Category Archives: Health and well-being

The modern welfare state in transition: framing new co-production roles and competences for public professionals

Nederhand-van MeerkerkBy José Nederhand and Ingmar van Meerkerk

“The place where we organize care, how we provide care, and those who provide the care will change” – Dutch Ministry of Care (2013), Vision on Care and the Welfare Labour Market.

The Dutch Ministry of Health has announced extensive reorganization of the care system. Just like in many other Western countries with ageing populations, the welfare state is subject to major reforms. In parallel with academic debates, the idea of co-producing and self-organizing public services seems to have penetrated the discourse of politicians and governors all over the world. Politicians state that in order to keep care provision affordable, accessible and in line with societal demands, responsibilities should be shifted ‘back’ to society. Through volunteering, citizens are expected to shoulder tasks formerly performed by the state, either by partnering and co-production with the state or by self-organization. Our systematic content analysis shows that citizens are now generally framed as active service producers which are, and should be, part of the general system of care service delivery. This activation of citizens has considerable implications for the roles, competences and responsibilities of care professionals. In fact, government is calling for a new public service ethos of professionals, see our recent article in Policy and Politics. Continue reading The modern welfare state in transition: framing new co-production roles and competences for public professionals

A pathway to precarity? Young workers and zero hour futures in the social care sector

Montgomery-Mazzei-Baglioni-SinclairTom Montgomery, Micaela Mazzei, Simone Baglioni, Stephen Sinclair

In an effort to solve crucial issues such as youth unemployment, policymakers can find it tempting when it looks like there is an opportunity to kill two birds with one stone. When you have a population living longer and requiring personal care for many years to come it can seem logical that there is a future in that sector for a generation of young workers. However there is a risk that the prospect of new potential employment for young people eclipses an awareness of the quality of work available in that sector.

Our recent article in Policy & Politics entitled Who Cares? The social care sector and the future of youth unemployment explores the actual potential of the social care sector in the UK to offer good quality career pathways for young people. Continue reading A pathway to precarity? Young workers and zero hour futures in the social care sector

Vodcast to promote article: Relational Wellbeing: Re-centring the Politics of Happiness, Policy and the Self

 

Take a look at this short video by Professor Sarah White, Professor of International Development and Wellbeing at the University of Bath, who talks about her research, published in Policy & Politics, on why all the interest and talk of our wellbeing may reflect an anxiety that all may somehow not be well…

 

If you enjoyed this blog post, you may also like to read Policy, politics, health and housing in the UK by Danny Dorling.

Is universal health coverage possible without strong public presence in its provision?

volkan-yilmaz-jpgVolkan Yilmaz, Assistant Professor of Social Policy at Boğaziçi University, Turkey

As part of the Sustainable Development Goals, a United Nations (UN) initiative covering a broad range of development issues, all members of the UN set an ambitious and greatly welcomed target to be achieved in healthcare policy by 2030: achieving universal health coverage. The World Health Organisation (WHO) defines universal health coverage as a set of policies ensuring everyone in need of healthcare services and medications receive a quality service yet without facing financial hardship. This notion of universal health coverage leaves no room for denying services and medications to people in need.

However, as is often the case, the devil is in the detail. As far as indicators for monitoring progress towards universal health coverage are concerned, it turns out that this is a broken promise. Two indicators are in use: the share of population that can access ‘essential’ healthcare services and the share of population that spends a large amount of its income on healthcare. The second indicator is estimated on the basis of households having to spend a disproportionate amount of their total income on health, measured as 25 per cent or more of their total household expenditure.

The first indicator in particular seriously limits the scope of universal health coverage by leaving out healthcare services that are not defined as essential. For example, while cervical cancer screening is listed among essential services, cervical cancer treatment is not. The second indicator may help by putting an upper limit on the proportion of total household expenditure to be spent on non-essential health services, but it may still fail to capture how many people don’t seek medical help for these services.

Dr Margaret Chan, Director General of World Health Organization, clearly suggests that free markets do not work in health care. Chan’s emphasis is on the financing component. Specifically, if public funding of healthcare is weak, achieving universal health coverage is generally not possible. Therefore, she identifies increasing public expenditure on healthcare as the only way towards universal health coverage, which will result in less reliance on out-of-pocket payments.

But healthcare systems have two major components that are of importance in achieving universal health coverage: financing and provision. To achieve universal health coverage, while public funding of healthcare is key, exclusive focus on the financing component in ensuring universal health coverage might be misleading. I believe the significant role that the public sector can play in healthcare provision – and has already been playing in some countries – has been long overlooked. Failing to pay enough attention to the role of the public sector in healthcare provision can pose two obstacles in monitoring progress towards universal health coverage.

First, this focus may blind us to how the dominant role of private sector or privatisation trends in healthcare provision restrict access to healthcare services that are deemed non-essential. On the one hand, exclusive focus on essential health services may be interpreted as rationing, which is indeed necessary for all public policies due to budget constraints. On the other hand, the restrictive definition of essential health services may go beyond rationing especially for middle income and upper middle income countries with historically strong public provision systems. This restriction of the scope of universal health coverage to essential services may take the form of people’s aversion to seek medical help due to financial hardship and/or increasing expenditures on health as a proportion of total household incomes. In this regard, the proposed strategy of WHO to achieve universal health coverage may be implicitly granting approval to the privatisation of non-essential health services in countries with strong public actors in provision.

Second, this disregard for the ownership of providers in healthcare leaves out the possible impact of private sector dominance on provision in healthcare financing. Not all market designs foster competition and lead to lower prices for services. Not all countries have strong public regulatory capacity to protect patients from possible abusive practices of private providers. Finally, not all political actors in power are willing and strong enough to block private providers’ demand for higher out-of-pocket payments and/or switch to private health insurance based financing models. Concerning these, WHO’s strategy falls short of addressing these concerns which may well affect the prospect or viability of universal health coverage in different countries.

My forthcoming book entitled The Politics of Healthcare in Turkey demonstrates that despite significant achievements towards universal health coverage in Turkey in the last decade, a country that Dr Chan also lists among best performers, striking the right balance between public sector and private sector in healthcare provision remains a challenge for Turkey. Passive privatisation in healthcare provision and the political dynamics it has generated, cast doubt on viability of universal health coverage.

Setting a target for all countries is not easy, especially given the vast differences among them and the presence of strong global interest groups against reforms towards universal health coverage. But these challenges should not lead us to settle for a narrowly defined version of universal health coverage as a global policy direction for all countries. I suggest therefore that the lack of focus on the provision component of healthcare systems in the global health policy debate must be re-thought, especially if we want to reclaim the proper meaning of universal health coverage.

If you enjoyed this blog post, you may also like to read When collaborative governance scales up: lessons from global public health about compound collaboration by Chris Ansell.

Who knows best? Understanding older people’s experience of emergency hospital admission

glasby-littlechildJon Glasby and Rosemary Littlechild

An extended version of this post was originally published on 4 October 2016 in the Policy Briefing section of Discover Society which is provided in collaboration with the journal Policy & Politics. The original post is available at http://discoversociety.org/2016/10/04/policy-briefing-who-knows-best-understanding-older-peoples-experience-of-emergency-hospital-admission/.

Every year, the NHS experiences more than 2 million unplanned hospital admissions for people over 65 (accounting for 68 per cent of hospital emergency bed days and the use of more than 51,000 acute beds at any one time).  With an ageing population and a challenging financial context, such pressures show no sign of abating – and the NHS is having to find ways of reducing emergency hospital admissions (in situations where care can be provided as effectively elsewhere).  Often, the assumption in policy and media debates seems to be that potentially large numbers of older people are admitted to hospital without really needing the services provided there, but because there is nowhere else for them to go or because other services are not operating effectively.    Continue reading Who knows best? Understanding older people’s experience of emergency hospital admission

Imagining the future: Growing older together?

Alexandra ChapmanAlexandra Chapman

There is a clear divergence emerging between each region in the UK in terms of the nature and pace of implementing a policy framework that supports older service users and promotes a person-centred framework.

Following devolution, Scotland and Wales have developed adult social care strategies underpinned by person-centred principles through divergent policies and provision from each other and England. Meanwhile, in Northern Ireland, policy developments have not progressed at the same pace as the rest of the UK and there has been emphasis on a person-centred policy for adult social care users. The acknowledged shift in dependency ratios and increasing social care projects have emphasised a sense of urgency to reform adult social care policy in Northern Ireland. Continue reading Imagining the future: Growing older together?

How politics and power create poor health: ‘I think they’re trying to kill folk aff’

Mhairi Mackenzie et al

By Mhairi Mackenzie, Chik Collins, John Connolly, Gerard McCartney, Mick Doyle

 

 

 

 

We know from decades of international research that power, politics and specific social and economic policies have a fundamental role in creating health.  These factors contribute very significantly to the gradient we see across income groups in terms of life expectancy and more general wellbeing.

However, many health policy researchers have identified how policies which claim to be about reducing health inequalities seldom squarely address these fundamental determinants of health.  Instead, policies have a distinct tendency to focus on changing the behaviours of (mainly) poor people. The message is often that people smoke too much, drink too much or don’t make the best use of services that are available to them.  These messages do not give proper consideration to why particular health damaging behaviours occur in particular places or why health is worse in certain places even in the absence of these behaviours. Even those policies which do start with a broader analysis of the problem of disparities in health are subject to lifestyle drift when it comes to putting policy into practice.  Although policy documents may state that the causes of poor health or inequalities in health are to do with poverty and deprivation, the interventions which actually operate on the ground focus much less (if at all) on changing people’s material circumstances and rather more on trying to change behaviours (which are in fact heavily shaped by material circumstances).

In light of the above, it is unsurprising that research in different countries also shows that when policy makers and practitioners talk about how health is created they tend not to give due regard to these known fundamental causes. Again, the emphasis is on explanations that focus on individual lifestyles. Behavioural interventions aimed at changing the lives of poor individuals clearly have a powerful draw on the attention of policy makers.  The reasons for this preference are many and varied and include the desire for quick policy wins over longer term action and the seductive appeal of short and simplistic causal pathways to health, in preference to having to deal, intellectually and practically, with the longer and more complex pathways which are actually at work.

Another reason, however, for the hardiness of the behavioural intervention as a policy tool – despite its apparent lack of success in addressing the problem – is that it fits within a broader contemporary political narrative.  That narrative tells us that individuals are responsible for making and breaking their own life chances.  Consequently, their health and social outcomes lie overwhelmingly in their own hands.  There is, in this view, ‘no such thing as society’, or at least no wider societal determinants which individuals can’t be expected to just over-ride through their personal choices and individual acts of will.  In this narrative the state’s role is to ‘nudge’, ‘activate’ or mandate individuals to do the right thing rather than to challenge fundamentally the existing power relations within society.

This kind of thinking is part of the wider set of discourses, policies and practices associated with neoliberalism.  These provide both the context in which, and the mechanisms through which, the lives of some communities have become in many ways much more difficult since the 1980s – and their existence and identity much more marginalised.  Research tells us that it is this fundamental part of the story of how poor health is created that is largely missing from the discourse of those in policy and practice.

In our recent Policy & Politics article: working-class discourses of politics, policy and health: ‘I don’t smoke; I don’t drink. The only thing wrong with me is my health’, we wanted to look at how people living in deprived communities – which had felt the brunt of deindustrialisation in the 1980s and had been at the sharp edge of austerity in current times – talked about how politics and policies had impacted on their health, and that of their families and their wider communities.  Unlike the messages from policymakers, our sample of participants in the towns of Kilmarnock and Cumnock in East Ayrshire, Scotland, brought vividly to life how it is that power, politics and social and economic policies are indeed a fundamental matter for health – at both an individual and community level.

Here are some of the things our participants told us:

They do not feel at all valued by political elites; on the contrary they are made to feel literally surplus to requirements. An ex-miner told us: ‘I’ve heated their bums wae coal…we’ve served wur cause. If they could dae away wae you noo, they would dae away wae you, because you’re a drain on society…They want me, noo, to work til I’m sixty-seven. I’ve no chance of working to I’m sixty-seven. I’ll no’ see sixty-seven.’ Similarly, another respondent, reflecting on ‘austerity’ and so-called ‘welfare reform’, simply said, “I think they’re trying to kill folk aff”.

They sense that deliberate action was taken by government to destroy the industries on which their communities had depended, and to undermine the strong and more solidaristic community relationships which had prevailed in the past. A respondent from Kilmarnock said: “She [Thatcher] allowed a’ the work to go abroad. And oor factories in Kilmarnock…we had a great town, and it just finished. Factory after factory, well-known brands…employers went. They all went wi’ a feeling o’ sorrow but it didnae help the workers.” Another ex-miner from Cumnock, reflecting on the 1984-85 Miners’ Strike across the UK, said: “looking back you can see the preparation got made. And they really backed the union into a corner … it was to diminish the power of the unions and fragment communities”.

Where ‘negative lifestyles’ exist within these communities, they are seen as closely connected to broader social and political circumstances. Another ex-miner told us how downwardly spiralling morale and behaviours in his community were rooted in changing circumstances: ‘The factories started slimmin doon, cutting workforces. The ability for young people to get into work was becoming limited. We started to see probably drugs in our community for the first time. And probably the excessive drinking was starting to take a hold as well…’ Further, not all of our participants were able to understand their current poor health in terms of their own behavioural decisions – as we indicate in the title of our research paper – one man in poor health summed up this personal conundrum by saying ‘I don’t drink; I don’t smoke – the only thing wrong with me is my health’.

Participants are conscious of current day political strategies to set poor and struggling communities apart from the rest of society. One young woman said: ‘They are using the media…tae bombard folk wi’ … the good old ‘divide and conquer’…it’s like stigmatising full groups at a time. It comes in waves. I mean, the immigrants’ll be due a shot…it’s a’ their fault. It’s like they’re trying to deliberately create this, ‘Everybody that’s on incapacity’s a scrounger.’”

All in all, our research participants provided a vivid articulation of links between politics, policies, deindustrialisation, damage to community fabric and impacts on health. We ask: given the way in which these lay participants’ understandings of health reflect (and enrich) the views of researchers, should our participants and the many who share their stories, actually be the ones educating policy makers and practitioners, rather than being seen as the recipients of perennially failing health education messages? What might be the impact of turning the traditional health education model on its head? How would such a shift in who is doing the educating be received by policy-makers and practitioners?

Mhairi Mackenzie is Professor of Public Policy in the School of Social and Political Sciences at the University of Glasgow.  Chik Collins is Professor of Applied Social Science in the School of Media, Culture and Society at the University of the West of Scotland. John Connolly is Senior Lecturer in Public Policy at the University of West of Scotland.  Mick Doyle works for the Scottish Community Development Centre. Gerry McCartney works for NHS Health Scotland.

If you enjoyed this blog you may also be interested to read Policy, Politics, Health, and Housing in the UK.

Reposted with kind permission from: http://discoversociety.org/2016/04/05/policy-briefing-how-politics-and-power-create-poor-health-i-think-theyre-trying-to-kill-folk-aff/