Health Care in the UK

1. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Health Care in the UK Health care and the social settlement When the NHS was launched by Beveridge it was a celebration of a free and universal approach based on the egalitarian and collectivist principles of the post war Labour government.

2. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Early Foundations and Principles Duality of images dominated the perception of the Health Service Heroic/authoritarian doctor Dutiful/wonderful nurse Stoical/Deferential patient. These images reflected dominant representations of the NHS and the reality of a health care system still influenced by inequalities in class, gender and race relationships

3. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Early Foundations and Principles During the early days of the social settlement Doctors – usually middle class backgrounds and usually male . Nurses – usually of working class origin Patients were also usually working class Harmony – reflected collective commitment to provision of public health care.

4. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Early Foundations and Principles During early 1960’s – changes in the social fabric of society were reflected in the dynamics of the health care system. Doctors were recruited from a broader range of social groups and included more women. Nursing became a more diverse profession. From 1950’s shortage of UK nurses led to recruitment of nurses from Ireland and the Caribbean and other former colonies. Patients changed to as memory of pre-war poverty and post-war austerity faded living standards rose and higher standards of health care were demanded. In place of consensus there was increasing conflict.

5. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Early Foundations and Principles By mid 1990’s old images were as unsustainable as old assumptions about class, gender and race. The patient became a customer demanding value for money. However in reality structural inequalities remained and had a powerful and pervasive impact on the delivery of health care in the UK

6. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Industrial Militancy amongst Health Workers During 1970’s industrial action became fairly common in the health services. Even Doctors were becoming militant. June 1974 hospital workers at London’s Charing Cross Hospital took industrial action, not for more pay but in ideological campaign to force private ‘pay beds’ out NHS hospitals

7. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Industrial Militancy amongst Health Workers Royal Free Hospital - feminists challenging the rights of traditional male obstetricians to dictate how women should have their babies delivered. Similar protests took place in Scotland, Wales and Northern Ireland.

8. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Crises with the NHS and the public expenditure crises of 1976-1977 Labour governments imposition of cash-limited budgets on the health authorities and strict wage controls on health service workers was largely due to the public expenditure crises of 1976-77. RAWP Resources Allocation Working Party Wave of hospital and bed closures, Protests led to the Winter of Discontent 1978-1979.

9. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Crises with the NHS in the 1980’s Militancy continued in the 1980s and the government tried to suppress the Black Report This report was prepared by a prestigious committee chaired by Sir Douglas Black; the report explicitly blamed the government for growing inequalities and social differentials in health standards and demanded more resources for a wide range of social services to tackle these inequalities.

10. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Crises with the NHS in the 1980’s Nurses and ambulance workers went on strike at this time over pay levels they were supported in their cause by the National Union of Mineworkers. Public opinion was firmly behind the nurses and ambulance workers however in December 1982 Margaret Thatcher’s government forced them to accept a pay rise well below the rate of inflantion.

11. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The Restructuring of the NHS in the 1980’s Compulsory Competitive tendering for hospital cleaning and laundry services. This often resulted in redundancies and pay cuts and weakened the unions Managerial reforms imposed by Sir Roy Griffiths – attempt to introduce commercial efficiency – opposed by the medical profession (Hunter, 1994)

12. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The Restructuring of the NHS in the 1980’s Curtailing the Powers of Doctors Imposition in 1984 – ‘limited list’ of drugs available on prescription this was against concerted resistance from doctors and drug companies. This was a ‘ watershed in the relations between the government and the BMA.

13. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The Restructuring of the Welfare State Central Policy Review Staff – think tank for Conservative Government Proposed series of radical reforms of the welfare state which included replacing NHS with a system funded through private health insurance.

14. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The Restructuring of the Welfare State and the NHS The government were not able to carry this through because of public opposition however over the next few years the imperatives of the market-place were brought to bear on the NHS. The Labour party shifted to the right during this period under the leadership of Neil Kinnock and policies of ‘new realism’ were to be adopted. Labour had abandoned the social democratic consensus and moved away from measures of state intervention and public expenditure and towards individual initiative and private and voluntary provision.

15. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The end of the social democratic consensus Who made the following statements? ‘Do you know there are still people in Britain who believe in consensus? I regard them as quislings, traitors’ ‘I have always regarded it as part of my job – and please don’t think of it in an arrogant way – to kill socialism in Britain’

16. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The restructuring of Health care and the Introduction of the internal market for health. Yes you’re right – Margaret Thatcher in 1979 and 1984 respectively. The statements heralded a major re-structuring of health care in the UK 1989 White Paper Working for Patients 1990 Community Care Act Both implemented in 1991. The introduction of the internal market into the NHS

17. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The Introduction of the Internal Market into the Health Care System ‘Once you say we want the good features of competition, with independent bodies competing, in a service that remains publicly funded’ then the internal market just falls out as a conclusion (David Willetts, Conservative policy advisor, quoted in Timmins, 995, p.433)’

18. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The Introduction of the Internal Market into the Health Care System 1980’s – decade of financial austerity for the NHS Rate of growth in public spending on the NHS was significantly lower in the 1980’s than it had been in the 1970s. The demand of health care had grown much faster than the resources supplied to it even though some improvement had been made with regard to the efficiency of the service. By the end of the 1980’s nearly one million people were on hospital waiting lists.

19. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The Introduction of the Internal Market into the Health Care System In 1988 Margaret Thatcher launched The White Paper ‘ Working for Patients’ ‘The most far reaching reform of the National Health Service in its forty year history’ (Department of Health 1989) Three key reforms Internal market The purchaser provider split Self-governing trusts.

20. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The Introduction of the Internal Market into the Health Care System GPs were to be given their own budgets ( and be known as fundholders) to purchase services from hospital trusts on behalf of patients Proposals Measures to improve performance and efficiency Enhance managerial autonomy The voice of the customer (choice agenda) This would advantage the more articulate middle class groups in society.

21. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The Introduction of the Internal Market into the Health Care System Medical profession campaigned against the internal market. Prominent GPs began to opt for fundholding and senior consultants opted for hospital trusts. Resistance was crushed and by 1996 hospital trusts were firmly established and half of the population was registering with a fundholding GP

22. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 A new consensus ‘primary care-led trusts. Logic of the internal market GPs were encouraged to ration services to patients and market discipline was imposed on hospital professionals ‘The aim is for decisions about purchasing and providing health care to be taken as close to the patient as possible by GPs working closely with patients through promary health care teams’ (NHS Executive, 1994,p.5)

23. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 A new consensus ‘primary care-led trusts. The New NHS White Paper 1997 Published by the New Labour Government six months later. The White Paper proclaimed that the internal market would be abolished and GP fundholding replaced however as Glennerster and Le Grand noted ‘the key elements of the old internal market will be retained’ and the proposed GP- led commisiioning amounted to an extension of fundholding (The Guardian 10th December 1997)

24. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The New NHS A central role for primary care groups in commissioning health care for local populations of 100,00 Partipation by GPs was now compulsory and stricter mechanisms of monitoring and control were put in place. This made reform more authoritarian than ever before. The Institute of Fiscal Studies argued that ‘the squeeze was more ‘stringent than anything the Conservatives managed in their 18 years of power (The Guardian, 4 July 1997)

25. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The New Public Health and the New Patient Restructuring of welfare – reconstitution of the welfare subject Relationship between individuals in society and agencies responsible for delivering health care and other forms of welfare delivery. New welfare discourses emerged at this time.

26. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 1991 The Health of the Nation The Health of the Nation White Paper in 1991 emphasises prevention rather than cure and health promotion rather that treatment of disease Targets were; coronary heart disease and stroke; particular cancers (breast, cervix, lung, skin); mental illness (particularly suicide) HIV/AIDS

27. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 1991 The Health of the Nation ‘Risk factor Target’ in four areas were identified; Smoking, diet and nutrition, blood pressure, and HIV transmission by injecting drugs. Policies for a new generation of public health doctors; advocated whole population approach prevention of diseases. Individual responsibility

28. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The Managerial Imperativemanaged competition From consensus management to executive direction Power was centralised to push through the reform agenda Her aim was to bring entrepreneurial vigour and competition to the public sector

29. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The Managerial Imperativeaccountability and decentralization Making doctors cost-conscious Previously doctors had enjoyed great power and autonomy in the allocation of NHS resources. There were distinct variations in practice across the UK Recipients of funds were to be held to account at local level by setting targets and doctors and health professionals generally were made more accountable.

30. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The Managerial ImperativeAudit Medical professionals in conflict with new mangers as resources become less and less available. Ensuring effective treatments. Rationing of resources meant that treatments would need to be evaluated more adequately in terms of their efficacy. Outcomes and inputs were measured in terms of quality performance and effectiveness

31. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The Managerial Imperative Maximizing the potential of human resources Promoting incentives through performance related pay re-inventing structures the flexible firm Moves toward local pay bargaining.

32. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The Managerial Imperative From patient to customer Patients rights – need to consult and involve patients choice agenda Ability to make complaints. As Mary Langan has argued resource constraints have let to more restricted choices for hospital referrals than in the past. Also range of drugs available is more limited. This has been evidenced in recent controversy over the breast cancer drug Herceptin.

33. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Legislation

34. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Legislation White Papers Recently Proposed Legislation

35. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Health and Housing The relationship between attributes of housing and health and how this impacts upon wider theoretical explanations of the relationship between social inequality and health.

36. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Explanations of social class differences in Health Artefact Social Selection Behavioural/cultural Materialistic

37. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Explanations of social class differences in Health: Artefact Theory Questions legitimacy of relationship between social class and health Questions the way in which the statistics were collected, analysed and calculated Variations in diagnosis, certification and classification are all examples of how the production of statistics may be limited to support strong conclusions.

38. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Artefact Theory Way in which mortality rates, for example, were calculated from two key sources:death certificates and census. It is possible that the information on each form could be described differently.

39. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Behavioural/cultural theories Cultural aspects associated with different social groupings are have more impact on health than material situation Theory assumes that people from particular socio-economic groups choose negative health behaviours and that this is culturally defined.

40. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Materialist theories Describe health as being impacted upon by material circumstances and situational constraints “The Black Report judged that Materialist explanations were the most important in accounting for social class differences in health” (Blane D., 1997 Inequalities in social class in Scambler (ed) Sociology as applied to medicine Saunders London.

41. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Social Selection Genetic factors hold key significance in terms of defining the relationship between individuals and their health. Some individuals are pre-disposed to specific illness as a result of hereditary factors

42. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The relationship between housing and ill- health: A biomedical view Causing of specific attributes of housing and ill health has been established in some cases e.g. Health effects of radon - lung cancer an lead piping -impaired cognitive development in children

43. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The relationship between housing and ill- health: A biomedical view The prevalence of illness appears to increase with the level of dampness: e.g. A recent study in Glasgow demonstrated the link between dampness and asthma(Williamson, I, Martin C, McGill G, Monie R, Fennerty A (1997) The study found that asthmatic are two to three times more likely to live in a damp home. This relationship persisted after controlling for socio-economic variables.

44. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Theoretical issues arising from this study The link between asthma and dampness suggests that a material explanation for ill health in these cases is valid. Importantly the direct nature of the relationship between physical environment and this medical condition is clear. Qualifying this it was found that in the case of asthma, differences in income and other confounding variables did not seem to confound the relationship between damp housing and ill-health.

45. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The relationship between housing and health: a social model approach Previous research has indicated that location and density of housing as well as living conditions may have a significant impact on psychological and emotional well-being. Thus overcrowding and living in high rise flats is associated with psychological symptoms including depression. Here the influence of other confounding social and economic problems is agreed to be strong. This re-inforces the materialist explanation of the relationship between social inequality and ill health

46. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Homelessness and health Poor health causes homelessness Poor health is caused by homelessness Poor health is exacerbated by homelessness Theoretical implications of these causal links: In one sense materialist explanations are re-inforced, however it is important to consider the life-course factors involved here in that poor-health can of itself cause homelessness and researchers need to take account of variations in the causes of this initial poor-health.

47. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Health Futures

48. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Providing Health Care in a Modern State Cure or Prevention Bio-medical approach has produced a system of health care in Britain that concentrates on medical intervention after the onset of illness These medical interventions have not been universally available and some groups in society do benefit more than others (Porter 1997)

49. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Health Care in Modern Britain  Delivery of Health Care in Britain has been beset with problems arising from: the structure of the system the absence of an overall coherent strategy difficulties in exerting control or imposing direction difficulties arising from inter-professional relationships.

50. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Health Care in Modern Britain  Can we continue to provide health care which attempts to translate founding principles into practice? Universality, comprehensiveness and Equity (Powell 1997; Klein 1995)

51. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Providing solutions Sector Reform Shift away from public towards voluntary and commercial sectors while attempting to make public sector operate more commercially. These processes were prompted by financial concerns regarding economy and efficiency

52. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Providing solutions Promoting a greater reliance on primary care challenging the centrality of the expensive curative hospital approach in favour of the (cheaper) community approach focussing on health promotion and illness prevention founded on a social model of health care informed by the principles of the Declaration of Alma Ata (1978)

53. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Providing solutions focussing on health promotion and illness prevention founded on a social model of health care informed by the principles of the Declaration of Alma Ata (1978) Elaborated on in subsequent WHO initiatives

54. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Providing solutions Towards a new public health agenda Exponents of the social model of health care have legitimized the concept of community participation in setting the health care agenda, designing services and models of delivery and in holding health care professionals accountable.

55. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Providing solutions Applying holistic set of principles to the health care system primary and secondary preventative or curative hospital based on located in community settings.

56. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The 1997 White Paper The New NHS; The third way . . . .a new model for a new century. ‘There will be neither a return to the old centralized command and control systems of the 1970’s nor a continuation of the divisive internal market system of 1990’s (Department of Health 1997b,para 2.1).

57. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 The 1997 White Paper

58. Lecture Three; Health Care in the UK; Dr. Marion Ellison; 2nd February 2006 Health Care in Modern Britain  Challenges: An ageing population changing patterns of disease fluctuating economic fortunes concern over public spending New political agenda’s and ideologies