The Politics of Healthcare in Britain

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Stephen Harrison & Ruth McDonald

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    Preface

    Our aims in this volume are to introduce readers to a fairly wide range of descriptive and analytical material about the past and present politics of healthcare in Britain. Our working definition of ‘healthcare’ is conventional; the majority of our material relates to the funding, organisation and delivery of diagnostic and therapeutic services to individuals, rather than to broader conceptions of public health. Our working definition of ‘politics’ is conventional too, though it perhaps merits some explanation. The funding and provision of healthcare in Britain, and indeed all western countries, is a central concern of public policy irrespective of widely differing degrees of public funding and public ownership of healthcare institutions. This concern extends beyond these matters of finance and provision to the extent of shaping other aspects of politics and public policy, an observation summed up in Moran's notion of the ‘healthcare state’:

    There is more to health care politics than health care policy; the scale of health care institutions means that they have ramifications for the modern state well beyond conventional health care arenas. Like any state, the health care state is about governing; and in the act of governing states shape health care institutions, and are in turn shaped by those institutions … Health care systems pose problems for statecraft; but they also offer ways of solving problems, often problems whose origins lie beyond health care systems themselves. (Moran, 1999: 4–5)

    This description is certainly apt in a Britain where not only does public expenditure on healthcare and direct provision of such care massively outweigh what is privately funded or privately provided, but also where this arrangement is routinely used by governments to enhance their political legitimacy. This connects with contemporary ideas about ‘governance’ which emphasise that, despite the formal provisions of national constitutions, states and governments do not simply govern in a top-down fashion. Rather, they seek to steer society through a variety of channels, some of which are indirect (Pierre and Peters, 2000: 4–5). In order to govern in this sense, governments must by various means enlist the efforts of other social actors. In Britain, the latter of course include ‘official’ public bodies, such as the institutions of the National Health Service (NHS), numerous professional, academic and other interest groups, and less easily definable ‘social movements’ (such as the ‘patient movement’ or the ‘evidence-based medicine movement’) based as much on shared identities as shared interests (Byrne, 1997). Mapping and analysing the interactions between governments and such actors are a central focus of this volume.

    The third element of our book title locates our work in the context of Britain, that is England, Scotland and Wales. There have long been organisational differences (and differences of official terminology) between the three countries (Williamson and Room, 1983). As we show in Chapter 7, these have widened in recent years as a result of devolution to the Scottish Parliament and the Welsh Assembly (Greer, 2004), which is also beginning to result in differences in patient entitlement. Elsewhere in the book, however, we have confined our official terminology to that of the English NHS, whilst trying to ensure that the overall thrust of our analysis is applicable to the whole of Britain. The continuing rapid rate of NHS organisational change precludes any attempt to include definitive organisation charts and even the Department of Health no longer seems to attempt this. In order to avoid becoming mired in the minute history of changes in the titles of statutory bodies, we have generally referred simply to ‘health authorities’ where the context does not require precision.

    A textbook such as the present volume does not have the same sort of aims as the research papers and conceptual reviews on which, as full-time researchers, we spend most of our time. The latter are tightly written in order to make at the most a few points; they therefore tend to employ a narrow range of concepts and literature that relate closely to the argument and/or evidence that is being deployed. In contrast, a textbook has the wider aim of informing readers about the general state of its subject matter. It must introduce a selection of relevant theories, concepts and evidence but it will necessarily leave loose ends and confine itself to indicating general lines of analysis and argument rather than pursuing them rigorously to a single conclusion. In order to meet this wider textbook aim, we have adopted a particular and distinctive structure for each of our substantive themes, that is Chapters 1 to 6. Each has four main sections; the first introduces a range of concepts that we take to be central to the particular theme, the second section provides a summary history of the theme, and the third summarises recent and contemporary developments. The final section of each chapter consists of discussion of how a small sample of theories might be used to address questions relevant to the chapter's theme. It is important to stress that these discussions do not constitute serious ‘tests’ of the theories; our purpose is rather to suggest to the reader how such abstract material can be related to substantive accounts. Our book would have been unacceptably long had we not been selective in our choice of themes. Important casualties of this selection process have included the politics of public/environmental health, the politics of pharmaceutical manufacture and regulation, and the politics of social care. On community care, see Means et al. (2003) and for public health, see Baggott (2000) and Lewis (1986). On pharmaceuticals, see Abraham (1997), Abraham and Lewis (2001), Davis (1997) and the edited European collection by Mossialos et al. (2004).

    Some excellent health policy texts are very limited in theoretical coverage, either employing it only implicitly or treating it as primarily critical. We have taken the opposite view here, employing a wide range of conceptual and theoretical material, drawn mainly from political science and sociology but with important contributions from economics. Some readers may feel that we have been too eclectic, and that we should have undertaken a consistent political analysis, or that important intellectual traditions have been neglected. Others may feel that there is altogether too much conceptual material. We hope, however, that most will find our approach stimulating in terms of generating questions and analyses of their own. Our policy of providing extensive citations and a reading guide is designed to support further study.

    Chapter 7 is designed to work in a different way from the other chapters. It follows from our textbook philosophy, summarised above, that we cannot provide a final chapter to summarise the book and neatly tie up the loose ends. Instead, Chapter 7 addresses the risk that our thematic approach diverts attention from potential interaction and tensions between themes. We therefore consider three such tensions that may set the scene for future political and policy conflicts.

    Readers will note that our book is extensively referenced in relation to specific points made in the text. The text also sometimes indicates sources for more detailed coverage or overviews of such points. In addition, at the end of each chapter we provide a brief guide to further reading which relates to issues covered in that chapter.

    With regard to reading materials on health policy and politics more generally, of the numerous UK health policy texts available, the current editions of Ham (2004) and Baggott (2004) offer wide-ranging and complementary coverage. The two-volume official history of the NHS (Webster, 1988, 1996) is comprehensive from before 1948 to 1979; a shorter but still detailed account of the first 50 years is Rivett (1998). Specifically political histories of the NHS are the current editions of Klein (2006) and Webster (2002). The creation of the NHS in 1948 is the subject of studies by Willcocks (1967) and Pater (1981). The detailed history of NHS organisation through to 1998 can be pieced together from the various editions of Levitt (1976; 1979), Levitt and Wall (1984, 1992) and Levitt et al. (1995, 1999). The history of the Department of Health is selectively covered in Rayner (1994), Day and Klein (1997) and Greer and Jarman (2007). The successive editions of the Compendium of Health Statistics (most recently Office of Health Economics, 2007) provide useful tabular and graphical data about the NHS and British healthcare, with some international comparisons.

    Academic authors incur numerous intellectual debts, most of which they quickly forget as others' ideas become incorporated in their own thought. The following list of acknowledgements is no doubt grievously incomplete, and we apologise for omissions: Andrew Gray (formerly University of Durham), Huw Davies (St Andrews), Tim Milewa (Brunel University), Christopher Pollitt (Catholic University of Leuven) and our University of Manchester colleagues Kath Checkland, George Dowswell, Mick Moran, John Pickstone and Martin Roland.

    Whilst writing this book we have both experienced rather closer contact with the NHS than we would have wished (as patient and carer respectively) so we are grateful to Karen Phillips and Anna Luker of Messrs Sage for their continued patience in the face of our numerous postponements of the manuscript delivery date. Finally, thanks for both support and appropriate diversion are due to our partners Annie Dearman and Tim Payne respectively, and in SH's case to Vic Gammon and the gang at Ryburn 3-Step (http://www.ryburn3step.org).

    SteveHarrisonRuthMcDonald
  • Glossary of Abbreviations

    • AHCPR – Agency for Health Care Policy and Research (USA)
    • BMA – British Medical Association
    • BRMA – Board of Registration of Medical Auxiliaries
    • CHC – Community Health Council
    • CMB – Central Midwives' Board
    • CMO – Chief Medical Officer (of Department of Health)
    • CPPIH – Commission for Patient and Public Involvement in Health
    • CPSM – Council for Professions Supplementary to Medicine
    • DHSS – Department of Health and Social Security (Department of Health after 1988)
    • DRG – Diagnosis-related group (casemix measure)
    • EBM – Evidence-based medicine
    • EBP – Evidence-based practice
    • EPP – Expert Patient Programme
    • FAD – Final Appraisal Determination (by NICE)
    • FT – Foundation Trust
    • GDP – Gross domestic product
    • GMC – General Medical Council
    • GNC – General Nursing Council
    • GP – General (Medical) Practitioner
    • GPFH – General Practice Fundholder/Fundholding
    • HAZ – Health Action Zone
    • HRG – Healthcare resource group (casemix measure)
    • ICAS – Independent Complaints Advocacy Service
    • LINk – Local involvement network
    • MMR – measles, mumps, rubella (‘triple’ vaccine)
    • MS – multiple sclerosis
    • NHS – National Health Service
    • NICE – National Institute for Clinical Excellence, renamed National Institute for Health and Clinical Excellence in April 2005
    • NPM – New public management
    • NSF – National Service Framework
    • OSC – Overview and Scrutiny Committee
    • PAD – Provisional Appraisal Determination (by NICE)
    • PALS – Patient Advice and Liaison Service
    • PBC – Practice-based Commissioning
    • PCG – Primary Care Group
    • PCT – Primary Care Trust
    • PFI – Private finance initiative
    • PPIF – Patient and Public Involvement Forum
    • QALY – Quality-adjusted Life Year
    • QOF – Quality and Outcomes Framework
    • R and D – Research and development
    • RCT – Randomised controlled trial
    • SMC – Scottish Medicines Consortium
    • TPPC – Total Purchasing in Primary Care
    • UK – United Kingdom (England, Scotland, Wales, Northern Ireland)
    • UKCC – UK Central Council for Nursing, Midwifery and Health Visiting
    • US – United States (of America)

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