The Sociology and Politics of Health

A Reader

David Banks, Michael Purdy, David Banks, Michael Purdy

• Publisher: Routledge
• Year: 2005
• eBook ISBN: 9781134569977
• Edition: 1
• Topic: Médecine
• Subtopic: Prestation de soins de santé

Health care systems, the role of health professionals and the experience of health and illness are all undergoing change and development as we enter the twenty-first century. The Sociology and Politics of Health is a collection of key readings through which to explore the sociological and political dimensions of health, illness and health care. Combining classic pieces with more up-to-date contributions, it includes examples taken from current domestic and international initiatives and draws on humanist, materialist, feminist and constructionalist perspectives. The Sociology and Politics of Health covers:
* ideology and policy
* social stratification
* professionalisation
* the experience of health and illness.
* This reader offers health studies students, nurses and other health professionals an invaluable introduction to an increasingly important field of social inquiry.

Part I
Ideology and policy

Introduction

The readings in this section are concerned with the broad ideological and political context in which the National Health Service (NHS) has been founded, developed and is expected to change as we move into the twenty first century. For excellent commentary on the history and development of the NHS since 1948 see, for example, Klein (1995), Rivett (1998), Webster (1998) and Berridge (1999). Two ideological traditions, ‘collectivism’ and ‘individualism’, have been responsible for the development of health policy over the last half-century in the United Kingdom. These are paired here with examples taken from the policy initiatives, which they have each generated.

The basis of ‘collectivism’ and the programmes of social welfarism which it gave rise to in the twentieth century is to be found in the condemnation of the social effects of rapid industrialisation and urbanisation which signalled the evolution of early industrial capitalism in the nineteenth century. The devastating effects on the health and welfare of the urban masses on which the new economic system depended are graphically illustrated here by an extract (Reading 1) from Engels’ critique of the factory system in England. Engels’ materialist analysis argues that the poor health and premature deaths of the English working class are caused by their conditions of life, conditions over which they have no control but which are determined by the demands of an economic system based on unrestrained exploitation and competition. It followed that if poor health was socially determined then society could improve health by improving the conditions of life of the population. The horrific conditions which Engels describes clearly provided an impetus for the public health movement of the late nineteenth century, although the extent to which such social (collective) intervention reflected a new-found benevolence on the part of the ruling class and state or served their economic self-interest, by securing a healthier workforce and armed force, is open to debate.

By the middle of the twentieth century, collectivist principles of social justice were being embraced by many Western democracies and the era of state welfarism began. In Britain the end of the Second World War saw cross party consensus on the need for a ‘welfare state’, a central component of which was a National Health Service (NHS). The collectivist principles of social justice which informed health and welfare policy during this period are found in the extract reproduced here (Reading 2) from the 1946 NHS Bill which provided a ‘summary of the proposed new service’. A ‘comprehensive’ health service was to be established, available to all regardless of ‘financial means, age, sex, employment or vocation, area of residence, or insurance qualification’, and free at the point of delivery. Whilst the NHS, which emerged on 5 July 1948, was very much the product of political compromise and accommodation to the self-interest of the medical profession, it nevertheless established a collectivist agenda at the heart of government policymaking. This agenda was to remain virtually intact for thirty years.

Challenges to collectivism have a longer history. Critics of the ‘social engineering’ which state welfarism was seen to require and of the dehumanising aspects of state bureaucracies associated with socialist and communist regimes countered the collectivist ideals of social justice with those of individual freedom of choice, illustrated here (Reading 3) with an extract taken from Hayek’s classic 1944 rejection of socialism and advocacy of individual freedoms. For Hayek, the individualist tradition had created Western civilisation. Since the seventeenth century, the increasing emphasis on the freedom and liberty of the individual from political constraints had permitted the growth of commerce, science and capitalist enterprise. In collectivism, Hayek sees a threat to individual freedom and liberty as the state seeks to direct social forces in the pursuit of an ‘equal distribution of wealth’ rather than allow the free competition of the market to unfold. Hayek restates the fundamental principle of liberalism, ‘that in the ordering of our affairs we should make as much use as possible of the spontaneous forces of society, and resort as little as possible to coercion’ (The Road to Serfdom, p. 13), and argues that the proper role for the state is to limit its activity to securing through its legislative apparatus the conditions for the market mechanism to operate, and, where competition cannot function, to supplement the provision of services.

Such ideas became politically acceptable in the UK with the election to office of a Tory government under the leadership of Margaret Thatcher in 1979 and the ending of the cross-party consensus on state welfarism which this signalled. Driven by economic imperatives, which challenged the continued viability of state welfarism in the late twentieth century, neoliberalist ideas gained currency once again with individualism replacing collectivism as the ideological framework structuring health and social policy. The impact of this ‘New Right’ thinking on health policy led to the increasing marketisation of health care and is represented here by an extract taken from the Conservative government’s 1989 White Paper Working For Patients (Reading 4), which detailed the setting up of an ‘internal market’ in the NHS in a bid to secure the ‘3Es’ of efficiency, economy and effectiveness. Whilst radical in its restructuring of the NHS and separation of ‘purchaser’ and ‘provider’ functions in order to create the conditions for market competition, the Conservative government remained publicly committed to an NHS available to all regardless of income, and financed from general taxation. This continued commitment to funding the NHS from general taxation following the extensive NHS Review of 1988 is a clear indication of the extent to which the NHS reforms represent a political compromise by the government of its ideological stance. This can be gauged from an example of work from the government’s Think Tank at the Institute of Economic Affairs (Reading 5). Here, David Green proposes as a solution to the financial crisis of the NHS, which manifested itself in the ward closures, lengthening waiting lists and staff demoralisation of the 1980s, and precipitated Margaret Thatcher’s call for the NHS Review, that the service should be funded not from general taxation but rather from private insurance, with government assistance in the form of vouchers to cover the cost of a minimum package of health care services being provided for the poor. Such an insurance-based system would, according to Green, offer both rich and poor alike more choice in the health care they accessed and received, and lead to a more efficient and cost-effective system as ‘priced demand’ for health care replaced ‘unpriced expectations’.

The restructuring of state welfarism, including health care, has continued following the election of a New Labour government in May 1997. Labour’s landslide victory heralded the appearance of a third major ideological force informing thinking and policy on health, health care and the wider social and welfare agendas. ‘Communitarianism’ represents a rejection of both collectivist and individualist ‘world views’ and seeks to avoid both the rampant selfserving dogma of the market and the collectivist excesses of ‘nanny state’ social engineering. The ‘communitarian agenda’ emphasises the need for individual social responsibility and locates a renewed commitment to social solidarity in the institutions of civil society, and particularly in the ‘family’ and ‘community’ (Etzioni 1993). At the policy interface the impact of communitarianism on New Labour’s policy agenda is illustrated by an extract (Reading 6) taken from the 1998 Home Office consultative document Supporting Families. In this document the government emphasises the role of the family at the heart of society, and whilst recognising ‘that families are, and will always be, mainly shaped by private choices well beyond the influence of government’ (p. 5), argues that government must nevertheless do what it can to support and strengthen this core social institution at a time when it is under stress. The crisis in the family is seen by the government to be reflected in the rising divorce rate, increasing numbers of single parent households, more child poverty, and rising crime and drug abuse which ‘are indirect symptoms of problems in the family’. A range of measures are identified to support and strengthen families – including the development of an ‘enhanced role’ for health visitors, the funding of Sure Start programmes (DfEE 1999) and the setting up of a national parenting help line – and to enable parents to better discharge their responsibilities.

Communitarianism’s ‘third way’ promises to provide the ideological and political ‘world view’ for health, health care and the experience of health and illness deep into the twenty-first century. Its impact on national and international health policy is represented in this collection by three readings.

Reading 7 from New Labour’s 1997 White Paper on the New NHS signals the government’s intention to rebuild a modern NHS for the twenty-first century which avoids both a return to the ‘command and control’ culture of the 1970s or a perpetuation of a public health service operating according to free market principles. The White Paper sets out the plans for replacing the ‘internal market’ with a system of ‘integrated care’ which is responsive to the needs of patients and ‘based on partnership and driven by performance’. New Labour envisages a ten-year programme of ‘evolutionary change’ which retains certain key elements of the system inherited from the Conservative administration that work, and which installs co-operation rather than competition as the principal mechanism for achieving improvements in both quality of service and cost effectiveness. A primary care-led NHS is the government’s goal and the New NHS details the structural changes, including the development of ‘primary care groups’, which it sees as essential to achieving this.

Labour’s retention of key elements of the Tory reforms, in particular the purchaser/provider split, demonstrates the inherent pragmatism of the ‘third way’, keeping those ‘New Right’ elements which make economic sense whilst dispensing with the ideological basis of the initial welfare consensus. Reading 8 lays out the basis of a new consensus in the context of public health. This extract from the 1999 White Paper on Public Health argues that far from ‘blaming the victim’ for poor lifestyle choices, government should seek to establish and build a partnership in which individuals, families, communities and government all recognise and act in terms of their social responsibilities and obligations rather than purely in terms of their individual rights. A new consensus may be found in a ‘contract for health’ involving ‘a three-way partnership between people, local communities and government’.

The new emerging consensus of the third way signals a ‘new universalism’ in the field of health for the twenty-first century. This is represented here (Reading 9) by the World Health Organisation’s call in 1999 for governments to increasingly target resources at those groups with the poorest health rather than attempt to provide universal care for all. Rationing is seen to be not only inevitable but also desirable in this ‘new universalism’, which combines ‘universalism with economic realism’. According to the World Health Organisation, ‘classic universalism’ failed to recognise both ‘resource limits and the limits to government’ whilst approaches to health based on free market principles ration services according to ‘the ability to pay’. In the new century, government will provide leadership and finance the health care system, with services being offered by many different types of provider and ‘open and informed debate’ deciding health priorities and identifying ‘lower priority services’ which individuals will need to purchase. In the twenty-first century, universalism is redefined to mean ‘coverage for all; not coverage of everything’.

References

Berridge, V. (1999) Health and Society in Britain Since 1939, Cambridge: Cambridge University Press.

Department for Education and Employment (DfEE) (1999) Sure Start: Making a Difference for Children and Families, London: DfEE.

Etzioni, A. (1993) The Spirit of Community: Rights, Responsibilities and the Communitarian Agenda, London: Fontana Press.

Klein, R. (1995) The New Politics of the NHS, 3rd edition, London: Longman.

Rivett, G (1998) From Cradle to Grave: Fifty Years of the NHS, London: King’s Fund.

Webster, C. (1998) The NHS: A Political History, Oxford: Oxford University Press.

1 The condition of the
working class in England^*
Frederick Engels

When one individual inflicts bodily injury upon another, such injury that death results, we call the deed manslaughter; when the assailant knew in advance that the injury would be fatal, we call his deed murder. But when society¹ places hundreds of proletarians in such a position that they inevitably meet a too early and an unnatural death, one which is quite as much a death by violence as that by the sword or bullet; when it deprives thousands of the necessaries of life, places them under conditions in which they cannot live – forces them, through the strong arm of the law, to remain in such conditions until that death ensues which is the inevitable consequence – knows that these thousands of victims must perish, and yet permits these conditions to remain, its deed is murder just as surely as the deed of the single individual; disguised, malicious murder, murder against which none can defend himself, which does not seem what it is, because no man sees the murderer, because the death of the victim seems a natural one, since the offence is more one of omission than of commission. But murder it remains. I have now to prove that society in England daily and hourly commits what the working-men’s organs, with perfect correctness, characterize as social murder, that it has placed the workers under conditions in which they can neither retain health nor live long; that it undermines the vital force of these workers gradually, little by little, and so hurries them to the grave before their time. I have further to prove that society knows how injurious such conditions are to the health and the life of the workers, and yet does nothing to improve these conditions. That it knows the consequences of its deeds; that its act is, therefore, not mere manslaught...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Acknowledgements
• General Introduction
• Part I: Ideology and Policy
• Part II: Social Stratification and Health
• Part III: Professionalisation and Health
• Part IV: Experiencing Health and Illness