Professional Power and the Need for Health Care

Ian Reese Jones

• Publisher: Taylor & Francis
• Year: 2018
• eBook ISBN: 9780429829000
• Edition: 1
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

First published in 1999, this volume discusses how the nursing and health care fields are developing rapidly. This series of monographs offers up-to-date reports of recently completed research projects in the fields of nursing and health care. The aim of the series is to report studies that have relevance to contemporary nursing and health care practice. It includes reports of research into aspects of clinical nursing care, management and education. The series is of interest to all nurses and health care workers, researchers, managers and educators in the field.

1 Introduction

 

 

 

 

 

The NHS was originally set up on the basis that it would provide universal health care to all, free at the point of need. Webster (1995, 1998) and Harrison et al (1990) have argued in different ways that from the very beginning the NHS was very much a hasty compromise. Klein (1983) on the other hand (among others) argued that the NHS was conceived and born from a political consensus. Despite their differences these commentators appear to be in agreement on at least one thing and that is early descriptions of the NHS as a needs based service were more a product of rhetoric than reality. As we shall see the ‘rhetoric of need’ has unfortunately sustained the idea of a NHS born of political consensus when its history has been, and continues to be, one of conflict (Higgs 1993). It is well known that since its inception the concept of a ‘free’ service has been redefined and the ability of the system to respond to needs has been continually questioned. The image of the NHS as a universal service is however strongly supported by the British public. This may be due in no small part to marked improvements in the health of the British public over the course of the twentieth century. Explanations for improvements in health have been the focus for considerable debate. McKeown (1979) has argued that most of the improvements in life expectancy and in health status from the 17th century onwards can be attributed, in the main, to improvements in socio-economic conditions and not to the developments made in modern health care. His thesis has been criticised for understating the impact of local politics and public health interventions (Szreter 1988) and for underplaying the role of health services (Mercer 1990), particularly in the period after the inception of the NHS. A question mark still remains over the impact of modern medicine in this post war period, whether this is raised by the critiques of radical doctors (Cochrane 1971) or by those starting from a Marxist tradition (Doyal 1979). Whatever the arguments surrounding improvements in population health status since 1948 it is clear that these improvements have not meant the disappearance of inequalities in health. Indeed, inequalities in health have persisted (Townsend and Davidson 1982) and during the decade of the eighties these inequalities have been seen to increase and have been attributed to the relationship between poverty and health (Whitehead 1987, Marmot 1989, Phillimore et al 1994, Bartley Blane and Davey Smith 1998, Acheson 1998).

It is against this background that we should view any changes to the structure of the NHS system itself as well as what motivated these changes. The history of structural and organisation change in the NHS has been sketched by Roberts (1992) as a progression through three periods; the administrative period, the planning period and the management period. In the 1980s, when the system moved into the management period, questions began to be asked about, not only the structure of health service delivery, but also about the supply and demand for health care and the way that health care could be financed in the future (Culyer, Donaldson and Gerard 1988). Such questions were prompted by Conservative views of the NHS as an inflexible and wasteful bureaucracy. They were to be disappointed by reviews that argued against a radical reform of the financing of the NHS and so the Thatcher government turned towards radical initiatives on the structure of the NHS. The capacity of quasi-markets¹ to introduce competitive disciplines to the public sector offered an attractive solution to the problem (Enthoven 1991), and led to the NHS reforms of 1991.

Structural reforms and their impact on needs

From 1st April 1991, District Health Authorities (DHAs) had to set up contracts for health services with providers (Hospitals, Community services, NHS Trusts and Directly Managed Units (DMUs), private and voluntary sector providers) on the basis of an assessment of the health care needs of their residents. General Practitioner fundholders were also allowed to contract for a limited set of health services, independently of DHAs. This arrangement was termed the ‘purchaser provider split’ where purchasers bought services on behalf of their residents or practice populations and providers sold their services in return for payments made from the purchasers’ limited budgets. Negotiations for the buying and selling of services were undertaken through what was called the contracting process. In most cases departments of public health took on the role of ‘needs assessors’ for the purchasing authorities. Although Working for Patients [wfp] (DoH 1989a) did not consider public health needs assessment in detail, the relationship between public health and needs can be traced back to the Acheson report (Acheson 1988), which called for regular reviews of the population’s health. The question of how needs assessment and purchasing health care were to be linked was addressed by the Department of Health (Secretary of State 1989; EL 1990) concentrating initially on an epidemiological approach to needs assessment. This was given a critical dimension by the work of Stevens (1991) who related Need (defined as what people benefit from) to Demand (defined as what people ask for) and Supply (defined as what is provided). The Department built on this by developing a three pronged approach to needs assessment, based on epidemiological, comparative and corporate approaches to health needs, (DoH 1991) as a basis for contracts. This approach was not without its critics however and some argued that health care should not be purchased on the basis of total needs assessment but on economic evaluations of competing demands for resources (Donaldson and Mooney 1991). In this way, it was argued, ‘rational’ decisions could be made about where resources should be allocated. It was never clear therefore, what needs assessment in the reformed NHS should amount to, and there was and is still confusion concerning how resources can be allocated to services by means of contracts according to estimates of need.

The NHS reforms provided an opportunity to develop processes for need assessment in the health care arena, but the Department of Health gave no guidance as to the theoretical basis for this work. As a result, much of the early work was based on a ‘synthetic’ epidemiological approach, applying estimates of disease incidence and prevalence to local populations. Whilst such an approach was useful, its relevance to the experiences of individuals and groups receiving care was limited. In addition there seemed to be no apparent attempt to link this work to a theory of needs and more significantly to operationalise a theory of needs in health terms, so that results of the work could be channelled into effective purchasing. These deficiencies were highlighted by Frankel (1991) when he delineated the confusion surrounding the term ‘health needs assessment’. This confusion stemmed from a number of different imperatives that influenced the relationship between ‘needs’ and the provision of health care. The public health imperative was concerned with total population needs and developing strategies based on prevention and health promotion. The economic imperative was concerned with marginal met needs and the most efficient ways of meeting needs, whilst the political imperative was one of reconciling a welfare system to the demands of free market ideology. In the midst of this an understanding of the relationship between the human subject and the system was in danger of being marginalised and the extent of this marginalisation seemed to be related to the lack of recognition given by health policy to the relationship between health and rights (Jones 1995). That is to say, policy was not grounded in any formal recognition of a relationship between needs and entitlements. On the contrary there seemed to be a deliberate muddling of the issue so that an already fragmented system was unable to take responsibility for the needs of those it was designed to serve.

The problem of need and scarcity

The 1980s saw many debates concerning the relationship between needs and welfare provision (Doyal and Gough 1984, Geras 1983, Wiggins and Dermen 1987, Soper 1981). The debate focused on absolute, normative and relative definitions of need, and discussed them in terms of their implications for political economy. Others used this debate to redefine the concept of need in economic terms (Culyer and Wagstaff 1991). Even those who argued for substantive needs, recognised that there are instances (particularly in areas like the provision of health care) where the concept of needs breaks down (Braybrook 1987, Thomson 1987) but that these instances can provide valuable insights into the dilemmas that surround the concept and the implications this has for health policy. The fair and just allocation of scarce health care resources according to need, requires a theory of need that calls on appropriate principles of justice and equity and can be operationalised within the system, but such an idealised approach falls on barren ground unless the problem of scarcity is addressed at the same time. How and whether suitable and appropriate principles of justice are embedded in the NHS is unclear. The NHS is funded from taxation and works in the main by means of allocating capped budgets by a central bureaucracy. Given budgets are limited it is axiomatic that rationing is necessary. Those who argued and still argue in favour of markets in the NHS, state that rationing has always gone on but the introduction of markets means that the criteria for rationing become more explicit and thus rationing itself will be fairer and more objective. If rationing is inevitable, it is not clear how the action of making it more explicit automatically leads to it becoming fair and objective. Doyal and Gough (1991) addressed this issue in their theory of need which has substantive and procedural elements. The theory is centred on the individual’s capacity to participate in social life. They state that the two most basic needs are physical health and autonomy forming the preconditions for participation in moral life. Their argument focuses on a negative definition of health based on survival and avoidance of harm. Health care, in this theory, is a specific satisfier of the need for health and autonomy. This is the basis for the substantive part of the theory. In the procedural part they utilise Habermas’ idea of the validity of human interests stemming only from agreement in free and open communication. For Doyal and Gough, agreement over needs and prioritisation between competing needs can only be legitimate if debates are grounded in this Habermasian approach.

The arguments presented in this book owe much to the theory developed by Doyal and Gough. The book does not aim to test Doyal and Gough’s theory of human need but to use it and the Habermasian framework it draws on, to evaluate policy making processes at a particular point in time. In doing this the relevance of Doyal and Gough’s theory for health policy in the UK should become clear. The next chapter will review arguments concerning ‘objective’, universal needs in the context of health care. If universal needs exist, can they form a basis for health policy and if so how can they be measured to inform this policy? I will address alternative notions of need as a basis for health policy, ranging from the new right, health economics and relativist notions of need. Definitions of need as a function of an individual’s capacity to benefit will be reviewed together with the values that underpin such an approach. The ‘objectivity’ of economics will be questioned in light of this. In contrast I will make a distinction between the need for health and the need for health care and relate Doyal and Gough’s paradigm of need to the health care system and consider a framework for assessing health care needs based on Doyal and Gough’s concepts of health and autonomy. Following on from this, principles of justice will be considered in relation to health care from the viewpoint of the new right, health economics, Marxist, communitarian, feminist and liberal thinkers. I will draw on the relationship between needs and rights to argue with Doyal and Gough that in striving for a just system, their framework for assessing needs must, in turn, be based on procedures that rely on communicative ethics. I follow a path illuminated by Doyal and Gough’s work and turn to the work of Habermas (1984) as a potential source of a theoretical basis for the communicative justice the health care system requires.

This review is not presented as an original theoretical contribution to the needs debate but as a background to inform my interpretation of the ways in which different understandings of need were employed in practical settings. Having set out the bases for the theoretical debate I outline Doyal and Gough’s theoretical framework and consider its potential for evaluating needs assessment in the NHS. I reflect on the implications that a theory of need has for health policy, focusing in particular on the development of quasi-markets in the UK. I look at the history of policy explanations in the context of health care and relate four major theoretical perspectives; pluralist, public choice, elitist and Marxist, to the theory of human needs. I look at the theoretical background to the development of quasi-markets in health care and consider the implications of this development for the system. I focus on the importance of theories of power for any understanding of health policy and highlight the relevance of Habermas’ communicative ethics to an analysis of decision making in the NHS. Habermas’ condition for universality is consensus arising from an ideal speech situation and Doyal and Gough base the procedural part of their theory on this idea. Habermas’ theory of communicative action presents a means for evaluating the ways in which needs are discussed in the public domain. It is the potential that Habermas’ approach has for evaluating debates concerning needs in the health care system that I will explore.

I will introduce an exemplar based on a case study of a review of renal services in London. This was undertaken by an independent review group as part of the process of implementing the Tomlinson proposals for rationalising health care in the capital (Tomlinson 1992). My focus will be the process of policy making with respect to renal services and the extent to which discussions concerning health needs acted as a rational basis for decision making. The review was undertaken in the four months between March and June 1993 as one of the six speciality reviews established by the London Implementation Group (LIG) set up in the wake of the Tomlinson report. The renal review group reported in June 1993 and made recommendations on the future of renal services in the Thames Regions (Renal review group report 1993). Not all of the review group’s recommendations were accepted or implemented. However, the London Strategic Review (Turnberg 1997) noted that for renal services:

Five tertiary centres in London were planned with 5 specialist centres in the Thames Regions. This has been achieved in the North Thames Regions and in South East London. Consolidation of services at St George’s Hospital and the St Helier Hospital has yet to be agreed. (Turnberg 1997, p. 22)

The ways in which the recommendations were received and acted upon is an important area for study but the focus of this book is on the quality of the debates undertaken during the period of the review. To develop my arguments on decision making and needs assessment therefore I will concentrate on the group’s technical assessment of the need for renal services in the four Thames Regions, covering a population of some 14 million people. Having set out the evidence of need presented in the case study I will consider the quality of debates concerning health care need in relation to the ‘democratic’ and ‘rational’ nature of discussions. This will be done by means of an analysis of minutes of the group’s meetings with renal units and transcripts of taped meetings of the review group where decisions about the future pattern of services were made. My stance will be a critical one but I should emphasise that the review group report was considered by many to be a remarkable achievement given the constraints the group were acting under. This achievement was due to the knowledge and commitment of the review group members. In a sense however, the high quality of their work adds strength to the critique I develop in this book and in particular should raise questions about the quality of less public decision-making in the NHS.

The research methods used in this work were based on an understanding of depth hermeneutics (Pile 1990). Using the three phases of social analysis, discourse analysis and interpretation I construct a narrative moving from the technical assessment of need made by the review group through to an analysis of debates concerning needs. I conclude by presenting a critique of health policy in the NHS based on Habermasian notions of the demise of the public sphere. I focus particularly on the systemisation of the life world by means of distorted communication that is characterised by the use of technocratic and arcane language by powerful interest groups. I argue that the ability of interest groups to override needs based arguments and even to use needs based arguments to promote particular interests, remained a dominant characteristic of the system. The drive towards competition and markets presented a challenge to interest groups but I argue that this contained a duality because of the capacity of market processes to reinforce the power base of certain interest groups. An important aspect of this is the way in which the medicalisation of need is both a means by which the ‘systemworld’ colonises the ‘lifeworld’ and a means by which challenges to the existing order can be made. These challenges were however held fast by the medical framework within which they were formed. I argue that quasi-markets appeared to play an important role in reinforcing this process. Finally, I draw conclusions about the practicalities of grounding health services in a theory of need and the implications of such an approach for evaluating the health system’s role as a specific satisfier of health care needs.

Note

1 The term quasi-markets refers to the separation of supply and demand within an organisation. The terms internal markets and managed markets are also commonly used to describe such a system.

2 Health care needs, justice and rights to health care

to render available to every individual all necessary medical service, general and specialist, and both domiciliary and institutional. (Beveridge Report, 1942 paragraph 427)

The Patients needs will always be paramount. (Margaret Thatcher 1989, foreword to Working for Patients)

In this chapter my intention is to map the relationship between theoretical and practical understandings of health care needs on the one hand and the determination of policy on the other. I wish to explore the nature of our understandings and interpretation of health care needs and their capacity to both inform policy decisions and legitimate policy making. I structure the chapter by contrasting concepts of need and justice that have been developed by the New Rights¹ and health economics² with a wider debate concerning the philosophical basis for a needs based health care system. I do this because health policy in the UK has been influenced by key ideas from these two separate, sometimes conflicting, but influential strands of thought. I use my critique of these approaches as a basis for considering the possibilities Doyal and Gough’s theory of human need (Doyal and Gough 1991) holds for health care needs assessment. Doyal and Gough have constructed a theory of human needs based on the notion of basic needs being health and autonomy, an...

Table of contents

• Cover
• Half Title
• Dedication
• Title Page
• Copyright Page
• Table of Contents
• Figures and tables
• Preface
• 1 Introduction
• 2 Health care needs, justice and rights to health care
• 3 Health policy: a critical perspective
• 4 Assessing need and planning health services: the case of renal services
• 5 Professional power and the need for health care
• 6 Needs and the political economy of the health service
• Bibliography