Steve Iliffe’s contribution to Foundation Hospitals & The Health Service Reforms: Imaginative Idea or Disaster in the Making? September 2003

The political class in Britain remains committed to the idea and the practice of a public health service, but its commitment is now qualified. If the current phase of investment and reform do not deliver visible changes in the provision of health care, the critics of the NHS may prevail. This was expressed in the Wanless Report, and the message was reinforced by Wanless himself in the recent New Statesman debate about the Norwich Union’s ideas about “stakeholder health care”.

The idea that an insurance-based system would be better than a taxation-based health service has had several lives. Its current incarnation starting with the Carlton Club conference in 1983. Then a group of Conservative politicians and NHS clinicians and managers met out of public sight to debate future options for the health service, concluding that a slow transition to an insurance-funded service was necessary, using an expanded form of National Insurance as a transitional arrangement. Now the debate is conducted in public, with Labour supporters seeing the value of market mechanisms in health care whilst Conservatives doubt that insurance-based systems can or should aim to deliver equity.

How should those on the Left respond to a political agenda set by commercial interests and appreciated by the current government? There are obvious topics, like the risks to equity and the judicious use of public money by Foundation Hospitals and Private Finance Initiatives, and there are old favourite slogans about democratic control, but there are no signs that political activity on these issues will do more than modify the reform process.

I want to suggest three themes that need to be considered and explored if the Left is to regain the initiative in policy for the NHS. The first is ‘provider capture’, the second is ‘modernisation’ and the last ‘responsiveness’.

PROVIDER CAPTURE

New Labour struggles with the forces of conservatism, which obstruct necessary reforms in defence of their own interests. In the health service they are found both in trades unions and in the professional organisations, which resist changes in working practices that would benefit the public. This identification of professional organisations as problematic was a strong feature of the policies of the Conservative governments of 1979-1997, particularly when Kenneth Clarke was Secretary of State for Health, and has carried over to New Labour. Whilst not wrong in itself, it is one sided, because the professions in particular have two other important attributes. They represent the health service, in a face-to-face relationship with citizens, in ways that administrators and policy makers are not; and they are to greater or lesser extent locked into tripartite alliances with industry and with the universities.

We can understand ‘provider capture’ not simply as the influence that professions have over the delivery of health care, but rather as the functioning of an industrial-medical-academic complex which shapes medicine itself, and so influences the priorities and performance of the health service. Consider two increasingly common problems as examples of ‘provider capture’; obesity and depression. Both are constructed and experienced as individual problems, amenable to control at individual level, if only the right technique could be found to achieve control. Fat-busting pills, faddish diets, dietary advisors and weight control groups offer solutions to the problem of obesity, but have little beneficial impact. Anti-depressants and assorted therapies are presented as treatments for depression, but the prevalence and incidence of depression rises, seemingly inexorably. Both problems may well be expressions of social malaise, in particular the commercial marketing of unhealthy food and the insecurities of life in market societies, but both are also market opportunities with numerous niches waiting to be exploited. For each problem a public health approach that promotes healthy consumption and social empowerment might be a better answer than any quantity of medication (they could hardly be worse), but such an approach must compete with commodified solutions supported by government and mediated by academia and the professions. This situation could change, of course, if government regulates medicine marketing more closely, changes the emphasis in research funding and alters its priorities in supporting the professions. And it might change even more if political movements began to argue for different solutions to our current problems, and openly question the motives and reasoning underlying current practice. This is a large task with plenty of potential for error. For example, the only serious and current threat to the medical model comes from those refusing to immunise their children with the MMR vaccine, a group with an understandably suspicious attitude to professional claims and an almost total ignorance of science.

MODERNISATION

The NHS was designed before penicillin became available, and it sometimes feels that way to those who use it or work in it, despite the best efforts of committed staff. Modernisation is necessary and in some places overdue, but has become almost synonymous with ‘choice’, a term whose meanings are easily overlooked. There are different kinds of choice, which in health can be seen either as object-related and discretionary (homeopathy for eczema, private rooms, operation dates, getting pregnant by artificial means) or related to direction and the resolution of uncertainty (should I have a PSA test, will chemotherapy for cancer buy me useful time or ruin the remains of my life?) The former types of choice are easily marketable, the latter depend more on knowledge, dialogue and trust. Those most concerned with ‘choice’ are keen to sell discretionary services, and are seeking to expand markets, by undoing public provision if necessary. We should be concerned with promoting knowledge, dialogue and trust. This does not mean advocating a bland ‘partnership’ approach, but understanding that dialogue and trust can be achieved through mutual criticism, if conducted safely by people whose existence is not threatened. A pious call for collaboration not competition may be worthless, when it is necessary to work through conflicting opinions. Nor does the view that ‘every cook shall rule the State’ help us, because on past experience it enforces an ultimately fruitless and token involvement in decision making. What are needed, in my view, are multiple opportunities for involvement in decision-making, from the individual to the strategic level. Here we have a huge amount of experience, from which we can learn much if we can synthesise it.

RESPONSIVENESS

Who can be in favour of unresponsiveness in public services? The issue in the current debate, however, is responsive to whom? Whether we induce responsiveness through a command-and-control approach, or through market mechanisms, depends upon whose interests are being met. A health service responsive to the affluent and largely healthy top third of the population would meet their needs for anxiety containment through counselling, satisfy their perceptions of safe treatments through alternative medicine, treat sports injuries well, value cosmetic surgery, run on time to their timetable and prevent their elderly parents becoming a drain on the family income. A health service responsive to the poorest third of the population might focus on their higher rates of illness, on health promotion and health maintenance, and on compensating for disabilities. Whilst we in the NHS have no choice but to try and respond to a broad range of needs and wants, the most articulate and affluent seem keen to re-engineer the public service towards their own agenda, and if that fails to abandon it altogether. This political problem is the central one, at the moment, but behind it lies another. Why do we assume that widening disparities in income and education are inevitable? Should we not think of the alternative, that the income gap decreases, with a consequent narrowing of health inequalities and less competition between social strata for resources and priority?

A EUROPEAN PROBLEM?

These issues seem to be common to all health care systems in industrialised countries, whatever the source of funding and the style of health service organisation. Perhaps it is time to think about health care reform beyond national boundaries, and seek a European solution to our problems. This is a task that the International Association for Health Policy in Europe tries to address in its Stockholm Manifesto, reproduced here. The Stockholm Manifesto is slowly evolving and changing, and anyone can contribute to this process by responding to any theme or arguing for new ones.


The Stockholm Manifesto : July 2003

Steve Iliffe, Alexis Benos, Rolf Gustaffson, Jane Lethbridge, Jens Niehoff, Jill Manthorpe, Dieter Borges, Jochen Zenker.

In the final discussion at the Stockholm IAHPE conference in May 2003 we tried to synthesise what participants had learned from the conference, with their own experience and understanding. The group used a focus group approach allowing themes to emerge through interaction and debate, but with a nominal group approach to clarifying and documenting these themes. An iterative approach to exploring, modifying and expanding the themes is underway, using email response, web-based discussion and conference debate as its mechanisms. The aim is to develop a critique of current European health care policy and a manifesto for change.

We produced three themes at the Stockholm conference, which have been expanded in the first round of email responses to create this version, draft 2 : a description of health care systems, in terms of their complexity; a critique of health system managerialism; and an agenda for change in European health care systems.

COMPLEXITY. We concluded that:

1. Health care systems are complex, because:

  • They are embedded in society, and rooted in culture
  • They are whole systems, not simple mechanisms
  • They reflect economic change and technological development
  • They are politically driven, and legitimise political ideologies and systems
  • They are based on social relationships rather than technical knowledge.

2. This complexity is:

  • Sometimes a problem for individuals using services, although superficially there is often a high level of public satisfaction with health services (except in the USA)
  • A source of stability but therefore of resistance to change
  • A management problem, that leads to managerial attempts to simplify the complexity.

3. Conclusion: To understand a part of a health care system you must understand the whole system.

A CRITIQUE OF MANAGERIALISM. We concluded that:

4. Current managerial approaches to system complexity define health and social care in terms of products (Fordist commodification), with the following consequences:

  • The development of panoptic control systems, and blaming of the workforce for system failure
  • Pre-occupation with costs & prices, and with productivity
  • Itemisation of work tasks and outcomes
  • Concern with defining and measuring quality
  • Codification and standardisation of knowledge
  • Actual needs of service users are not met
  • Citizens are reduced to consumers of health services
  • The system becomes more complex, not less, and management becomes part of the system’s problems.

5. There are two other features of the current situation that are important. This type of managerialism emphasises the importance of regulation, but in practice this tends to be weak. There is a clear lack of vision within the system.

AN AGENDA FOR CHANGE

6. An agenda for change in European health care systems should include:

  • Basing all health care on not-for-profit institutions and organisations, and creating clear distinctions between the not-for-profit sector’s activity and that of commercial interests. This is distinctly different from a stakeholder approach.
  • A return to an understanding of whole systems, both for service users and for service providers. This requires an awareness of policy that amounts to the “politicisation” of healthcare.
  • Promotion of an awareness of common interests, as well as individual and national interests, through a continuous process of dialogue (for example, about the social implications of medical care)
  • Democratic and multi-disciplinary norm-setting, with needs defined and prioritised in a transparent process. The process of engaging citizens in policy decisions is the most problematic issue for those opposed to current managerial approaches. Norm-setting identifies priorities that will determine investment needs, and prices can be derived from this.
  • Strong regulation, using qualitative rather than quantitative ‘contracts’& professional training for self-regulation and self-evaluation, as mechanisms to create a system that develops dynamically.

The Stockholm Manifesto will evolve over the two years between the 2003 conference in Stockholm and the 2005 meeting in Thessaloniki, at which it will act as the theme. Those interested in contributing to this evolution should do so through the IAHP website www.healthp.org, by email to s.iliffe@pcps.ucl.ac.uk, or in writing to Dr. Steve Iliffe, Department of Primary Care & Population Sciences,RFUCLMS, Royal Free Campus, Rowland Hill St., London NW3 2PF

Steve Iliffe is a general practitioner in London, Reader in General Practice at the Royal Free & UCL Medical School and president of the International Association for Health Policy in Europe.

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