health and health policy

Question 1

definition of health

positive and negative

Answer 1

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

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

Question 2

What is health policy ?

What are the aims of health policy ?

Answer 2

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

Question 3

Strands of health policy

Public health

Answer 3

prevention of illness and disease

promotion of health and wellbeing

Question 4

Strands of health policy

Medicine/ personal health care

Answer 4

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)

Question 5

Public health before the NHS

Answer 5

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

Question 6

Medicine before the NHS

Answer 6

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)

Question 7

Medical power and medicalisation

Medic

Answer 7

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.

Question 8

Medical power

Answer 8

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

Question 9

The elements of medical power

Answer 9

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

Question 10

1948: Labour’s health care policy aims

Answer 10

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

Question 11

Resistance from the medical profession

Answer 11

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

Question 12

Historical instutionalism

Does medical power prevent changes to health policy ?

Answer 12

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

Question 13

NHS: The socialisation of medicine

Answer 13

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

Question 14

The politics of UK health policy1930s-1970s

Answer 14

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

Question 15

The NHS since 1948

Answer 15

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

Question 16

Assessing the NHS 1948-80

Answer 16

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)

Question 17

In brief …

Answer 17

Cheap to run
Universal
Accessible
Popular
But
Unknown impact on health
No impact on health inequality
Unequal access

Question 18

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

Answer 18

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

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

Question 19

The Black Report (1980)

Answer 19

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 ?

Question 20

Black Report explanations of health inequalities

Answer 20

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

Question 21

The politics of health policy 1980s-2010

Answer 21

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.

Question 22

How neoliberals saw the NHS

Answer 22

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 .

Question 23

The story so far

Answer 23

Two strands of health policy
Medicine
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’)

Question 24

How the story ends ?????

Answer 24

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

Question 25

1960s/70s: How neoliberals saw the NHS

Answer 25

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 .

Question 26

Neoliberal healthcare solutions

Answer 26

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.

Question 27

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

Answer 27

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 ?

Question 28

Criticisms of the changes

Answer 28

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

Question 29

1997 – 2010: New Labour fails to challenge neoliberal policies

Answer 29

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 …..

Question 30

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

Answer 30

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

Question 31

Health and Social Care Act 2012 The triumph of neoliberalism ?

Answer 31

-Changing the way the NHS is organised
Clinical Commissioning Groups (CCGs) replace remaining administrative structures. Doctor-controlled budgets. Doctors’ priorities now money not health care.
-Changing the way money is spent
‘opening up the delivery of services to any provider’ … a competitive market. No limit on role of private providers, even though these are still paid for (at the moment) by public money raised from taxation.
-Changing the duties of the Secretary of State for Health
the end of universal health care ?

Question 32

Duty to care abolished

Answer 32

1946 NHS Act
“it shall be the duty of the Minister of Health … to promote the establishment in England and Wales of a comprehensive health service … and for that purpose to provide or secure the effective provision of services in accordance with the following provisions of this Act.”

2012 Health and Social Care Act
“The Secretary of State must exercise the functions conferred in this Act so as to secure that services are provided in accordance with this Act.”

Question 33

How the 2012 Act will change the NHS

Answer 33

Clinical Commissioning Groups (CCGs) will control spending in health care
CCGs not required to provide comprehensive services for all persons living in an area, only “such services or facilities as it considers appropriate”.
Many services transferred to local authorities, who can charge for them, or are abolished altogether

Question 34

Abolition of statutoacry requirement for services

Answer 34

Services/facilities for pregnant women, women who are breast feeding
Services for older and younger children
Services for the prevention for illness
Ambulance services
Services for people with mental illness
Sexual health services
Dental public health services