As part of the Social Policy and Development Seminar Series, the Institute for Social and Economic Research (ISER) recently hosted Dr Rebecca Surender, senior lecturer at the Department of Social Policy and Intervention at the University of Oxford, to present a paper entitled “Politics, Policy Making and Health Care: What social policy analysis can teach us about the drivers of health care reform: a case study of the UK National Health Service”.
Dr Surender, who was in Grahamstown as part of a research visit to ISER to contribute to the programme of social policy research and teaching, described the presentation as an exploration of how health policy reform occurs globally, and its broader implications. In recent decades, rising costs, growing demands and the pressures of meeting wider health system goals of efficiency, quality and equity has placed healthcare reform at the top of policy agendas all around the world. However as recent attempts at reform in America have revealed, and ongoing debates in South Africa suggest, change is complex and difficult, and radical change, even more so.
Dr Surender, who has worked as a healthcare specialist in the UK, provided a historical overview of the UK’s NHS healthcare system from its beginnings in 1948. Originally having been conceived as part of the broader post-war settlement and initial beginnings of a welfare state, the health system replaced a private system with a socialised one, and was premised on notions of universalism and equity; entitlement to healthcare was based on citizenship and was thus a social right. A central factor to the original system was the prominent role of general practitioners (GPs) who Dr Surender described as the gatekeepers to the system. “You couldn’t, and still can’t, access specialist hospital care without a referral by your GP, which made the system less costly, but also less open in terms of patient choice,” she said. While economists and health policy analysts praised the system for its cost-effectiveness, Dr Surender said the inspiration and logic behind the system was not a result of evidence-based rational policy planning. “The truth is that it came about as a result of conflict, infighting and power struggles between the state and the medical profession,” she said.
The system remained fairly static until the mid 1970s, though various structural and fiscal pressures led to a series of continual reforms during the 1980s. By 1989 under the Conservative ‘New Right’ administration of Margaret Thatcher, the internal market had been introduced, which saw services, including management, replaced with private sector tenders, which were outsourced. “This was a key moment, almost as seminal as 1948 when the NHS was first established. The same blueprint of the internal market was used across the policy board in Britain, from education to housing and social security,” she explained. At this point the purchasing and provision of healthcare services were formally separated, and an emphasis on competition to secure quality and cost effectiveness was advocated. “In this sense markets, consumerism and user rights replaced bureaucracy, professionalism and paternalism as the driving factors. Choice and efficiency became the main focus and not equity,” she added.
With the election of Tony Blair’s New Labour government in 1997 the ideological pendulum swung in a different direction and the healthcare system saw further changes, including the formal abolishment of the internal market as introduced under Margaret Thatcher. “There are some parallels and continuities with Thatcher’s regime, but also some breaks with it. I would argue that the changes Blair introduced are more complex than are often understood,” she said. The health system under Blair presented as a social democratic model in contrast to Thatcher’s straight New Right model, but there is debate about whether the ‘Third Way’ really constituted a new paradigm. “In many ways it was a rebranding exercise, with a focus on presentation, but it rested on the premise that society had become more heterogeneous and plural and people wanted greater choice. Government tried to respond by creating a new flexible service but one still committed to principles of redistribution and social solidarity,” she said.
“Health systems must thus be understood within the context of the broader institutional, political and ideological context in which they are located. Narrow fiscal analysis as a driver of reforms, or analysis which suggests reforms are simply the result of a technical evidence-based approach and are insufficient. The role and impact of ideology, interest groups and institutional structures on health policy must also be considered,” she said.
Dr Surender’s current areas of research include UK health policy and social policy in developing countries on which she has published in a number of international journals. She also teaches on the Masters and doctoral programmes in Comparative Social Policy in Oxford. Dr Surender is a Research Associate of the Institute for Social and Economic Research and is currently co-editing a volume with ISER’s director Professor Robert Van Niekerk entitled “Social policy in a developing world”, to be published by Elgar in 2012.
Story and photo by Sarah-Jane Bradfield
Photo: Dr Rebecca Surender