the University ofPortsmouth. He has research interests in the geography of health-related behaviour in medico-Iegal studies and in health policy reform with particular reference to primary care and to developments in East-Central Europe. Nancy North is Lecturer in Health Policy at the U niversity of Portsmouth. Previous publications have focused on internal markets and professional and consumer interests. Her current research inter ests are in health care commissioning, consumerism and primary health care. x Introduction The National Health Service, together with all public services, has come under intense scrutiny and has been judged, by Conservative governments since 1979, as inefficient, wasteful and unresponsive to the needs of consumers. There are many aspects to the Conservatives' reform agenda for the health service, as the following chapters identify, but the general thrust of reform has been the pursuit of better value for (public) money within a quasi-market framework. The principles wh ich had underpinned the post-war welfa re con sensus came under sustained attack after the general election of 1979. The language of value for money, choice and self-help superseded that of equality, universalism and state provision. The health service was portrayed as a bureaucratised monopoly which was profligate in its use of taxpayers' money, with little interest in meeting the genuine needs of patients. Evaluation and analysis ofhealth care policy takes many forms and the way in which the New Right-influenced Conservative govern ments approach this will differ from that of advocates of alternative, competing perspectives. The differences between perspectives, the problems they highlight and the concomitant policy proposals are the themes pursued in Chapter I of this volume. Policy making is not a straightforward process of decision making and implementation. There are many complexities involved in this process and, as Chapter 2 demonstrates, a range oftheories about how this process takes place. Even when adecision on policy has been reached, this can be changed during the process ofimplementation, a factor which is also discussed within this chapter. What health care policy should achieve, the way it should be provided and funded, lead to different models of health care provision being advocated. These models of health care, the way in which one model has been superseded by another in the past and the implications of this form the substance of Chapter 3. Xl
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