Health Care in the UK

1
Health Care in the UK

• Health care and the social settlement
• When the NHS was launched by Beveridge it was a
  celebration of a free and universal approach
  based on the egalitarian and collectivist
  principles of the post war Labour government.

2
Early Foundations and Principles

• Duality of images dominated the perception of the
  Health Service
• Heroic/authoritarian doctor
• Dutiful/wonderful nurse
• Stoical/Deferential patient.
• These images reflected dominant representations
  of the NHS and the reality of a health care
  system still influenced by inequalities in class,
  gender and race relationships

3
Early Foundations and Principles

• During the early days of the social settlement
• Doctors usually middle class backgrounds and
  usually male .
• Nurses usually of working class origin
• Patients were also usually working class
• Harmony reflected collective commitment to
  provision of public health care.

4
Early Foundations and Principles

• During early 1960s changes in the social
  fabric of society were reflected in the dynamics
  of the health care system.
• Doctors were recruited from a broader range of
  social groups and included more women.
• Nursing became a more diverse profession. From
  1950s shortage of UK nurses led to recruitment
  of nurses from Ireland and the Caribbean and
  other former colonies.
• Patients changed to as memory of pre-war poverty
  and post-war austerity faded living standards
  rose and higher standards of health care were
  demanded.
• In place of consensus there was increasing
  conflict.

5
Early Foundations and Principles

• By mid 1990s old images were as unsustainable as
  old assumptions about class, gender and race.
• The patient became a customer demanding value for
  money.
• However in reality structural inequalities
  remained and had a powerful and pervasive impact
  on the delivery of health care in the UK

6
Industrial Militancy amongst Health Workers

• During 1970s industrial action became fairly
  common in the health services.
• Even Doctors were becoming militant.
• June 1974 hospital workers at Londons Charing
  Cross Hospital took industrial action, not for
  more pay but in ideological campaign to force
  private pay beds out NHS hospitals

7
Industrial Militancy amongst Health Workers

• Royal Free Hospital - feminists challenging the
  rights of traditional male obstetricians to
  dictate how women should have their babies
  delivered.
• Similar protests took place in Scotland, Wales
  and Northern Ireland.

8
Crises with the NHS and the public expenditure
crises of 1976-1977

• Labour governments imposition of cash-limited
  budgets on the health authorities and strict wage
  controls on health service workers was largely
  due to the public expenditure crises of 1976-77.
• RAWP Resources Allocation Working Party
• Wave of hospital and bed closures,
• Protests led to the Winter of Discontent
  1978-1979.

9
Crises with the NHS in the 1980s

• Militancy continued in the 1980s and the
  government tried to suppress the Black Report
• This report was prepared by a prestigious
  committee chaired by Sir Douglas Black the
  report explicitly blamed the government for
  growing inequalities and social differentials in
  health standards and demanded more resources for
  a wide range of social services to tackle these
  inequalities.

10
Crises with the NHS in the 1980s

• Nurses and ambulance workers went on strike at
  this time over pay levels they were supported in
  their cause by the National Union of Mineworkers.
• Public opinion was firmly behind the nurses and
  ambulance workers however in December 1982
  Margaret Thatchers government forced them to
  accept a pay rise well below the rate of
  inflantion.

11
The Restructuring of the NHS in the 1980s

• Compulsory Competitive tendering for hospital
  cleaning and laundry services.
• This often resulted in redundancies and pay cuts
  and weakened the unions
• Managerial reforms imposed by Sir Roy Griffiths
  attempt to introduce commercial efficiency
  opposed by the medical profession (Hunter, 1994)

12
The Restructuring of the NHS in the 1980s
Curtailing the Powers of Doctors

• Imposition in 1984 limited list of drugs
  available on prescription this was against
  concerted resistance from doctors and drug
  companies.
• This was a watershed in the relations between
  the government and the BMA.

13
The Restructuring of the Welfare State

• Central Policy Review Staff think tank for
  Conservative Government
• Proposed series of radical reforms of the welfare
  state which included replacing NHS with a system
  funded through private health insurance.

14
The Restructuring of the Welfare State and the
NHS

• The government were not able to carry this
  through because of public opposition however over
  the next few years the imperatives of the
  market-place were brought to bear on the NHS.
• The Labour party shifted to the right during this
  period under the leadership of Neil Kinnock and
  policies of new realism were to be adopted.
  Labour had abandoned the social democratic
  consensus and moved away from measures of state
  intervention and public expenditure and towards
  individual initiative and private and voluntary
  provision.

15
The end of the social democratic consensus

• Who made the following statements?
• Do you know there are still people in Britain
  who believe in consensus? I regard them as
  quislings, traitors
• I have always regarded it as part of my job
  and please dont think of it in an arrogant way
  to kill socialism in Britain

16
The restructuring of Health care and the
Introduction of the internal market for health.

• Yes youre right Margaret Thatcher in 1979 and
  1984 respectively.
• The statements heralded a major re-structuring of
  health care in the UK
• 1989 White Paper Working for Patients
• 1990 Community Care Act
• Both implemented in 1991.
• The introduction of the internal market into the
  NHS

17
The Introduction of the Internal Market into the
Health Care System

• Once you say we want the good features of
  competition, with independent bodies competing,
  in a service that remains publicly funded then
  the internal market just falls out as a
  conclusion
• (David Willetts, Conservative policy advisor,
  quoted in Timmins, 995, p.433)

18
The Introduction of the Internal Market into the
Health Care System

• 1980s decade of financial austerity for the
  NHS
• Rate of growth in public spending on the NHS was
  significantly lower in the 1980s than it had
  been in the 1970s.
• The demand of health care had grown much faster
  than the resources supplied to it even though
  some improvement had been made with regard to the
  efficiency of the service.
• By the end of the 1980s nearly one million
  people were on hospital waiting lists.

19
The Introduction of the Internal Market into the
Health Care System

• In 1988 Margaret Thatcher launched
• The White Paper Working for Patients
• The most far reaching reform of the National
  Health Service in its forty year history
• (Department of Health 1989)
• Three key reforms
• Internal market
• The purchaser provider split
• Self-governing trusts.

20
The Introduction of the Internal Market into the
Health Care System

• GPs were to be given their own budgets ( and be
  known as fundholders) to purchase services from
  hospital trusts on behalf of patients
• Proposals
• Measures to improve performance and efficiency
• Enhance managerial autonomy
• The voice of the customer (choice agenda)
• This would advantage the more articulate middle
  class groups in society.

21
The Introduction of the Internal Market into the
Health Care System

• Medical profession campaigned against the
  internal market.
• Prominent GPs began to opt for fundholding and
  senior consultants opted for hospital trusts.
• Resistance was crushed and by 1996 hospital
  trusts were firmly established and half of the
  population was registering with a fundholding GP

22
A new consensus primary care-led trusts.

• Logic of the internal market
• GPs were encouraged to ration services to
  patients and market discipline was imposed on
  hospital professionals
• The aim is for decisions about purchasing and
  providing health care to be taken as close to the
  patient as possible by GPs working closely with
  patients through promary health care teams (NHS
  Executive, 1994,p.5)

23
A new consensus primary care-led trusts.

• The New NHS White Paper 1997
• Published by the New Labour Government six months
  later.
• The White Paper proclaimed that the internal
  market would be abolished and GP fundholding
  replaced however as Glennerster and Le Grand
  noted
• the key elements of the old internal market will
  be retained and the proposed GP- led
  commisiioning amounted to an extension of
  fundholding (The Guardian 10th December 1997)

24
The New NHS

• A central role for primary care groups in
  commissioning health care for local populations
  of 100,00
• Partipation by GPs was now compulsory and
  stricter mechanisms of monitoring and control
  were put in place. This made reform more
  authoritarian than ever before.
• The Institute of Fiscal Studies argued that
• the squeeze was more stringent than anything
  the Conservatives managed in their 18 years of
  power (The Guardian, 4 July 1997)

25
The New Public Health and the New Patient

• Restructuring of welfare reconstitution of the
  welfare subject
• Relationship between individuals in society and
  agencies responsible for delivering health care
  and other forms of welfare delivery.
• New welfare discourses emerged at this time.

26
1991 The Health of the Nation

• The Health of the Nation White Paper in 1991
  emphasises prevention rather than cure and health
  promotion rather that treatment of disease
• Targets were coronary heart disease and stroke
  particular cancers (breast, cervix, lung, skin)
  mental illness (particularly suicide) HIV/AIDS

27
1991 The Health of the Nation

• Risk factor Target in four areas were
  identified
• Smoking, diet and nutrition, blood pressure, and
  HIV transmission by injecting drugs.
• Policies for a new generation of public health
  doctors advocated whole population approach
  prevention of diseases.
• Individual responsibility

28
The Managerial Imperativemanaged competition

• From consensus management to executive direction
• Power was centralised to push through the reform
  agenda
• Her aim was to bring entrepreneurial vigour and
  competition to the public sector

29
The Managerial Imperativeaccountability and
decentralization

• Making doctors cost-conscious
• Previously doctors had enjoyed great power and
  autonomy in the allocation of NHS resources.
• There were distinct variations in practice across
  the UK
• Recipients of funds were to be held to account at
  local level by setting targets and doctors and
  health professionals generally were made more
  accountable.

30
The Managerial ImperativeAudit

• Medical professionals in conflict with new
  mangers as resources become less and less
  available.
• Ensuring effective treatments. Rationing of
  resources meant that treatments would need to be
  evaluated more adequately in terms of their
  efficacy. Outcomes and inputs were measured in
  terms of quality performance and effectiveness

31
The Managerial Imperative

• Maximizing the potential of human resources
• Promoting incentives through performance related
  pay re-inventing structures
• the flexible firm
• Moves toward local pay bargaining.

32
The Managerial Imperative

• From patient to customer
• Patients rights need to consult and involve
  patients choice agenda
• Ability to make complaints. As Mary Langan has
  argued resource constraints have let to more
  restricted choices for hospital referrals than in
  the past.
• Also range of drugs available is more limited.
  This has been evidenced in recent controversy
  over the breast cancer drug Herceptin.

33
Legislation
34
Legislation

• White Papers
• Recently Proposed Legislation

35
Health and Housing

• The relationship between attributes of housing
  and health and how this impacts upon wider
  theoretical explanations of the relationship
  between social inequality and health.

36
Explanations of social class differences in Health

• Artefact
• Social Selection
• Behavioural/cultural
• Materialistic

37
Explanations of social class differences in
Health Artefact Theory

• Questions legitimacy of relationship between
  social class and health
• Questions the way in which the statistics were
  collected, analysed and calculated
• Variations in diagnosis, certification and
  classification are all examples of how the
  production of statistics may be limited to
  support strong conclusions.

38
Artefact Theory

• Way in which mortality rates, for example, were
  calculated from two key sourcesdeath
  certificates and census.
• It is possible that the information on each form
  could be described differently.

39
Behavioural/cultural theories

• Cultural aspects associated with different social
  groupings are have more impact on health than
  material situation
• Theory assumes that people from particular
  socio-economic groups choose negative health
  behaviours and that this is culturally defined.

40
Materialist theories

• Describe health as being impacted upon by
  material circumstances and situational
  constraints
• The Black Report judged that Materialist
  explanations were the most important in
  accounting for social class differences in
  health (Blane D., 1997 Inequalities in social
  class in Scambler (ed) Sociology as applied to
  medicine Saunders London.

41
Social Selection

• Genetic factors hold key significance in terms of
  defining the relationship between individuals and
  their health.
• Some individuals are pre-disposed to specific
  illness as a result of hereditary factors

42
The relationship between housing and ill- health
A biomedical view

• Causing of specific attributes of housing and ill
  health has been established in some cases
• e.g. Health effects of radon - lung cancer an
• lead piping -impaired cognitive
  development in children

43
The relationship between housing and ill- health
A biomedical view

• The prevalence of illness appears to increase
  with the level of dampness
• e.g. A recent study in Glasgow demonstrated the
  link between dampness and asthma(Williamson, I,
  Martin C, McGill G, Monie R, Fennerty A (1997)
• The study found that asthmatic are two to three
  times more likely to live in a damp home. This
  relationship persisted after controlling for
  socio-economic variables.

44
Theoretical issues arising from this study

• The link between asthma and dampness suggests
  that a material explanation for ill health in
  these cases is valid. Importantly the direct
  nature of the relationship between physical
  environment and this medical condition is clear.
  Qualifying this it was found that in the case of
  asthma, differences in income and other
  confounding variables did not seem to confound
  the relationship between damp housing and
  ill-health.

45
The relationship between housing and health a
social model approach

• Previous research has indicated that location and
  density of housing as well as living conditions
  may have a significant impact on psychological
  and emotional well-being. Thus overcrowding and
  living in high rise flats is associated with
  psychological symptoms including depression.
  Here the influence of other confounding social
  and economic problems is agreed to be strong.
• This re-inforces the materialist explanation of
  the relationship between social inequality and
  ill health

46
Homelessness and health

• Poor health causes homelessness
• Poor health is caused by homelessness
• Poor health is exacerbated by homelessness
• Theoretical implications of these causal links
  In one sense materialist explanations are
  re-inforced, however it is important to consider
  the life-course factors involved here in that
  poor-health can of itself cause homelessness and
  researchers need to take account of variations in
  the causes of this initial poor-health.

47
Health Futures
Medicine and The State The Socialisation of
Medicine an the Medicalization of Society
48
Providing Health Care in a Modern State

• Cure or Prevention
• Bio-medical approach has produced a system of
  health care in Britain that concentrates on
  medical intervention after the onset of illness
• These medical interventions have not been
  universally available and some groups in society
  do benefit more than others (Porter 1997)

49
Health Care in Modern Britain

• Delivery of Health Care in Britain has been beset
  with problems arising from
• the structure of the system
• the absence of an overall coherent strategy
• difficulties in exerting control or imposing
  direction
• difficulties arising from inter-professional
  relationships.

50
Health Care in Modern Britain

• Can we continue to provide health care which
  attempts to translate founding principles into
  practice?
• Universality, comprehensiveness and Equity
  (Powell 1997 Klein 1995)

51
Providing solutions

• Sector Reform
• Shift away from public towards voluntary and
  commercial sectors while attempting to make
  public sector operate more commercially.
• These processes were prompted by financial
  concerns regarding economy and efficiency

52
Providing solutions

• Promoting a greater reliance on primary care
• challenging the centrality of the expensive
  curative hospital approach in favour of the
  (cheaper) community approach
• focussing on health promotion and illness
  prevention
• founded on a social model of health care
  informed by the principles of the Declaration of
  Alma Ata (1978)

53
Providing solutions

• focussing on health promotion and illness
  prevention
• founded on a social model of health care
  informed by the principles of the Declaration of
  Alma Ata (1978)
• Elaborated on in subsequent WHO initiatives

54
Providing solutions

• Towards a new public health agenda
• Exponents of the social model of health care have
  legitimized the concept of community
  participation in setting the health care agenda,
  designing services and models of delivery and in
  holding health care professionals accountable.

55
Providing solutions

• Applying holistic set of principles to the health
  care system
• primary and secondary
• preventative or curative
• hospital based on located in community settings.

56
The 1997 White Paper

• The New NHS The third way . . . .a new model
  for a new century.
• There will be neither a return to the old
  centralized command and control systems of the
  1970s nor a continuation of the divisive
  internal market system of 1990s (Department of
  Health 1997b,para 2.1).

57
The 1997 White Paper
58
Health Care in Modern Britain

• Challenges
• An ageing population
• changing patterns of disease
• fluctuating economic fortunes
• concern over public spending
• New political agendas and ideologies