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Flashcards in health and health policy Deck (34)
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definition of health
positive and negative

“a state of complete physical, mental and social wellbeing”.

the absence of symptoms or disease
assumes that good health is the normal human condition


What is health policy ?
What are the aims of health policy ?

Policies primarily intended to maintain or improve health and reduce health risks
Policies primarily intended to reduce health inequalities: class-based inequalities in
life expectancy and
healthy life expectancy
Policies primarily intended to achieve other goals but which also have an impact on health


Strands of health policy
Public health

prevention of illness and disease
promotion of health and wellbeing


Strands of health policy
Medicine/ personal health care

access to professional healers trained in biomedicine for those who are ill
socialised medicine: public / state provision of health care free at the point of use. In UK the National Health Service (NHS)


Public health before the NHS

Mid 19th century public health reforms
improvements in sanitation, housing and diet
Provided mainly through local authorities
The Sanitary Conditions of the Labouring Population (1842)


Medicine before the NHS

State regulation of doctors (1858 Medical Registration Act)
1911 Liberal reforms – 50% of population (mainly employed men) covered by national insurance for access to GPs and sick pay
Two types of hospital
voluntary (charitable)
municipal (ex-workhouse infirmaries)


Medical power and medicalisation

The processes through which everyday problems and issues come to be seen as medical problems and issues subject to the control of doctors. Medical definitions of health become dominant. Illness rather than health becomes the focus of health policy.


Medical power

The power of the medical profession based on their expert knowledge and organizational base in the health care system


The elements of medical power

Based on expert knowledge
Exercised through professional discretion rather than bureaucratic rules
Self-regulating profession
Control of new recruits and knowledge base


1948: Labour’s health care policy aims

Went beyond Beveridge recommendations
Central to the idea of ‘social rights’
Free access to medical care at the point of use, funded out of taxation (‘decommodified’)
Comprehensive – full range of services
Universal – available to all
Controlled directly by central government


Resistance from the medical profession

British Medical Association represented professional doctors
Hospital consultants agreed to become salaried employees in return for being allowed to use NHS facilities for private practice
GPs won their demand to be self-employed


Historical instutionalism
Does medical power prevent changes to health policy ?

Existing social institutions shape the development of social policy and state welfare
In particular bureaucratic organisations and professional groups, which develop their own vested interests.
Becomes very difficult to change policy fundamentally – ‘path dependent development’ more common than ‘path departing development’
‘policy creates politics’, rather than the other way round


NHS: The socialisation of medicine

NHS to be organised in three parts
GP / community services (primary health care)
Hospitals (secondary health care)
Public/environmental health duties marginalised and given to local authorities
70% of NHS spending on secondary care
a National Health Service or a National Illness Service ?
power and influence of Big Pharma (private drugs companies)
The institutionalisation of professional medical power
A compromise between social democratic principles of equity and social justice and professional medical power


The politics of UK health policy1930s-1970s

Medicalisation of health and health policy
Public health strand of health policy marginalized by medicine

1940s – public expectation that free universal health care would improve health and reduce costs of health care
1960s – widespread belief that state welfare had been effective and the main cause of remaining inequalities was behavioural
1970s – health education seen as the best way of changing unhealthy behavior
1980 – Black Report: first comprehensive report into health inequalities


The NHS since 1948

Expenditure on the NHS increased x 3, but the UK has been a low spender on health care compared to other countries.
NHS has lower transaction costs than other socialised healthcare systems
Despite significant changes in organisation, health care in the UK, as in most other rich countries, is still paid for mainly from public expenditure


Assessing the NHS 1948-80

Reduced inequalities of health ?
1980 Black Report showed that the gap between the health of rich and poor remains
recommended non-health policies as the best way of reducing health inequalities
2013: austerity’s ‘toxic genetic legacy’
Equity of access to health care ?
Tudor Hart (1972) showed that there is an ‘inverse care law’ – those with greatest health care needs have least access to health care
Improved health ?
unknown, no systematic evidence. NICE (1995)


In brief …

Cheap to run
Unknown impact on health
No impact on health inequality
Unequal access


The question for UK health policy in 1980The question for UK health policy in 1980

Why do health inequalities persist in Britain despite the introduction of the National Health Service (NHS) in 1948 ?

NHS principles:
comprehensive medical care
free at the point of use (funded from taxation)


The Black Report (1980)

To measure the gap between the health of rich and poor in Britain

To provide an answer to the question:
why do health inequalities persist in Britain despite the introduction of a free universal national health service in 1948 ?


Black Report explanations of health inequalities

Is it survival of the fittest ?
natural selection
social selection
Is it a statistical artefact ?
the gap between health of rich and poor is wider but there are fewer poor
Are cultural factors the main cause ?
risk behaviours eg smoking, drinking, poor diet
Are material factors the main cause ?
poor housing, working and living conditions


The politics of health policy 1980s-2010

Conservative Government of 1980s rejected Black Report recommendations and refused to use the term ‘health inequalities’. They used the term ‘health variations’ instead.
New Labour (from 1997) put health inequalities back on the policy agenda, but with no clear commitment to reduce inequalities of income and wealth.


How neoliberals saw the NHS

Inappropriate – private markets are a superior to the state as a way of meeting needs
Inefficient – poor value for money because of a lack of financial controls over what doctors spend and how they spend it.
Ineffective – unresponsive to people’s needs because of medical power .


The story so far

Two strands of health policy
Public health
The medicalisation of health policy and marginalisation of public health
Socialisation of medicine: creation of NHS (1948) as a universal, comprehensive health care system, free at the point of use. Social rights
Institutionalisation of medical power
Continuing inequalities of health (Black Report 1980)
‘Inverse care law’ (Tudor Hart) (later the ‘postcode lottery’)


How the story ends ?????

The neoliberal plot against socialised medicine
The privatisation of health care ? – a path departing policy
The end of universalism in social policy ?
OR ?????


1960s/70s: How neoliberals saw the NHS

Inappropriate – private markets are a superior to the state as a way of meeting needs
Inefficient – poor value for money because of a lack of financial controls over what doctors spend and how they spend it. Professional power of doctors needs to be ‘managed’
Ineffective – unresponsive to people’s needs because of medical power .


Neoliberal healthcare solutions

Privatise medical insurance
Privatise some forms of treatment and care – contracts with private providers
Marketise the NHS – make it more ‘businesslike’ by introducing an ‘internal market’: a publicly funded service that is made to behave as if it were a private company
Managerialise the NHS – make doctors more accountable by introducing managers to control them or by making them work with cash limited budgets.


1980s/1990s: the first wave of neoliberal attacks on the NHS

Small increase in private insurance – mainly provided by employers
Cleaning, laundry and catering services partially privatised
Creation of internal market in health care. NHS split into purchasers (health authorities and GPs) and providers (hospitals) – 1990 NHS & Community Care Act. Purchasers role is to commission services from providers rather than a single organisation to plan and provide services.
NHS managers introduced between 1983-96 – an attack on medical power ?


Criticisms of the changes

NHS becomes fragmented by the internal market
High ‘transaction costs’ – the costs of administration, always low in the NHS, are increased by the internal market
Variation in standards of provision mean that equity of access - already imperfect because of the ‘inverse care law’ - is further reduced by a ‘postcode lottery’ – treatment depends on where you live
Neoliberals thought the changes did not go far enough – not path departing


1997 – 2010: New Labour fails to challenge neoliberal policies

NHS Trusts converted to ‘foundation trusts’ - more like businesses, still commissioning services.
payment by results for hospital treatments
private health companies allowed to provide NHS acute care and GP services (up to 15% of non-emergency treatments)
all part of …..


3 changes are required to privatise the NHS and depart from the path of free, universal, comprehensive health care

Need to overcome the taboo on private provision of NHS clinical services, and create a bridgehead for private companies to move in
Need to convert NHS organisations into real businesses, not the make believe business of the internal market
Need to weaken commitment of health workers to the NHS