Health Policy, Power and Politics

Sociological Insights

Michael Calnan

• Publisher: Emerald Publishing Limited
• Year: 2020
• ISBN:
  9781839093968
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

In the context of substantial changes in health service policy and public health policy in England over the last two decades, Health Policy, Power and Politics fills an important gap by providing an up-to-date and accessible account of recent trends in health policies and a sociological analysis of why these policies have taken the shape they have.
This book provides a theoretically informed analysis of key recent policy changes in England and how the interplay of powerful structural interests has influenced policy in health. It includes chapters on recent reforms in the NHS and the drift towards privatisation, policies aimed at enhancing public and patient involvement, the regulation of the drug industry, medicalisation and mental health policy, the role and effect of the media and recent changes in social and environmental health policy. The analysis examines the influence of the State, professional medicine, the media, commercial interests such as those of the pharmaceutical, food and fossil fuel industries, patient's groups and the wider global environment.
While the key focus of the book is on England, the analysis drawn on by the author comes from a plethora of policy examples in health systems in high and low to middle income countries across the world. This widened context shines a light on the influence of globalisation and highlights both the distinctive character of health policy in England, as well as the common themes it shares in a world-wide context.

Chapter 1

Continuity or Change? Organisational Developments in the National Health Service

This chapter will characterise different types of organisational policy and focus on recent changes in the English NHS with a view to understanding the organisational characteristics of the current NHS and what has shaped it. The emphasis will be placed on policy developments in England because in the early part of this century, there was some element of devolution with the four countries of the UK tending to adopt their own distinctive and diverging health policies (Prior et al., 2012) with the policy in England being particularly characterised by choice and the market. The analysis will focus on the extent recent reforms reflect a significant, radical change or are incremental, building on and continuing from what has gone before. This chapter will look at the extent to which fears or claims about privatisation in the NHS have materialised. Finally, it will present data which compare the performance of the NHS with different health systems in other high-income countries.

Recent Reforms: The Case of the 2012 Health and Social Care Act

The NHS was set up in 1948 as a universal health service system free at the point of access and funded by the state, primarily from public taxation. Its structure is based on general practice, located in the community, being the first port of call for most patients who are then referred on to hospital and other specialist services if necessary. This structure is based on the idea of the general practitioner (GP) being the coordinator of care for the patient, but this also might be seen as a gatekeeping role where the GP acts as a controller by rationing patient access to expensive high technological and specialist services usually based in the hospital. This gatekeeping strategy has proved to be an efficient rationing policy as will become evident in the final section of this chapter. However, patients do have direct access to hospital through the accident and emergency services, but this is rationed mainly through strategies aimed at educating patients about its ‘appropriate’ use. The common pathway for most patients to gain access to the NHS is through general practices which the vast majority of the population are registered with. Survey evidence consistently shows strong public support for a high level of investment of money in the NHS at least compared with other areas of welfare (King’s Fund, 2015a, 2019a), and it appears that the NHS was and continues to be a ‘sacred’ institution (Hunter, 2016). Politicians are therefore wary of proposing and implementing significant reforms, the dangers of which are clearly exemplified in the recent, initial response to the attempted reforms by the coalition government. However, in spite of this caution, the NHS has gone through a number of different reorganisations (four – which is more than in other high-income countries with different sources of healthcare funding; Touhy, 2018) since its inception which have primarily reflected the influence of the interests of both the medical profession and the state or government in power at the time (Hunter, 2016).

Harrison and McDonald (2008) proposed a typology of ideal types of organisation which include markets where equilibrium emerges from providers and consumers each pursuing their own interests, bureaucracy/management where members can only pursue their own interests by obeying the hierarchy, professionals where interests are shaped by values and culture and networks where members exchange resources voluntarily in pursuit of common interests. In the early days of the NHS, the organisation was very much dominated by medical professionals, and a professional type of bureaucracy began to emerge linked to the approach of consensus management. The 1980s saw the introduction of the new public management after the Griffiths report which began to gain ground and was fully enshrined in the new Labour administration’s health service policy in the late 1990s and in the first decade of this century. There was an emphasis on hierarchy which posed a potential challenge to the medical profession (see Chapter 2). The new Labour administration initially flirted with the idea of patient-focused organisations based on networks and communitarianism rather than hierarchy, although this theme seems to have been dropped in favour of managerialism and competition in the later terms of the government. The market type of organisation had been introduced which involved the introduction of market principles, such as choice and competition and incentives to complement command and control, although the beginnings of this approach were also evident in the early 1990s, with the development of the internal/quasi market in the NHS. The latter policy development was based on the idea of managed competition in the state sector with hospitals being expected to compete for patients. The assumption inherent in this policy of the introduction of the internal market with its purchaser/provider split was that the responsiveness and efficiency of the private sector is the ideal to follow and thus the public sector should do its utmost to adhere to these principles (Dopson, 2009).

The most significant recent reforms in the NHS in England were those associated with the implementation of the Health and Social Care Act (2012) in 2013. This piece of legislation was formulated by the coalition government (Conservatives and Liberals) and was the product of a turbulent series of negotiations and consultations (Timmins, 2012). The policy proposals in the earlier 2010 white paper had to be significantly diluted due to the strong opposition from key interest groups such as the elite branches of medicine which led to an extensive consultation/listening exercise or what was termed an ‘enforced pause’ for thought. The architect of the 2010 white paper was a staunch marketeer Andrew Lansley, but the consultation exercise led to a reduction of an emphasis on competition with an attempt to place more emphasis on integration which became increasingly prominent in more recent policy. It was not clear why these ‘big bang’ reforms (Jarman & Greer, 2015) were being proposed as it was not prominent in the two main parties’ policy manifestos, or what particular problem they were trying to solve through the proposed reforms, in that there was little evidence of a crisis of performance or financial crisis in the NHS (Hunter, 2016). For example, as Powell and Exworthy (2016) state in trying to understand why these reforms were introduced (drawing on Jarman & Greer, 2015):

one remarkable thing about coalition health policy has been the sheer improbability: of all the problems facing the UK (let alone the NHS) in 2010 the reorganisation of the NHS could not have been a big one. (p. 369)

One speculative argument suggests that the reforms were driven primarily by a group including Andrew Lansley which was committed to neoliberal ideologies aimed at rolling back the state particularly in a key area such as the socialised healthcare system (Hunter, 2016).

The main legislative changes associated with the 2012 Act (Powell, 2016) involved the abolishment of primary care trusts (PCTs) and strategic health authorities and the setting up of clinical commissioning groups (CCGs) which were to take over from PCTs and work with the newly created body entitled NHS England (Timmins, 2018). The latter body was an arm’s-length quango with the purpose of trying to distance the NHS from micro political management by the Department of Health (DoH) which it is argued that it failed to do (Timmins, 2018). Two other key agencies were set up to regulate these commissioning groups, which were NHS Improvement and the Care Quality Commission (CQC) which aimed to be the OFSTED in the healthcare sector. Monitor extended its role into economic regulation and aimed to have a key role in monitoring competition rules in commissioning decisions with an emphasis being placed on the promotion of integration and patient interests. The clinical commissioning consortia were to include nurses, hospital doctors and allied health professionals as well as GPs and managers. Health and Well-Being boards were set up to enable integration of health and social care. The voice of patients was to be reflected through Healthwatch and local Healthwatch organisations, and Public Health England (PHE) was to lead on public health with local authorities taking the lead at the local level. One of the more radical proposals in the 2010 white paper was to remove the Secretary of State’s powers to intervene in detailed NHS matters, but this was subsequently amended, so the Secretary of State was still ministerially accountable to Parliament for the NHS. More generally, there was a shift towards the market as a form of organisation with less bureaucracy, with an increasing emphasis on professional, clinical judgements and influence in the commissioning processes at least at the local level (Calovski & Calnan, 2019; Timmins, 2012).

Major concerns were voiced about these reforms, not least the claim that they will lead to greater privatisation and the fragmentation of services (Pollock et al., 2012). The concerns about privatisation were related to a number of themes in the new reforms, such as the increased emphasis on choice and competition, and under the any qualified provider system, patients would be able to choose to be treated by any qualified organisation that is registered with the necessary regulatory agencies, willing to accept NHS prices and agree to the terms laid out in the NHS contract. There was also concern that there would be an increasing proportion of NHS-funded care delivered by the private and voluntary sectors along with new opportunities for organisations to provide support services to the commissioning side of the NHS. In addition, there was the abolition of the cap on the proportion of income that the NHS hospitals could earn from private income. Furthermore, private providers could now complain to the new body called Monitor as well as the Competition Commission and thus would have the ability to challenge commissioning decisions, which could enhance their leverage and increase their opportunities for involvement in the market (Calovski & Calnan, 2019). A further concern was that the radical restructuring of the NHS would be a major distraction to clinicians and managers at a time when it faced one of its biggest financial challenges in history (Ham, Baird, Gregory, Jabbel, & Alderwick, 2015).

There is some evidence about the impact of these reforms, at least over the short term, but before this is considered, it is necessary to clarify what the ‘contested’ concepts of marketisation and privatisation mean (Krachler & Greer, 2015). Some authors suggest that marketisation forms part of the overall concept of privatisation (Le Grand & Robinson, 1984), whereas others suggest that they are distinctive concepts (Krachler & Greer, 2015). Marketisation has been defined as when the health service does not leave the public sector, but there is a move to make it more market like. Privatisation, on the other hand, is when there is a change in the funding or provision of a service rather than organisational change, such as the withdrawal of the state and its replacement by another group (Calovski & Calnan, 2019).

The private health sector in England has been relatively small compared with the NHS but has varied in size according to the socio-political values of the government in power (Calnan, Cant, & Gabe, 1993). Pay beds were available in the NHS at its inception but were gradually phased out by the 1970s. However, the most significant expansion occurred in the 1980s when the Conservative government policy encouraged both the expansion of private health insurance and private hospital provision Calnan, Cant, & Gabe, 1993). These were privatisation policies which created opportunities for the private sector to grow through deregulation and through tax incentives. Subscription to private health insurance peaked in the 1990s (12% in 1997) when NHS hospital waiting lists were relatively long. However, the majority of subscribers tended to be in company rather than individual schemes, in professional and managerial occupations and were self-employed and located in the South East of England. Private insurance therefore could not be characterised as a consumption good as it was very much a company ‘perk’ not directly based on patient demand. Coupled with the increase in private health insurance coverage was the expansion of the privately financed independent hospital sector which also peaked (227) in the 1990s due partly to the deregulation and the relaxation of restrictions on hospital development. This led to an increase in the influx from the US of ‘for profit’ or commercial hospital companies, as opposed to charity-funded hospitals, particularly located in the south-east of England (Calnan et al., 1993).

One of the key players in the maintenance of the hospital-based private sector in England competing with and/or complementing the NHS was hospital consultant specialist doctors whose contracts enabled them to work in the private sector as well as in the NHS. In the 1980s, consultants’ contracts were revised allowing them to spend more time working in the private sector. It has been noted that there is a correlation between those specialties with the longest waiting lists and those which produce the most lucrative earnings for consultants in the private sector. The evidence suggests that those hospital consultants who do the most private work do less NHS work than their colleagues (Shaw, 2003). For example, a recent report (British Medical Journal (BMJ), 2019a), which investigated how private hospitals use financial incentives to win the business of medical consultants, found that a significant number of NHS consultants (546) own shares and equipment in private hospitals, giving them a potential financial incentive to refer patients to these hospitals for treatment. Private hospitals were also found to give consultants who referred patients to them ‘substantial amounts of corporate hospitality’, with an estimated £1.5 million worth of gifts given.

Another lucrative area for private work is cosmetic or plastic surgery. Some plastic surgery is available on the NHS where there are health-related reasons for the procedure such as for breast reconstruction. However, there has been a marked increase in the use of the private sector, usually through out-of-pocket payments, for cosmetic surgery which can involve medical tourism. The value of the cosmetic sector in the UK had risen from £720 million in 2005 to £2.3 billion in 2010 and was estimated to grow to a value of £3.6 billion by 2015 (Sanchez Taylor, 2016) although austerity policies appears to have slowed down this rapid growth. Cosmetic surgery appears to be gender related and suggested explanations for its popularity include increasing affordability, technological change making more procedures available, the pervasiveness of celebrity culture, the development of digitally manipulated photographs (typifying unrealistic representations of beauty), the rise in the use of social media (including the trend of posting ‘selfies’ online) and self-monitoring apps and easier access to pornography depicting unrealistic images of what is normal or desirable. In the context of the UK, these proposed explanations are also embedded in a society where body image is said to be poor compared with other countries (Sanchez Taylor, 2016).

In summary, the Conservative government policies in the 1980s encouraged the expansion of the private sector and an attempt to shift towards a perhaps more pluralistic health system. A further key policy development developed by the Conservative administration in 1992 was the private financial initiative (PFI). PFI is used as a way of resourcing capital investment in the NHS by designing, building, owning, operating facilities in return for an annual availability payment over an extended period and is a way of harnessing private corporate resources to supplement those available from general taxation (Mohan, 2009). Since 1994, all planned capital developments are required to include an option appraisal of viability for PFI, and this initiative has only very recently been abandoned. There are also specialisms of medicine which are more likely to be colonised by the private sector particularly where there is the opportunity for profit such as dentistry, ophthalmology and more recently physiotherapy and some areas of mental healthcare although the area of elective surgery is in more direct competition with the NHS.

The policy approach to the private health sector taken by the Labour government which followed this Conservative administration in the late 1990s offered, at least in some ways, a different approach. The share of the independent sector (acute and long-term care) of healthcare expenditure decreased, which was primarily the result of a decade of budgetary NHS expansions (Mohan, 2009). Certainly, the decrease in the length of hospital waiting lists led to a decrease in the proportion of the population covered by private health insurance although this was also a result of the increased price of insurance premiums due to the rising cost of medical technology (Calnan et al., 1993). Private health insurance is generally more expensive in England compared to other high-income countries (King’s Fund, 2014). However, the new Labour government’s policy used the private sector to work in partnership with the NHS to reach its targets. Government policy with its continued use of the PFI put in place by the previous government, setting up of Independent Sector Treatment Centres run by for-profit companies for reducing waiting lists and expanding the plurality of provision particularly in primary care, outsourcing and contracting out and an increasing emphasis on patient choice and expansion of private providers led to a blurring of the boundaries between the public and private sectors (Mohan, 2009). The private sector, particularly the acute sector, under that policy, relied on the NHS for a significant source of income (Shaw, 2003):

New Labour differs from what it chooses to call ‘Old Labour’ in that it is not inhibited by outdated ideological formulae. The old battle-line of public versus private is an irrelevant one, which has only served to distract the party from ‘the real challenge of improving our public services’. The old nostrums are irrelevant because ‘in the modern world, governments are judged not on what they own, or on how much they spend, but on whether they deliver’. ‘What matters is what works’. (p. 289)

By 2011, overseas patients represent 2.8% of private hospital revenues; a higher percentage in London; UK patients who paid out of their own pocket accounted for just under 15% of revenue; 26% of private hospital revenues (or just under £1.1 billion) came from NHS purchase of operations and procedures, mainly at standard NHS prices, and 56% came from private medical insurance (King’s Fund, 2014).

One type of policy which has been popular and used regularly over the last 40 years by governments irrespective of political persuasion is outsourcing, which has been defined as where private or third-sector providers deliver services to the government or the public and these contracts are subject to competitive tendering (Sasse et al., 2019). Recent evidence suggests that these policies appear to work adequately when the service is relatively straightforward such as for cleaning, catering and waste collection but perform poorly and are inefficient for more complex service such as probation services (Sasse et al., 2019). The evidence about the impact of outsourcing of health services is inconsistent as the following quotation suggests:

Outsourcing has provided extra capacity in the NHS and, in some cases, improved the performance of public hospitals, but there is a lack of comparable data on cost and quality and some case studies show damaging failures. (Sasse et al., 2019, p. 7)

What is the impact of the most reforms and is there evidence to support the narrative that the recent reforms have led to a dismantling of the NHS? The evidence from the short-term evaluations (Ham et al., 2015) of the recent reforms suggests an increase in marketisation through the increasing use of procurement and commissioning levers but no evidence as yet of mass privatisation, although there was an increasing use of private providers suggesting a ‘creeping’ privatisation. For example, in the last five years, there has been a 50% increase in the amount spent by PCTs/CCGs on non-NHS providers (Charlesworth, Robert, & Lafond, 2016). In 2006, spending on independent sector providers (ISPs) amounted to 3% of total NHS spending, rising to 5% by 2010 and 8% in 2017 (Keep Our NHS Public, 2019). More recent evidence (King’s Fund, 2019b) showed that in 2018/2019, NHS commissioners spent £9.2 billion on services delivered by the private sector (also called ISPs). This is more than the £8.8 billion spent in 2017/2018, but due to inflation and growth in the Depar...