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Author: David J. Hunter

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.

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The UK government’s reforms of the NHS and public health system require partnerships if they are to succeed. Those partnerships concerned with public health are especially important and are deemed to be a ’good thing’ which add, rather than consume, value. Yet the significant emphasis on partnership working to secure effective policy and service delivery exists despite the evidence testifying to how difficult it is to make partnerships work or achieve results.

Partnership working in public health presents the findings from a detailed study of public health partnerships in England. The lessons from the research are used to explore the government’s changes in public health now being implemented, most of which centre on new partnerships called Health and Wellbeing Boards that have been established to work differently from their predecessors.The book assesses their likely impact and the implications for the future of public health partnerships. Drawing on systems thinking, it argues that partnerships can only succeed if they work in quite different ways. The book will therefore appeal to the public health community and students of health policy.

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Health systems everywhere are experiencing rapid change in response to new threats to health, including from lifestyle diseases, risks of pandemic flu, and the global effects of climate change but health inequalities continue to widen. Such developments have profound implications for the future direction of public health policy and practice.

The public health system in England offers a wide-ranging, provocative and accessible assessment of challenges confronting a public health system, exploring how its parameters have shifted and what the origins of dilemmas in public health practice are. The book will therefore appeal to public health professionals and students of health policy, potentially engaging them in political and social advocacy.

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Repeated calls for improved joint working between agencies and professionals providing social care have had limited success. Following a brief review of possible reasons for this, it is argued that joint working cannot truly succeed unless it does so at street level at the professional/user interface. Yet this level has received little attention. Taking the example of a mechanism created to ease communications and negotiate transitions between a range of services for the elderly, the paper demonstrates that there exists an important but neglected role for brokers or mediators (so-called ‘reticulists’) who display an awareness of the political realities and power dimension of organisational life and who operate on the margins and in the interstices of services. Of the lessons to be learned from this initiative in joint working the most important is that a direct transplant is likely to suffer rejection. The mechanism reported on is a product of its environment—a ‘bottom-up’ response to a perceived problem—and tailored accordingly.

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Author: David J. Hunter

This chapter highlights the need for partnership working, which has been a long-standing objective of health and social policy. For many years, the National Health Service (NHS) and local authorities have been attempting to deal with ‘wicked issues’. Issues such as homelessness, disaffection of young people, and the ageing society that have complex multiple causes require joined-up approaches by the statutory and third sectors at national and local levels. In 2012, at the time when Public Health responsibilities were transferred from the NHS to local authorities, health and wellbeing boards (HWBs) were established in England. With few exceptions, HWBs punch below their weight and are not the powerful system leaders that were hoped for. Evidence of their value and impact is negligible, with poor-performance indicators, and the difficulties in overcoming deep-seated departmentalism and a silo approach prevalent in government and public services, leaving ‘wicked issues’ as deep-seated as ever.

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Author: David J Hunter

As in the case of other parts of the UK wider health system, it has been a turbulent time for public health since 2010. Not only has the function undergone major structural and cultural change following its return to local government from the NHS, where it had been located since 1974, but it has had to confront new challenges in public health arising from lifestyle behaviours and a widening health gap between social groups. All of this has occurred during a period of unprecedented financial austerity affecting public services in general but local government in particular. This chapter reviews the state of public health in the lead up to the changes announced by the Coalition government in 2010. It then summarises the reforms before offering an interim assessment of their impact. Finally, it discusses the evidence to date concerning the reforms and speculates on likely prospects in the years ahead.

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Author: David J. Hunter

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).

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Author: David J. Hunter

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.

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Author: David J. Hunter

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.

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Author: David J. Hunter

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:

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