Healthcare in Transition

Understanding Key Ideas and Tensions in Contemporary Health Policy

Cribb, Alan, Alan Cribb

• Publisher: Policy Press
• Year: 2017
• ISBN:
  9781447323259
• Edition: 1
• Topic: Medicine
• Subtopic: Health Policy

Health policy thinking must change. This book explores the fundamental currents and tensions that lie behind recent trends such as shared decision-making, co-production, and personalisation.

These are often discussed in relation to an epidemiological transition but this text argues that they embody a philosophical transition – a change in our conceptions of healthcare and of appropriate forms of knowledge and analysis. As clinical concerns are increasingly nested within social concerns then policy analysis must engage with the multiple philosophical tensions that are now centre stage.

This focus on key underlying ideas and tensions in healthcare couldn't have come at a better time. With international relevance, the book's arguments help fuel a shift away from a 'delivery' model towards a more deliberative model of healthcare.

SEVEN

Shaping the future

In this book I have been looking at some of the ways in which the currents of healthcare thinking have started to flow down different channels. New organising ideas have emerged that embody and produce different healthcare architectures and practice logics. I have relied on some very broad–brush terms to indicate these changes – the shift in emphasis from clinical to social lenses and agendas, including the relative decline in the dominance of the biomedical model and the growth of more person–centred models. Most of what I have said has raised concerns about these new emphases, and shown how they produce new problems or complications, but that is not meant to suggest that the trends I have been discussing should be resisted. (Certainly not – for the most part I want to cheer them along.) Rather, it is to stress that there are no problem–free paths in health policy, and to highlight, in particular, that there are normative tensions or 'value contests' built into any paths we might take.

In this chapter I will summarise some of the arguments of the book and draw some broad conclusions about the ongoing philosophical transition in health policy. There are signs of progress – for example, less presumed hierarchy between clinicians and the populations they serve and the growing acceptance that everyone can be seen as a health actor in a range of ways. In what follows I will explore some promising avenues for realising this more democratic conception of health–related action, especially around new ways of thinking about the spaces and resources that can support care. But there are also serious outstanding problems, most notably persisting health inequalities – and not only serious inequalities in health experiences but also inequalities in meaningful opportunities to be an effective healthcare actor.

This concluding chapter is necessarily broad ranging. I will begin by critiquing a 'delivery' paradigm of healthcare thinking and reiterating my contention that the philosophical transition is a transition 'towards philosophy'. In the main body of the chapter I will consider the importance of both 'digital health' and 'asset–based working' as potential paths forward, and I will then move on to reflect on the viability of making health a collective responsibility. Overall I want to argue that we are now required to think about health policy and healthcare in fundamentally different ways. This, I suggest, requires us to adopt a much more expansive and radical conception of a 'learning healthcare system'.

I am keen to displace, and in many places to dissolve or destroy, the tendency to think about healthcare as a question of 'delivery'. There can be a place for this notion but it is one that has a tendency to overrun the landscape like a deadly weed. At the professional– patient level we have become accustomed to the idea that the patient is not simply a destination to which healthcare is delivered. This insight has become familiar from work in healthcare ethics, on the evolving nature of healthcare professionalism, on quality and 'patient experience', and from work that highlights the nature of 'service goods' as contrasted with 'product goods. But essentially the same insight – I am suggesting and will underline in this chapter – applies equally to health policies, systems and institutions across the board. The image or metaphor of 'delivery' fundamentally misses the point. At every level debates and questions about bringing about or achieving the 'goods' in question cannot be disentangled from debates and questions about what we think should be done and by whom, about what matters and about the nature of the relevant goods. Hence the focus of this book on the 'internal goods' of healthcare – crudely, 'health and 'care' – and on the contests that arise when these goods are translated into either biomedical or/and person–centred categories and logics.

At the professional– patient level it is possible to do great harm if we 'deliver' something to an individual that does not accord with his or her values and preferences. Analogously it is potentially very harmful (and at scale) if we pursue health–policy ends driven by a commitment to 'what works', unless this is accompanied by an equal commitment to confronting very challenging debates and questions about what should count as working for the relevant stakeholders from case to case. The key thing to note is that neither 'health' nor 'care' is a clear–cut good; nor are they, in very many cases, goods that can be independently identified and packaged up by some for the benefit of others. Both the identification and realisation of these kinds of goods depend upon collaborative working, and on sometimes uncomfortable or difficult relationships between people with regard to both knowledge and action.

In concentrating my attention on policy transitions that relate to the internal goods of healthcare – about what, in general terms, healthcare is and is for – I have more or less neglected many other questions that are quite properly treated as relevant to the changing landscape of health policy. For example, I have not focused in on controversies about specific innovations – such as applications of stem cell therapy or gene editing and so on – or overlapping debates about what packages of specific treatments should be legally available, or how common resources should be allocated. Similarly I have neglected other questions that are central to health policy analysis; for example, although I have acknowledged the importance of questions about the appropriate balance between market and state forms of system coordination, I have said comparatively little about them.

Before continuing I should stress again that, despite their neglect here, questions about technological change or the social organisation of healthcare are very relevant to my theme. The goods of healthcare are shaped by many contextual factors, including the technological nexus and the networks of relationships and norms in which they are embedded. This is merely the corollary of the point that healthcare does not simply consist of separable 'products that remain consistent and intact wherever they sit (like trays of nuts or bolts moving along conveyor belts). Hence even largely ignoring (important) questions about how efficient or equitable different models of provision are, we cannot afford to ignore related questions about their constitutive effects on healthcare goods. In relation to the 'market versus state' question, for example, these effects, although real, can sometimes be quite difficult to read, and subtle. There are crude generalisations and stereotypes in circulation – that markets are highly responsive to finely grained differences in preferences between people, or that they are merely a mechanism for getting vulnerable people to pay for things that they don't need or would be better off without; that state–organised collective provision is a way of underpinning the universal availability and quality of all worthwhile treatments, or that it is no more than an insensitive means of rationing 'bog standard' care. Except by underlining (as discussed, for example, in Chapter Four) the persuasive concerns that many have raised about the limits to market practices in healthcare, I am not interested in arbitrating between these kinds of generalisations. In practice we would need to look much more closely – both theoretically and empirically, and using methods that are sensitive to different contexts and cases – at how the milieux in which healthcare is enacted shape the ways in which various healthcare goods are interpreted and realised and in which healthcare is lived and experienced. In addition, as I will go on to argue later in the chapter, we need to look beyond the state 'versus' market debate, or even questions about the contribution of a 'third sector', and ask how the coordination of healthcare can reflect the more democratic aspirations embedded in reforming currents. Indeed the issue of the mix of state, market and 'third sector organisation is only one very general example of the social construction of healthcare goods. Overlapping analyses can and should be applied to the constitutive effects of different kinds of institutional regimes, approaches to management, models of professionalism and so on – in every case social milieux shape healthcare goods.

Healthcare goods as social goods

The philosophical transition I have looked at – which can be summarised very roughly as the rise of a social conception of healthcare – can be described in contrasting ways and deployed in different stories. One story is a straightforwardly positive account of policy progress in which the healthcare agenda has been enlarged to enable more respect for, and responsiveness to, persons, including more attention to the broader social determinants of health. But there is a contrasting story – less straightforward, and more problematic to evaluate – according to which the philosophical transition 'muddies' the waters of healthcare, that is, produces fuzzier categories and ever–increasing contestability and uncertainty. These two stories are not wholly incompatible with one another; indeed I am inclined to subscribe to both of them. But they do not sit together entirely comfortably because they highlight different things. The former is useful for indicating general policy directions and aspirations; but the latter underlines the many complexities and balancing acts generated by attempts to translate these general aspirations into real– world policy and practice decisions. In this section I will develop this point and say more about how these two stories – positive and problematising – are connected.

I have adopted the language of 'person–centred care' to illustrate and discuss the philosophical transition in earlier chapters. But the same themes can be briefly summarised, albeit at quite an abstract level, by sticking with the underlying idea that there is a shift in emphasis from clinical to social concerns (that is, where 'concerns' includes both social matters and social perspectives).

If we place a lot of weight on clinical agendas, and interpret these in terms of the management of disease, or the pursuit of other biomedically defined outcomes, then there is at least a plausible case for being able to make relatively value–free, impersonal or 'objective' claims about what we are doing. (Noting, of course, that there are important contests even here relating to the socio–cultural constitution, organisation and exercise of clinical knowledge.) This is because the claims we are making refer largely to bodies or to other biophysical or biochemical entities. However, the moment we move away from this focus things become more uncertain and contested, and each step further away that we move, the more this process accelerates until it soon becomes quite dizzying.

For any single individual, having their biological constitution moved closer to a state that might 'objectively' correspond with what is 'normal' or 'clinically healthy' for them may or may not be desirable – depending upon the broader costs and benefits entailed and on their other projects and commitments. The values of individuals determine what counts as 'good' or 'bad' here; and this is now an uncontroversial thing to say, even if it is not always easy to operationalise in practice (which involves ensuring proper mutual communication, understanding and reliable identification of values and so on). One (rough) way to handle this 'incursion' of individual values and preferences in the case of relatively immediate treatment decisions is to envisage a practical split between clinical 'facts' and personal 'values', and to see the latter as an important extra consideration, and 'veto', to the former. But this tactic becomes much harder, and eventually unsustainable, as we broaden the frame of reference along one or both of two axes. Specifically, that is, if (i) we look at broader time– space continua (for example at policies that affect more than one person, especially system or population–level judgements); or (ii) we consider broader conceptions of health and health–related action, including both the range of conditions underpinning, and various manifestations of, health.

Firstly, there is a high level of uncertainty and contestability attached to broad–based policy claims; for example, claims about health system organisation, health service design or health promotion. And this is not simply because of difficulties of making causal judgements, in relatively open–ended social systems, about what would happen if x or y is done, but also because the lenses through which we make such judgements, or the categories that we use in constructing them, are heavily value laden. In addition we are, at the same time, seeking to be responsive to numerous people who will often have very different sets of values and preferences. Secondly, once we acknowledge that claims about health may not solely be claims about biological states of affairs but might be about other aspects of health–related quality of life – such as how people experience illness, how far they are (enabled to) engage in matters that affect them (clinically or more broadly), the quality of relationships and trust they experience with carers, the overall satisfaction they have with their lot, and whether the opportunities are in place for them to be able to have a life they regard as fulfilling, and so on – then it becomes obvious that there are multiple and competing value–laden conceptions of what might and should count in organising or assessing healthcare. In short, a shift in emphasis from clinical to social concerns moves us towards a heavily contested arena in which potential controversies abound and value tensions become the norm.

Thus, as I briefly indicated in the opening chapter, we are arguably talking about a philosophical transition in two senses. The opening up of agendas and complexities – as the centre of gravity of health policy has gradually shifted to embrace broader conceptions of healthcare, including health–related action and goods – amounts to a philosophical transition in the sense of a shift in underlying 'philosophies' of healthcare. But, I want to say, this can also be seen as a transition towards 'philosophy'. That is, the emerging world of health policy is one that demands the management of pervasive disagreements about what matters (including the categories we should be operating with, and the voices that should determine this) and the continuous negotiation of normative tensions. These broadly philosophical issues are not a 'side show', or an extra layer of considerations occurring alongside strategic, regulatory and technical questions about service organisation or 'good practice'; rather, they are inseparable from these questions and sit at the heart of them.

My argument, in summary, has been that while each strand of person–centred thinking provides a fundamentally important counterweight to narrow framings of healthcare, and can be defended in these terms, they each also take us into difficult territory. Bluntly speaking, they cannot simply be treated as providing 'solutions' to the shortcomings of biomedically dominated healthcare. This is for a variety of reasons, which I will pull together into three points.

First, in each case there is some value to be attached to the more traditional and narrower emphases, and some grounds to defend them. This leaves a question of how to combine and balance the narrow and broader emphases. Second, in each case there are many possible interpretations of what is meant by, and entailed by, the reference to 'persons' and the aspect of person– centredness that is foregrounded. That is, there are multiple contests of interpretation to be had both within and across the strands discussed in Chapters Three, Four and Five. A key axis here is how far 'persons' should be read in an individualist way, that is, as relating to persons as separate, or in more social ways, that is, as relating to persons as related and socially embedded. Third, overlapping with the first two points, there are no clear means of agreeing how much of what kinds of these 'counterweights' are for the good. In other words, it is not simply that the kinds of 'corrections that are pointed to are open to considerable interpretation but also that they can be the subject of legitimate and conscientious disagreements going well beyond the arena of technical judgement. In these three points, and in the preceding chapters, I have sketched out a large matrix of contestation.

A simple way of summarising some of the contests here is to ask whether there is any case that could be mounted for (rather than just against) the social authority of professionals, the management of diseases or the standardisation of provision in healthcare. Clearly the answer, in relation to each of the three strands, is yes. Advocates of these things could easily produce principled arguments to support their positions. Furthermore, no one (or at least, virtually no one) is suggesting that these things don't have a place or that the arguments that could be rehearsed for them could be wholly rejected. For example, the roles of doctors (and health professional roles more broadly) may need to adapt, they may even need to be substantially reconfigured, but advocates of person– centred approaches are not suggesting that they should disappear altogether. And part of the core rationale of professional roles is that professionals are licensed to exercise specific kinds of expertise– based social authority. Given this, there are limits to how far it is meaningful, sensible or morally defensible for health professionals to subjugate their judgement to other people's preferences or demands. This seems relatively non– contentious. However, this leaves scope for very widespread disagreements about quite how, and how extensively, we should reconceptualise the professional– patient relationship, and how best – in various respects – to combine professional and patient (or lay, public and so on) agency and authority.

It is arguably this reconceptualisation of relationship – and indeed the intensified emphasis on relationship – that is the central issue here. Health services and professionals, in, for example, deciding on the relative emphasis to be given to disease management and/or standardised protocols and practices, need to work in dialogue with the people they serve and to be responsive (among other things) to what matters to people. Indeed – as I will go on to explore further in the following sections – most fundamentally they need to find ways of collaborating with and working alongside individuals and communities, that is, ways of working with people and not just for or on them. Both for these reasons and as an end in itself services and professionals need to build relationships. This marks a change from a transactional or 'delivery' paradigm and this inevitably also moves us onto a landscape where instrumentalist and technicist categories, centred on outcomes, effectiveness and efficiency, are inadequate. In the emerging landscape some degree of comfort in dealing with personal and social values, and associated value contests, has become an 'essential requirement' in the job descriptions of all policy makers and professionals.

The fact that emerging ideas – and the value contests that attach to them – make both policy making and analysis complicated does not mean that we cannot come to any substantive conclusions about policy directions. It is rather that we have to be mindful of the complications and contests that arise when we seek to interpret and apply these conclusions in practice. For example, I would argue, based on the ground I have covered, that any defensible interpretation of person–centredness needs to be 'plural'. That is, that it should both reflect the multi–faceted nature of persons (not reducing person–centred thinking to one dimension) and – equally vital – be alive to the reality of people in communities, and as collectives, and not just to individual persons considered separately. If people are to be able to enjoy health, and participate in health–related practices and policies, there needs to be a heavy emphasis on structural action towards building better health ecologies for the common good. And this should not be seen as simply about 'public health' in a restricted sense but as applying equally to the systems that underpin social well–being, including healthcare services. Good healthcare depends upon 'integrated' attention to the social and material conditions of our lives, including the organisation of effective healthcare systems and services. This is not in any way to reject the importance of personalised attention to, and biographical working with, individuals. It is vital – although not necessarily easy – to ensure that these things are not squeezed out by system designs and priorities. But, while recognising this, it should be clear that these individually oriented forms of person–centred care actually depend upon us acting holistically and collectively, and crafting systems accordingly.

These, by way of 'headlines', are some of my own substantive conclusions. However, to repeat, I fully appreciate that the translation of these broad ideas into practical reality will be both challenging and contested. In the reminder of this chapter I consider some of these complications.

Person power – digitally delivered?

One of the most clear–cut trends in policy thinking is the ever–growing recognition of the importance of patients and populations as health–related actors. This basic idea lies behind diverse developments such as self–management, co–design of health services, patient–led research or education, community development partnerships, health–related social media fora and so on. The notion that everyone is a health actor is one example of the process, which I have referred to from time to time, of challenging or 'inverting' limited traditional norms. In this case, for example, it can be accompanied by sentiments and statements (or slogans) to the effect that healthcare is becoming more equal or more democratic. This broadly 'democratising' current is an absolutely key dimension of ...

Table of contents

• Coverpage
• Title page
• Copyright
• Contents
• Acknowledgements
• Preface
• one: Building blocks
• two: Taking less medicine
• three: Choosing care
• four: Systems and lives
• five: Especially for you
• six: The challenge of integration
• seven: Shaping the future
• References