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  • Author or Editor: Ian Greener x
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Health services are among the most expensive and complex areas of social policy.

Using qualitative comparative analysis to explore 11 developed countries’ health services, this volume considers the links between a range of different outcome measures and levels of funding, social determinants and different types of health expenditures. It also reflects on how those systems responded to the first wave of COVID-19.

This ambitious text identifies which underpinning factors are associated with the strongest outcomes, providing a rigorous account of health systems and health policies in the context of their wider economies and societies.

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Understanding continuity and change
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This book contends that attempts to reform the NHS can only be understood by reference to both the wider social and political context, and to the organisational and ideational legacies present within the NHS itself. It aims to take students beyond a basic understanding of the historical development of health policy in the UK, to one that demonstrates an appreciation of the interactions between health policy, organisation and society.

Continuity and change in the NHS:

· acts as a crucial bridge between conventional textbooks on the NHS and contemporary health policy research;

· provides a theoretically rigorous but accessible account of the development of policy and organisational change not found elsewhere;

· presents new scholarship in the political economy of welfare in a clear format.

The book is aimed at third year and post-graduate students of politics, public management and health studies. It provides a theoretically inspired account of the development of health policy and organisation in the UK which will also be of interest to academics and researchers in the field.

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This article examines the three ‘moments’ of health policy discourse under New Labour. It contends that, since 1997, there have been two significant changes: the first from an initially very Fabian rhetoric to one based instead around performance measurement and investment, and the second adding a new version ‘internal market’, based around the application of the discourse of consumerism in the NHS, to the performance discourse of the first change. These shifts in the language of policy are matched by changes in its underpinning assumptions, and the frenetic nature of their introduction appears to lead to the conclusion that New Labour are resorting to a ‘garbage can’ approach to policy making.

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There is a danger that we have become so used to the idea of markets in the public sector that they become taken for granted. This article first problematises the terms ‘market’ and ‘public’, before going on to talk about markets as they are being used in present policy, and applying a morphogenetic-inspired analysis of their use. Finally, it attempts to work out when and where markets might work in the public sector, and what we might do in terms of public reform where they do not.

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This chapter examines the extent of change that has taken place since 1997. The key policy question is whether Labour’s approach to public reform represents an approach with a new hierarchy of goals in place, a new policy ‘paradigm’, or, instead, a variant of the Conservative approach that preceded it. Can Labour policy be divided into a series of stages or moments that show changes in Labour’s approach? Labour’s approach to public reform appears to have incrementally reordered the hierarchy of goals the Conservatives had in place rather than creating a distinctively new set. It represents, even at its most radical, a series of second order changes, particularly based around inspection, performance management, and the increased use of the market, rather than a third order or paradigmatic change.

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This book compares the health systems of 11 countries in terms of their social determinants, health funding and health expenditure, and explores how the different configurations of these factors, in turn, relate to a range of different outcome measures. It also compares a wider range of countries in relation to the factors found most important for the 11 countries, as well as exploring the first-wave response to COVID-19 in 2020. By exploring health systems in terms of several of their most important aspects, we can assess what they have in common and in difference, and whether those commonalities and differences are linked to better or worse outcomes.

No empirical work takes place in a theoretical vacuum. Things that seem important are more likely to be measured, and those measures often already come in clusters, based on the relationships that we assume exist between them. It is therefore important to actively think about what it is we are trying to measure, what theories are explicit (or implicit) in those measures, and then whether the empirical findings that we find support or challenge those theories.

It is also really important in comparative research to have a method for linking together the existing data and theory, and for testing it in a robust and transparent manner. Not everyone will agree with the findings in this book, but they will be able to see exactly where they agree or disagree. I hope this can lead to debate, and in turn to greater understanding.

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When comparisons of different health outcomes are carried out, there is still often an assumption that the reasons for those differences must be due to the performance of the health services in those countries. Politicians and policymakers debate league tables of health outcomes as if the results are entirely dependent on what goes on in healthcare services, and plans are put in place to attempt to address what have been identified on problem areas (Greener, 2016). However, it may often be the case that the health outcomes differences between different countries may be due to factors outside of the direct control of healthcare services.

Healthcare services are undoubtedly important, and the book will explore how they are funded, and what the money is spent on, in Chapters 3 and 4. But however important healthcare is, our health depends on a range of other factors that fall outside the remit or control of healthcare organisations and institutions (Schrecker and Bambra, 2015).

In respect of our own lives, we are fully aware that health services are not the only, or perhaps even the most important, factors in determining our health. Whether we can access health services (or not) when we are ill or injured is clearly important. This will be especially the case where people have a serious injury or life-threatening illness, but is also the case for the millions of people with long-term health problems that may require medications or medical devices, as in the case of diabetes or asthma.

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The way in which health systems are funded is often based on a series of political decisions which were made in the early development of different nations’ health systems, and yet, through processes of institutional reproduction, have remained remarkably intact today (Immergut, 1992b; Wilsford, 1995). As health systems absorb such substantial levels of resources, and because access to healthcare is not only recognised as a human right, but is also an international business of enormous scale, methods of healthcare funding in a particular country will be the result of a series of compromises between competing interests. Key stakeholders are those working in health services (with doctors usually having the most influence), government, public, private or not-for-profit providers of care, as well as other organisations such as insurance companies, patient representative groups and regulatory bodies. At election time the public will also have a say, but generally only from the ‘menu’ of options presented to them. Should events occur with particular salience to the general public (such as a rogue doctor or nurse, or a vulnerable person not receiving the right care), this can also mobilise change, especially should those events occur near an election.

This chapter explores the different configurations of the funding of health systems among the 11 countries included in the book, and the relationship between these configurations and access to healthcare, as well as a measure of the efficiency of the health system.

It therefore aims to discover whether there are patterns of healthcare funding that have necessary or sufficient relationships with healthcare access and measured efficiency, as well as whether there are any health systems which achieve both of these outcomes.

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Typologies of health system expenditures tend to be based on their degree of publicness (Blank et al, 2018, p 73), or countries are compared on the basis of their total spend on healthcare (Kotlikoff and Hagist, 2005). However, there is still relatively little work which explores different categories of health expenditure and how these contribute to good or bad care, and whether that care, in turn, leads to better or worse health outcomes.

In terms of arguments around levels of expenditure, there is often a general assumption that greater healthcare expenditure allows the purchase of more health services, and that this should lead to better health outcomes. However, this clashes with critical work, perhaps best exemplified by Illich (1977b), suggesting that increased spending on healthcare may itself be detrimental (Blank et al, 2018, p 260), with medicine being portrayed as a ‘disabling profession’ (Illich, 1977a) that prevents us from trying to find our own sources of well-being. As well as the disabling profession critique, Illich argued that the toxic or dangerous effects of medicine (its ‘iatrogenetic’ dimension) were not being taken into account, and raised questions that more recent authors (O’Mahony, 2016) have used as a basis for questioning the legitimacy of many medical interventions, which they find fall short of the standards of evidence which medicine aspires to (Stegenga, 2018).

There have been significant debates on the implications of trying to shift expenditure between primary and secondary care, which has been explored both in terms of individual health systems, but also comparatively (Peckham and Exworthy, 2003).

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This chapter utilises the same method as the rest of the book (QCA) but with a different dataset. During the book’s writing, the COVID-19 pandemic began and spread across the world. This gave me two options – I could ignore it, as the pandemic was not in the original book proposal, or I could incorporate it, and see how different health systems had responded to the challenge that it offered. I have decided on the latter, but of course any analysis I can offer is limited in that, at the time of writing, the pandemic is far from over. This has resulted in some methodological choices about what I can and cannot write about, but I hope that the chapter offers an insight into the ‘first wave’ of the pandemic and so makes a contribution to the comparative analysis of health systems.

Understanding why some countries were more successful than others in responding to the pandemic in its first wave – with the analysis here running up to mid July 2020 – gives important insights into the relative importance of the structural influences which are now known to be important in containing the virus, as well as giving an opportunity to assess the success (or otherwise) of different countries’ COVID-19 testing regimes.

Comparative studies have the potential to bring insight into how COVID-19 risk factors and testing regimes interrelate, but there are significant data limitations in terms of what can and cannot be measured in a robust way at the time of writing. This necessarily means some compromises have to be made.

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