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Over the past two decades, choice and competition have become central planks of health policy in many countries. Such notions are in keeping with the consumerist ethos and increasing commodification of health care now prevalent in health system reform thinking and noted in earlier chapters. Of course, it is quite possible to have choice without competition, and competition without allowing choice. However, the two are generally regarded as going hand in hand, since choice without competition may result in people not having a sufficient range of options from which to choose – the problem of choosing any colour as long as it is black. Competition without choice is seen as unworkable unless there is a mechanism whereby people not only exercise voice if they do not perceive themselves to be getting a good service, but can also exit by taking their health problems elsewhere. For these reasons, these two central planks of health reform have been coupled for the purposes of this chapter.
Opponents of choice are invariably also opposed to competition and believe that both pose serious risks for the ethos and values of a public health service such as the NHS in the UK and threaten to destabilise the principle of universal access to care. Of course, as is discussed below, it is possible to confine competition to the public sector so that a genuinely internal market is created as distinct from a provider market that is open to both public and private providers. Indeed, Julian Le Grand, an influential health adviser to the former British Prime Minister, Tony Blair, argues that it is perfectly possible to have competition between publicly owned entities without any participation from the private sector.
Health care systems everywhere face multiple pressures from changing demography, the rise of non-communicable disease, the growing demand on health services, and limited resources at a time of austerity.
Focusing on the British NHS from a political science perspective, this second edition of this best-selling book offers a fresh look at how it is coping with such pressures. The book explores the complexity of health policy and health services, offering a critical perspective on concerns including integrated care, the return of public health to local government and moves to devolve health services to local level. Crucially, it offers a critique of the market-style changes introduced by the Coalition government between 2010 and 2015.
Students of health care and health policy, policy-makers and public health and health care professionals will find this lively and accessible reassessment of NHS reforms invaluable.
Health system reform is likely to remain an international preoccupation as countries of different political persuasions and at different stages of development seek to balance rising demand and limited resources. In balancing these, policy makers have to wrestle with a variety of interlocking political cleavages that constitute an ongoing health debate. The spread of universal health coverage, actively encouraged by the World Health Organisation (WHO) and others, is an example of this global phenomenon.
The purpose of this book has been to describe and analyse several of the principal policy cleavages that have exercised, and continue to preoccupy, policy makers in their never-ending pursuit of the perfect health system. On the evidence reviewed here, such a laudable goal is probably unattainable – less imperfection is the best that can be hoped for – although this truism will not prevent policy makers and their advisers from making the attempt, especially in a context where there is a loss of institutional memory and a seeming reluctance to learn from history. As Judt perceptively cautions: ‘there is something worse than idealising the past … forgetting it’ (Judt 2010: 41-2).
Running through each of the policy cleavages considered here – the funding and organisation of health systems, the attempt to shift the emphasis from health care to health to combat dramatically rising lifestyle problems like obesity, alcohol misuse and mental ill-health, priority setting and rationing health care, and the appeal of markets and choice and competition as drivers for reform – is a tension between the bureaucratic reformers and market reformers that Alford (1975) described over 30 years ago.
The reader may wonder why another book on health policy is deemed necessary given the numerous texts already available, many of them updated versions of earlier ones. It is a fair question, particularly when this text is a second edition and falls into that category. In its defence, it attempts to do a different job. The aim of the book is to explore four key contemporary debates evident in health systems and consider how they have shaped the way in which such systems have evolved over time and continue to evolve. It is not a traditional comparative text since its principal focus is on health policy developments in the UK, with selective use made of examples from other countries and health systems where appropriate and of particular illustrative value. Most of the examples from outside the UK are drawn from other European health systems as well as from arrangements in North America, Australia and New Zealand.
The British NHS celebrated its 67th birthday in July 2015, but this book is not a history of its development or achievements over this period. Many existing texts already admirably serve this purpose, notably Baggott (2004), Ham (2004) and Klein (2006), and there is little to be gained by going over much the same ground, although there is some inevitable overlap. However, what sets the present book apart is a focus on a number of what might be termed policy cleavages that are evident in health and health care policy and in the development of health systems, and which are the subject of lengthy, often acrimonious and inconclusive, debate. The book is structured around four of these cleavages. They are:
In Chapter One, the value of a comparative approach in describing and understanding health systems was mentioned albeit with an acknowledgement of the limitations of such an approach and the tendency to overlook key cultural and historical differences between countries and their health systems. These cultural and historical factors often play a major role in the way those systems function regardless of the details of their funding and organisation. Through making comparisons it is possible to identify both commonalities and differences. The notion of convergence in an increasingly globalised world was also considered in Chapter One. Whatever the value, and reality, of the convergence thesis, a variety of health systems exists and important differences remain. This chapter describes the principal features of health systems and explores the powerful appeal of managerialism and markets to provide an overall context against which to consider the various policy cleavages that occupy the rest of the book.
In this section, we describe the various types and key features of health systems. The principal types are set out in Box 2.1.
The US ‘non-system’ of health comes closest to the free market system, while, at least until recently, the UK’s NHS comes closest to a system representing a government monopoly at the other extreme. Box 2.2 shows the principal types of funding.
The UK’s NHS is an example of a health system funded principally by direct taxation, although there are user charges for some groups of patients in the form of prescription charges. However, these charges only apply to England and, since devolution, no longer apply in Wales and Scotland.
This chapter describes and analyses the three phases, and contrasting models, of reform of the UK NHS that have occupied governments, principally key ministers and their advisers, from 1997 up to 2015. They have been articulated by one of the last Labour government’s most influential health policy advisers, Simon Stevens, who labelled the phases as follows:
command and control
Stevens left his position as adviser to former prime minister, Tony Blair, to take up a new post as president of United Health in Europe, a major US health care provider, which over the years has competed for work in the UK, including providing general practitioner services in parts of the country. In April 2014, Stevens returned to the UK to take over as NHS chief executive. Although his phases of reform were developed during the Labour government’s term of office, they remain relevant to the more recent changes introduced by the coalition government in 2013.
Britain is something of a market leader in health care reform, having been at it longer than most countries and with a determination and persistence not evident to quite such an extent anywhere else. One eminent commentator, Rudolf Klein, argued that although health care reform ‘has been one of the worldwide epidemics of the 1990s … Britain stands out from the rest’ (Klein 1995: 299). Moreover, since 1999, and as is described later, post-devolution Britain has created growing interest as a laboratory for the study of differences emerging in the health systems taking shape in England, Wales, Scotland and Northern Ireland (Connolly et al 2010; Timmins 2013; Bevan et al 2014).
One of the most protracted and impassioned debates in health policy concerns the imbalance between the attention and resources devoted to health care as distinct from health. Virtually all the attention from policy makers, professionals, public and media, together with the bulk of resources available, are focused on ill-health, sickness and disease. It is a curious irony that few health systems pay much attention to health, focusing instead on ill-health and disease. They are diagnose-and-treat systems rather than systems designed to predict and prevent, and operate in such a fashion even when making a pretence of putting health before health care. A good example of this tendency can be found in a speech delivered by a former British health secretary, Alan Milburn. The lecture was given in 2002, two years after Milburn launched Labour’s 10-Year Plan for Health and Care, which, in contrast to the message delivered in his lecture, focused almost exclusively on health care services. His lecture was an impassioned plea for putting health before health care: ‘The health debate in our country has for too long been focused on the state of the nation’s health service and not enough on the state of the nation’s health’. He continued: ‘The time has now come to put renewed emphasis on prevention as well as treatment…. It is time for a sea change in attitudes’ (Milburn 2002: 1). But arguably, the issue is not a lack of strategies or policies. As Derek Wanless, special adviser to Brown and Blair on the future challenges facing the NHS up to 2022, wryly commented, ‘what is striking is that there has been so much written often covering similar ground and apparently sound, setting out the well-known major determinants of health, but rigorous implementation of identified solutions has often been sadly lacking’ (Wanless 2004: 3).
A recurring policy dilemma for health systems concerns the rationing of health care, or, as some prefer to call it, priority setting. The discourse here is about the extent to which rationing health care should (or can) be explicit or whether the implications of this are too painful to contemplate, which makes implicit rationing a more attractive option. This chapter reviews the arguments on both sides. These continue to preoccupy commentators. Taking issue with Mechanic’s (1995) argument that explicit approaches to rationing are ‘too damaging to public and patient trust in services’, and one with which this author has much sympathy (Hunter 1997), Williams and colleagues are convinced that implicit rationing is both ‘ethically and politically unacceptable.’ They proceed from the assumption that ‘explicit priority setting is a legitimate and necessary feature of contemporary policy and practice in health care’ (Williams et al 2012: 125). For their part, Light and Hughes consider that critics of explicit rationing make important points about the limitations of formal attempts at rationing but that implicit rationing can cover up poor professional practice and quality of care. They favour a solution that ‘lies in re-conceptualising professionalism around accountability rather than autonomy’, thereby ensuring that ‘the use of power in both explicit and implicit rationing are subject to transparent review’ (Light and Hughes 2002: 12). They also make a plea for a sociological perspective to counter-balance and challenge the dominant economic view with its tendency to frame the issues ‘in a narrow and misleading way’ (Light and Hughes 2002: 17) and ‘set up an over-blunt dichotomy between treatment and denial, when what is at issue is more nuanced and uncertain’ (Light and Hughes 2002: 15).