Navigating Private and Public Healthcare: Experiences of Patients, Doctors and Policy-Makers [1st ed. 2020] 978-981-32-9207-9, 978-981-32-9208-6

Table of contents :
Front Matter ....Pages i-xxv
Introduction (Karen Willis)....Pages 1-11
Front Matter ....Pages 13-13
Chapter Two: Universalism in Healthcare and Social Citizenship in Chile, Uruguay and Costa Rica (Monica Budowski)....Pages 15-39
Chapter Three: Privatisation and Marketisation Within a Healthcare System: The Swedish Experience (Paula Blomqvist)....Pages 41-60
Front Matter ....Pages 61-61
Chapter Four: ‘Looking Outside Their Walls’: Exploring Community Health in Chicago Hospitals (Fernando De Maio, Raj C. Shah, Kerianne Burke)....Pages 63-86
Chapter Five: Contracting-Out Care: Nursing Homes in Canada (Pat Armstrong, Hugh Armstrong)....Pages 87-103
Front Matter ....Pages 105-105
Chapter Six: Gatekeepers in a Mixed Private/Public System (Fran Collyer)....Pages 107-130
Chapter Seven: Creeping Privatisation? Examining Procurement Choices in the ‘New’ NHS in England (Vid Calovski, Michael Calnan)....Pages 131-154
Front Matter ....Pages 155-155
Chapter Eight: Safeguarding Through Work Arounds: Socio-Materiality and the Organising of Care in a Private Hospital (Trudy Rudge, Luisa Toffoli)....Pages 157-180
Chapter Nine: Reducing Healthcare Costs in Portugal: Outcomes and Implications for Public and Private Medicine (Tiago Correia)....Pages 181-199
Chapter Ten: Promoting Health as a Form of Capital: The Transformation of the Danish Healthcare Field as Experienced By Private Healthcare Professionals (Kristian Larsen, Ivan Harsløf)....Pages 201-223
Front Matter ....Pages 225-225
Chapter Eleven: The Imperative of Choice in Australian Healthcare (Karen Willis, Sophie Lewis)....Pages 227-248
Chapter Twelve: The Marketisation of Aged Care: The Impact of Aged Care Reform in Australia (Julie Henderson, Eileen Willis)....Pages 249-267
Front Matter ....Pages 269-269
Chapter Thirteen: Navigating Private and Public Healthcare (Fran Collyer)....Pages 271-294
Back Matter ....Pages 295-304

Citation preview

Navigating Private and Public Healthcare

Experiences of Patients, Doctors and Policy-Makers

Edited by  Fran Collyer · Karen Willis

Navigating Private and Public Healthcare

Fran Collyer  •  Karen Willis Editors

Navigating Private and Public Healthcare Experiences of Patients, Doctors and Policy-Makers

Editors Fran Collyer Department of Sociology and Social Policy University of Sydney Sydney, NSW, Australia

Karen Willis School of Allied Health, Human Services and Sport La Trobe University Melbourne, VIC, Australia

ISBN 978-981-32-9207-9    ISBN 978-981-32-9208-6 (eBook) https://doi.org/10.1007/978-981-32-9208-6 © The Editor(s) (if applicable) and The Author(s) 2020 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Cover illustration: Robert Christopher / Stockimo / Alamy Stock Photo This Palgrave Macmillan imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Acknowledgements

We acknowledge and thank the contributors to this volume, the ongoing support of the School of Social and Political Sciences at the University of Sydney and the support of the School of Allied Health, Human Services and Sport at La Trobe University. We also acknowledge the support of the Social Research Assistance Platform, La Trobe University, for providing financial support for editorial assistance and wish to thank Dr Ashleigh Watson for the editing work in the final draft.

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Other Works by the Editors

Fran Collyer Knowledge and Global Power: Making New Sciences in the South (with Raewyn Connell, Joao Maia and Robert Morrell) (Monash University Press 2019). The Palgrave Handbook of Social Theory in Health, Illness and Medicine (edited, Basingstoke: Palgrave Macmillan, 2015). Mapping the Sociology of Health and Medicine: America, Britain and Australia Compared (Basingstoke: Palgrave Macmillan, 2012). So We Write Star Authors: Another Anthology of the Society of Women Writers South Australia (edited, The Society of Women Writers South Australia 2006). Public Enterprise Divestment: Australian Case Studies (with James McMaster and Roger Wettenhall) (Fiji: University of South Pacific Press, 2001). Technology Strategies in Australian Industry (with Ron Johnston; Don Scott-Kemmis; Terry Darling; Dave Roessner and John Currie) (Canberra: The Centre for Technology and Social Change, University of Wollongong, Australian Government Printers, 1990).

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Other Works by the Editors

Karen Willis Society, Culture and Health: An Introduction to Sociology for Nurses (co-­ authored with Shandell Elmer) (South Melbourne: Oxford University Press, two editions: 2007, 2011). Selected recent articles: ‘Goals for Living With a Chronic Condition: The Relevance of Temporalities, Dispositions, and Resources’ (with Marika Franklin, Sophie Lewis, Ann Rogers et  al.; Social Science and Medicine 233: 13–20. 2019). ‘Relatives’ Strategies in Subacute Brain Injury Rehabilitation: The Warrior, The Observer and the Hesitant’ (with Guldager R; Larsen, K and Poulsen I.; Journal of Clinical Nursing 28: 289–299. 2019). ‘Navigating and Making Choices About Healthcare: The Role of Place’ (with Lewis, S. and Collyer, F.M. Health and Place 52: 215–220. 2018). ‘Healthcare in the News Media: The Privileging of Private Over Public’ (with Lewis, S.; Collyer, F.M., Harley, K.; Marcus, K.; Calnan, M. and Gabe, J. Journal of Sociology 54(4): 574–590. 2018). ‘Better to Save One Life Than Build a Seven-Storied Pagoda’: A Qualitative Study Of Health Education For Patients with Acute Coronary Syndrome and Type 2 Diabetes Mellitus in Shanghai, China’ (with Liu X-L; Wu C-J J; Shi Y and Johnson M.; BMJ Open 8: 1–11. 2018). ‘Controlled, Constrained, or Flexible? How Self-Management Goals Are Shaped by Patient–Provider Interactions’ (with Franklin M, Lewis S, Rogers A, Venville A et al., Qualitative Health Research 29. 2018). ‘Fall Prevention Programs for Culturally and Linguistically Diverse Groups: Program Provider Perspectives’ (with Jang H; Lovarini M; Clemson L; Lord S. et al., Ethnicity and Health. 2018).

Contents

Introduction  1 Karen Willis

Part I About the System: Universalism and Privatisation

  13

Chapter Two: Universalism in Healthcare and Social Citizenship in Chile, Uruguay and Costa Rica 15 Monica Budowski Chapter Three: Privatisation and Marketisation Within a Healthcare System: The Swedish Experience 41 Paula Blomqvist

Part II Institutions of Health  61 Chapter Four: ‘Looking Outside Their Walls’: Exploring Community Health in Chicago Hospitals 63 Fernando De Maio, Raj C. Shah, and Kerianne Burke ix

x Contents

Chapter Five: Contracting-Out Care: Nursing Homes in Canada 87 Pat Armstrong and Hugh Armstrong

Part III Gatekeepers in the System 105 Chapter Six: Gatekeepers in a Mixed Private/Public System107 Fran Collyer Chapter Seven: Creeping Privatisation? Examining Procurement Choices in the ‘New’ NHS in England131 Vid Calovski and Michael Calnan

Part IV Healthcare Professionals 155 Chapter Eight: Safeguarding Through Work Arounds: SocioMateriality and the Organising of Care in a Private Hospital157 Trudy Rudge and Luisa Toffoli Chapter Nine: Reducing Healthcare Costs in Portugal: Outcomes and Implications for Public and Private Medicine181 Tiago Correia Chapter Ten: Promoting Health as a Form of Capital: The Transformation of the Danish Healthcare Field as Experienced By Private Healthcare Professionals201 Kristian Larsen and Ivan Harsløf

Part V Patients, Consumers and Citizens 225

 Contents 

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Chapter Eleven: The Imperative of Choice in Australian Healthcare227 Karen Willis and Sophie Lewis Chapter Twelve: The Marketisation of Aged Care: The Impact of Aged Care Reform in Australia249 Julie Henderson and Eileen Willis

Part VI Conclusion

 269

Chapter Thirteen: Navigating Private and Public Healthcare271 Fran Collyer Index295

Notes on Contributors

Hugh  Armstrong  is Distinguished Research Professor and Professor Emeritus of Social Work, Political Economy, and Sociology at Carleton University in Ottawa, Canada. His research interests include long-term care, the political economy of healthcare, and paid and unpaid work in healthcare. Armstrong is co-investigator on the ‘Re-imagining Long-­ Term Residential Care: An International Study of Promising Practices’ project, a major collaborative research initiative with $C2.5 million in funding from the Social Sciences and Humanities Research Council (SSHRC) of Canada. The project began in 2010 and is wrapping up in 2019, having spawned a number of related funded research projects in which he is involved. Armstrong’s publications include numerous journal articles and book chapters and, with Pat Armstrong, several books. Most recent are Critical to Care: The Invisible Women in Health Services (with Krista Scott-Dixon), About Canada: Health Care and Wasting Away: The Undermining of Canadian Health Care. Pat Armstrong  is Professor of Sociology at York University, Toronto. She held a Canada Health Services Research Foundation/Canadian Institute of Health Research Chair in Health Services, is Distinguished Research Professor in Sociology and Fellow of the Royal Society of Canada. Focusing on equity in the fields of social policy, of women, work and the health and social services, Armstrong has published widely, ­co-­authoring more than a xiii

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Notes on Contributors

dozen books and co-editing another dozen, as well as many journal and technical reports. Much of her work has been for or with unions. She was chair of Women and Health Care Reform, a group funded for over a decade by Health Canada, principal pnvestigator (PI) of a seven-year SSHRC-funded project on ‘Re-imagining Long-Term Residential Care: An International Study of Promising Practices’, now in its tenth year, and coordinator of a smaller one embedded within it on ‘Healthy ageing in Residential Places’. Armstrong is PI on ‘Changing Place: Unpaid Work in Public Places’ and co-investigator on ‘Invisible Women: Gender and the Shifting Division of Labour in Long-term Residential Care’ and ‘Seniors— Adding Life to Years: Late Life Issues’ projects. Armstrong serves as cochair of the Canadian Association of University Teachers’ Equity Committee. Paula  Blomqvist is Associate Professor  in the Department of Government, Uppsala University, Sweden. Her research interests include health and social care organisation and the politics of policy reform. Blomqvist has had several books published in Swedish and numerous articles in English in international peer-reviewed journals such as Public Administration, Social Science and Medicine and the Journal of European Social Policy. Recent publications include: ‘Why No Nonprofits? State, Market, and the Strive for Universalism in Swedish Elder Care’, Nonprofit and Voluntary Sector Quarterly (2019); ‘Privatisation of Social Care Delivery—How Can Contracts Be Specified?’, Public Management Review (2018); ‘Free Establishment of Primary Health Care Providers: Effects on Geographical Equity’, BMC Health Services Research (2016); and ‘Sweden: Continued Marketisation Within a Universalist System’ in Emmanuele Pavolini and Ana M. Guillén (eds.), Health Care Systems in Europe Under Austerity: Institutional Reforms and Performance (Palgrave Macmillan, 2014). Monica  Budowski is Professor  in the Department of Social Work, Social Policy and Global Development at the University of Fribourg and a member of the Swiss National Science Foundation Research Council. Budowski studied sociology and ethnology at the University of Zurich, and held research fellowships at LSE (London School of Economics and

  Notes on Contributors 

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Political Science), Princeton and University of Costa Rica. She did her field work in Albania, Bangladesh, Costa Rica, Chile, Spain and Switzerland on poverty, social inequalities, sociology of the family, gender, social support and networks, health and social policy in developing countries. Recent publications from Budowski include: ‘Reducing Gender Inequalities in Poverty: Considering Gender-­ Sensitive Social Programmes in Costa Rica’ (2010) and ‘Lateinamerika als Modernisierungsvorbild? Vom Korporatistisch-klientelistischen zum Neoliberalen Sozi-alpolitik Modell’ (2009). Kerianne Burke  holds an MA and MPH (from DePaul University in Chicago, IL), and is a project manager managing women’s sexual health research projects for the Ruth M. Rothstein CORE Center, part of Cook County Health, the largest safety-net hospital system in Chicago. Burke obtained her Bachelor of Arts from Hampshire College in Amherst, MA. She has a background in sexual assault advocacy and spent five years working as a crisis counsellor for the Chicago Rape Crisis Hotline and medical advocate for survivors presenting in Chicagoland emergency rooms. Burke is interested in health equity as it pertains to women’s health and sexual violence. Michael Calnan  is Professor of Medical Sociology at the University of Kent’s School of Social Policy, Sociology and Social Research, UK. Calnan is also Director of Studies for BA Social Policy and BA Health and Social Care. He is interested in the sociology of health, illness and health policy, and has had his work published extensively in journals, chapters and books about a range of health-related issues. Books include: Health and Illness: The Lay Perspective, Going Private: Why People Use Private Health Care, The Prevention of Coronary Heart Disease: Prospects, Politics and Policies, Work Stress: The Making of a Modern Epidemic, Modern Medicine: Lay Perspectives and Health, Medicine and Society. Key Theories, Future Agendas. Vid  Calovski  is Lecturer in Social Policy in the School of Sociology, Social Policy and Social Research, University of Kent, UK. His research interests include the privatisation and marketisation of health services,

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Notes on Contributors

primary care commissioning and the sociology of the health service. His projects explore the development of Clinical Commissioning Groups in the English National Health Service (NHS), the effects of their decisions on the selection of private providers in the NHS and the growth of marketisation in the NHS.  Future publications include Clinical Decision Making and the Market—the Effect of the Health and Social Care Act (in preparation). Fran  Collyer  is Associate Professor of Sociology at the University of Sydney in the Department of Sociology and Social Policy. She is on the editorial boards for the American Sociologist, the Health Sociology Review and Sociology, journals of the American Sociological Association, Australian Sociological Association and the British Sociological Association, respectively. Her research interests include: the privatisation of healthcare services; the sociology of the healthcare system; the history of sociology, disciplines and institutions; and the sociology of knowledge. Her projects focus on the history and impact of Australian sociology, the growth of private medicine and the transformation of healthcare systems, and the inequalities of global networks of expert knowledge. Collyer holds a three-year grant from the Australian Research Council to examine the history of sociology and its impact on policy, legislation and the media. Recent books include Knowledge and Global Power: Making New Sciences in the South (with Connell, Maia and Morrell, 2019), the Palgrave Handbook of Social Theory in Health, Illness and Medicine (2015) and Mapping the Sociology of Health and Medicine (2012), for which she won the Stephen Crook Memorial Award for the best Australian monograph in 2014. Tiago Correia  is Associate Professor at the Institute of Global Health and Tropical Medicine, NOVA University of Lisbon. He has a member of the executive committee of the European Society for Health and Medical Sociology and is associate editor for the journals Frontiers in Sociology (specialty in medical sociology) and Interface—Communication, Health, Education (an indexed journal published by the Public Health Department, School of Medicine of Botucatu, Brazil). Correia’s research interests include social theory as applied to health, the g­ overnance of

  Notes on Contributors 

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health systems, the functioning of health organisations, the health professions and medical epistemology. His projects focus on managerialism in the Brazilian health system, the effects of economic and financial crises in European health systems and reforms in the health workforce. Recent publications can be found in Current Sociology, Health Research Policy and Systems, Human Resources for Health, and BMC Health Services Research. Tiago Correia has co-edited two special issues on the professions: Professions and Professionalism in Market-Driven Societies (Professions and Professionalism, 2018) and Professions Under Suspicion: What Role for Professional Ethics and Commitment in Contemporary Societies? (Sociologia, Problemas e Práticas, 2018). Several prizes have been awarded for his contributions. Ivan  Harsløf  is Associate Professor,  at Oslo Metropolitan University, Norway, in the Department of Social Work, Child Welfare and Social Policy. Harsløf offers courses in the Bachelor of Social Work and Master in International Social Welfare and Health Policy. His research interests include comparative welfare state research, the organisation of social services, social inequalities in health, poverty and social exclusion, and European social policy. Harsløf has co-edited The Dynamics of Poverty (2008), Inclusive Consumption (2019), Changing Social Risks and Social Policy Responses in the Nordic Welfare States (2013) and New Dynamics of Disability and Rehabilitation: Interdisciplinary Perspectives (Palgrave Macmillan, 2019). Julie Henderson  has a research interest in rationed care and was part of a research team which undertook a study funded by the Australian Nursing and Midwifery Federation on staffing and skill mix in Australian residential aged care. Henderson has recently undertaken research into the impact of PTSD on partners of veterans and first responders, improving trust in food safety, and primary healthcare planning by regional primary care organisations. Henderson has had her work published in various journals, including Nursing Inquiry, British Food Journal, the Journal of Sociology, Ageing and Mental Health, Contemporary Nurse, the Australian Journal of Primary Health, Australian Health Review, Health Sociology Review and Social Science and Medicine.

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Notes on Contributors

Kristian Larsen  is Professor at Oslo Metropolitan University, Norway, and senior researcher at the University Hospitals’ Centre for Nursing and Care Research (UCSF) and Department of Public Health, Copenhagen University, Denmark. Larsen leads the Danish-Norwegian inter-­ disciplinary research network Phlegethon (www.phlegethon.net), which focuses on rehabilitation, primarily with trauma patients. He is chair of the Nordic Bourdieu network (www.hexis.dk), editor of the Nordic journal of cultural and social sciences Praktiske Grunde (www.praktiskegrunde.dk) and on the editorial advisory board for Profession and Professionalism. Larsen’s research interests involve sociology, health, education, Bourdieu, historical epistemology (with reflections on break, construction, theory and methods), studies of inequality in health, the genesis and structure of the healthcare field and the rise of health capital, dominance in the healthcare field, materiality, technology and health, and the sociology of knowledge. Recent books include Materiality and Learning (in Danish) and Critical Perspectives in the Healthcare Field (in Norwegian), and the article ‘Prestige Hierarchies of Diseases and Specialities in a Field’ in Social Theory and Health. Sophie  Lewis is a Senior Research Fellow and Australian Research Council Discovery Early Career Researcher Award (DECRA) Fellow at the Centre for Social Research in Health, University of New South Wales, Sydney. With expertise in qualitative research methods, her research broadly focuses on sociological understandings of the experiences of living with long-term conditions, including cancer and obesity, and how to support people to live well with these conditions. Her projects focus on uncertainty and incurability in the context of advanced breast cancer; the intersections between culture and cancer; how people navigate and make choices about their healthcare; and how social interactions and social context enable people to set goals and live well with a long-term condition. Fernando  De  Maio  is Professor of Sociology at DePaul University in Chicago. He serves as co-director of the Center for Community Health Equity and as affiliated faculty of the Master of Public Health programme. De Maio is an associate editor of Health Sociology Review. His research interests include the social determinants of health, particularly income

  Notes on Contributors 

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inequality, structural violence and quantitative methods. De Maio received a BA (Honours) degree in Sociology and Economics from the University of Toronto, and his MA (Sociology and Health Studies) and PhD (Sociology) degrees from the University of Essex. His work appears in a wide range of scholarly journals, including the American Journal of Public Health, Critical Public Health, Global Public Health, the Journal of Health Care for the Poor and Underserved, Health Sociology Review, the International Journal of Epidemiology and Teaching Statistics. De Maio has authored two books: Health and Social Theory (Palgrave Macmillan, 2010) and Global Health Inequities (Palgrave Macmillan, 2014), and coedited two books: Latin American Perspectives on the Sociology of Health and Illness (2018) and Community Health Equity: A Chicago Reader (2019). Trudy Rudge  is Professor of Nursing associated with the Susan Wakil School of Nursing and Midwifery at the University of Sydney. Rudge has both anthropology and nursing degrees. Her research interests include nursing and body care, safety and pharmaceutical issues in mental healthcare, and workplace relations for nurses. She has published On the Politics of Ignorance in Nursing and Health Care: Knowing Ignorance (with Dr Amélie Perron, University of Ottawa, 2016) and (Re)thinking Violence in Health Care Settings: A Critical Approach (with co-editors Dave Holmes and Amélie Perron, University of Ottawa, 2012). Rudge is advisory editor for Nursing Inquiry and on the editorial board of Organizational Ethnography. Raj C. Shah  is Associate Professor and a geriatrician in the Department of Family Medicine and the Rush Alzheimer’s Disease Center at Rush University Medical Center in Chicago. He is the co-director of the Center for Community Health Equity. Shah’s research interests focus on the design and conduct of system-wide clinical research based on design thinking to promote health equity in diverse communities of older adults. His projects include serving as Rush’s co-representative on the Alliance for Health Equity Steering Committee, developing a curriculum for social entrepreneurship in the health sciences and promoting innovative primary care to promote mental health equity. Shah has authored many

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Notes on Contributors

peer-reviewed research articles and co-edited Community Health Equity: A Chicago Reader (2019). Luisa Toffoli  is a registered nurse and Senior Lecturer in the School of Nursing and Midwifery, University of South Australia, teaching in both the undergraduate and post-graduate programmes. Her research interests include the use of theoretical approaches to nursing work, workforce, health system governance and aged care. Toffoli has diverse disciplinary and interdisciplinary research collaborations in Australia, New Zealand, the United States and Europe. Her research focuses on topics such as ‘missed care’, also referred to as unfinished or rationalised care, and teaching compassion to undergraduate nursing students. She has written extensively in the area of missed care, in journals such as Nursing Inquiry, Health Sociology Review and the Journal of Industrial Relations, and contributed to the textbook for nursing, health science and allied health students, titled Understanding the Australian Healthcare System. [Editors’ note: Luisa Toffoli passed away shortly after completing this chapter of the book. She will be sorely missed by family, friends and colleagues]. Eileen  Willis  is Emeritus Professor at Flinders University, Adelaide, Australia, and has research interests in rationed and cross-cultural care in residential aged care. Her most recent research in this area was as lead for a study funded by the Australian Nursing and Midwifery Federation on staffing and skills mix in Australian residential aged care. Willis has also conducted research on the increase in culturally and linguistically diverse registered nurses and care workers in aged care and the ways in which not-for-profit providers are managing staff-resident interactions. Her other research interests are in rationed healthcare and public policy. Willis is part of a large-scale evaluation of the capacity of nurse navigators within Queensland Health to facilitate patient-­centred care and reduce hospital admissions, as well as part of an National Health and Medical Research Council (NHMRC) study on the contribution of Aboriginal hospital liaison workers to quality and risk. Willis is co-author of Understanding the Australian Health Care System (2016) and Society and Health: Social Theory for Health Workers (1996). She has published widely in journals, including the International Journal of Nursing Studies, Palliative and

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Supportive Care, the International Journal of Mental Health Nursing, Australian Family Physician, the Australian and New Zealand Journal of Public Health and Focus on Health Professional Education. Karen  Willis is a health sociologist, qualitative researcher, and Professor in the School of Allied Health, Human Services and Sport, La Trobe University, with a joint appointment at Melbourne Health. Willis is the La Trobe/Melbourne Health Chair of the Academic and Research Collaborative in Health (ARCH) and joint editor-in-chief of Health Sociology Review. Her research focuses on how people navigate healthcare, how they choose between private and public healthcare, and how people with chronic conditions interact with healthcare professionals. Willis has also written a textbook, Society, Culture and Health (in two editions), and contributed to other edited texts. She is an active user of Twitter (@KarenWillis19) to promote debate in the areas of health sociology and healthcare systems.

List of Figures

Chapter Four: ‘Looking Outside Their Walls’: Exploring Community Health in Chicago Hospitals Figure One The ‘causes of the causes’ in Chicago Figure Two Health Impact Collaborative of Cook County—mission, vision, and values. Source: Health Impact Collaborative of Cook County

75 80

Chapter Seven: Creeping Privatisation? Examining Procurement Choices in the ‘New’ NHS in England Figure One Internal/external conceptual framework. Source: Calovski (2018)137

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List of Tables

Chapter Four: ‘Looking Outside Their Walls’: Exploring Community Health in Chicago Hospitals Table One

Socio-demographic profile of Chicago, by race/ethnic group (selected indicators, 2015) in US dollars Table Two Health profile of Chicago, by race/ethnic group (selected indicators, various years) Table Three CHNA priorities, by hospital, first wave Table Four Original health systems and health department partners in the Health Impact Collaborative of Cook County

67 68 70 78

Chapter Seven: Creeping Privatisation? Examining Procurement Choices in the ‘New’ NHS in England Table One

Decision-makers interviewed and meetings observed

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Introduction Karen Willis

Private healthcare and the provision of private sector medicine is now a significant characteristic of many healthcare systems worldwide. The growth of private sector medicine has occurred in different ways across the globe. Many advanced economies developed public, universal healthcare systems following WW2, but since the 1980s have increasingly privatised these under conservative and neoliberal governments. In contrast, many developing nations have only recently begun to build their healthcare systems, and, under very different historical circumstances, have supported the growth of private medical services. Despite its ubiquity across diverse health policy settings, the profound effects of private medicine and increased marketisation of health for populations has received relatively little sociological attention. The collection of chapters in this book is an attempt to open up the debate about what is occurring, and to give insight into how the increased shift towards ‘the private’ has effects at all levels of healthcare—from broader K. Willis (*) School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, VIC, Australia e-mail: [email protected] © The Author(s) 2020 F. Collyer, K. Willis (eds.), Navigating Private and Public Healthcare, https://doi.org/10.1007/978-981-32-9208-6_1

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K. Willis

policy initiatives, to key stakeholders in healthcare provision, and to citizens seeking healthcare. The book is also a call for increased examination of the growth of privatisation and private medicine across the globe. Drawing on accounts from a diverse range of countries, it is evident that this is a global trend, not restricted to a particular type of political system, economic structure, or stage of development. Overall, our key argument is that increased privatisation of healthcare contributes to, and maintains, inequality in healthcare.

 eoliberalism, Privatisation, and the Trend N Towards ‘the Market’ Public provision of healthcare is the cornerstone of a social democratic health system; yet, in many countries, we witness the winding back of public provision and an emphasis on privatisation and market principles. Encapsulated by Michael Pusey’s Economic Rationalism in Canberra (1991), in the late twentieth and early twenty-first centuries, there has been a dominant view in policy circles that ‘economies, markets and money can always deliver better outcomes than states, bureaucracies and the law’ (Pusey 2017: 11). Pusey’s empirical study of decision-making in the public sector demonstrated a shift in values about how best to administer government departments, the extent to which market principles could be applied within the bureaucratic setting, and the shift from a nation-building state to a marketised one. The term neoliberalism is used to capture this shift in economic systems, which sees the state transformed ‘from a provider of public welfare to a promoter of markets, and competition helps to enable this shift’ (Birch 2017). In such a move, there is a primacy of private interests and celebrations of the market as flexible, responsive, and providing choice, and these are contrasted with perceptions of bureaucratic inertia and red tape (Clark 2004). Integral to acceptance of such perceptions is the promotion of consumers as ‘active’, ‘choosing’ agents. This is particularly pertinent in discussions about healthcare, where individuals bear the brunt of responsibility for health choices ranging from financing their health needs through to engaging actively with health advice.

 Introduction 

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The insertion of market principles into healthcare provision is vast and diffuse. It extends from public-private partnerships where the private sector is contracted to build the health infrastructure (e.g., hospitals) on behalf of the government, to fully owned and operated services, fee for service medical and healthcare services, and contracting-out of services in the public sector (e.g., cleaning and security services). The argument for most of these arrangements is that the private sector will provide such services more cheaply and efficiently than is possible in the public sector. There is little evidence to support such an argument. Indeed, in one example in the Spanish National Health system, arguments of reduced cost and increased efficiency were used both to establish a public-private partnership and to subsequently reverse the partnership, returning service provision to the public (Comendeiro-Maaløe et al. 2019).

 niversal Healthcare Systems and the Role U of the State The shift towards neoliberalism and market principles contrasts with the World Health Organisation (WHO) ideal of universal healthcare—the proposal that health systems should enable all individuals to have access to the care they need, of sufficiently high quality, and accessed without the threat of financial hardship (WHO 2019). The provision of universal healthcare, thus, is aligned with social values that support a strong role for the state in ensuring healthcare needs are met. Wendt et al. (2010) argue that such social value orientations are important in explaining the high level of support for public provision in European countries, with a strong social democratic policy framework. Similarly, Fotaki (2014) argues that in the United Kingdom the National Health Service (NHS) remains ‘one of the most revered institutions’, partly because it symbolises the overcoming of class divisions and the shared values of contemporary British identity. While there is general acceptance of and support for universal healthcare, in many countries, achieving universality that meets the WHO requirements of breadth (coverage across the population), scope (sufficient coverage of the spectrum of health services), and depth (level of

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funding provided for services) is contested terrain. Added to such a mix are the philosophical approaches of government—debates about the extent to which governments should intervene in the lives and choices of its citizens, along with a medico-industrial complex for which healthcare is a major source of profit, and increasing demands by the population. Policy initiatives occur within this dynamic and changing context. Examples from three countries (China, Ireland, and the United States) illustrate well the intersections between philosophical approaches, the view of players in the health industry, and the dynamics of the healthcare field. Although the level of benefit coverage is modest, China achieved universal health insurance in 2011, and analysis of this success highlights the political context within which such achievements occur. In this case, universal coverage was achieved as a response to the failure of ‘de facto’ privatisation (largely brought about because of lack of public investment in healthcare) and universal coverage was viewed as a way of correcting the ‘market failures’ of the private system. However, while lauded for achieving universal coverage, significant challenges remain, and initiatives such as encouraging private health insurance for services not included in the universal coverage are likely to maintain and increase inequality (Yu 2015). Unlike most of its European counterparts, Ireland has been unable to institute universal healthcare, despite a commitment to do so in 2011. This policy commitment was a response to poorly funded public services, particularly in relation to services for chronic illness and mental health conditions. However, the impact of the austerity measures following the 2008 global financial crisis, along with other factors related to marketisation (Byers 2017), has meant that this policy commitment has been abandoned (Byers 2017), and the resultant impact on population health is yet to be fully measured. The ‘reframing’ of priorities away from universal healthcare has emphasised the purchase of private health insurance (Burke et al. 2016). Most starkly, the struggle to achieve a semblance of universal coverage from a voluntary and privatised system is evident in the United States. Here the struggle to access healthcare in a user pays system, particularly for those with pre-existing conditions, has been well illustrated. While not achieved, the Affordable Care Act (ACA) passed in 2010 attempted to extend a system of universal coverage (Rice et al. 2018). In a federal structure, where policies are set at

 Introduction 

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the top, individual states become key players in implementing policy, and Lanford and Quadagno (2016) point to policy legacies, provider interests, political ideologies, and racial attitudes as all implicated in shaping state responses to the ACA reform at the level of implementation.

Private Health Insurance In many countries private health insurance (PHI) has a growing role in the financing of healthcare needs. There are differences between whether such policies are complementary (covering items not available in the universal health insurance) or supplementary (generally enabling faster access or access to private care for services covered within existing universal schemes), or a combination of both. The growing rates of PHI in the Scandinavian countries, which have been strongholds of universal health insurance, illustrate how the move to a market-based healthcare system can occur. In these countries, growth of PHI has occurred through employer-based provision, with PHI being a ‘benefit’ or status symbol of employment with a ‘good’ employer. This shows how cultural values are used to shape the market, independent of government policy approaches (Tynkkynen et  al. 2018), although some tax benefits to employers are provided by government. In essence, the provision of PHI is now part of the ‘competition to attract and retain skilled employees’ (Tynkkynen et al. 2018: 488), with PHI associated with the status of being a valued employee in the organisation. In some countries, such as Norway, we see that increased marketing and provision of PHI does not appear to undermine support for a strong public system (Martinussen and Magnussen 2019). However, the increased use of PHI to fund healthcare has implications for inequality. In OECD countries where healthcare provision relies on a large share of private insurance and ‘out of pocket’ expenses, and where universal healthcare provision is not fully achieved, there is persistent inequality (Devaux 2015). One country that provides a stark example of the link between inequality and PHI is South Africa. It is claimed that ‘just under half of health spending services 16 per cent of the population who can afford to access private providers through private voluntary health insurance’ (Barber et  al. 2018: 558). Invoking the ‘inverse

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care law’ (where those in least need receive most care) in South Africa in 2008, ‘72 per cent of health-care visits [were] by the richest quintile and 89 per cent of visits by those with medical insurance were to the private sector, whereas the percentages for the poorest quintile and the uninsured were 13 per cent and 19 per cent, respectively’ (Mackintosh et al. 2016). It can be argued that South Africa represents the worst fears of public system advocates, where a lightly regulated private sector produces a two-­ tier health system.

Chapters in This Volume In light of the factors discussed above, this edited collection focuses on the global growth of private sector medicine in both developed and lesser developed countries, and the impact of this on patients, health workers, managers and policy-makers. With experts from several countries with extensive experience in researching the field either nationally or internationally, this volume provides a unique perspective on healthcare systems: a view from those trying to access healthcare services, working inside systems, or responsible for managing and organising services. Collectively, the chapters contribute an international perspective on the navigation of healthcare systems, and to the growing salience of ‘choice’ between public and private medicine in a variety of different systems and contexts. The book commences with a focus on health policy, and takes case examples from four countries. In Chapter Two, Monica Budowski presents case studies from three South American countries, demonstrating the ‘varieties of universalism’. She links these varieties to various types of citizenship, and argues the case for looking closely into what is represented in universal healthcare systems and how this compares with what is actually intended and delivered. Similarly, in Chapter Three, Paula Blomqvist, in a case example from Sweden, takes the theme of universalism and discusses how introducing private providers changes the universal character of healthcare. As yet, the effects may not be evident, but subtle, with the most significant implications of the reforms being not their actual effects but the value reorientation they represent. The idea of healthcare in Sweden is being transformed from a public service, allocated on the basis

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of need alone, to a service where individual patients can ‘shop around’ and seek care from different providers as they see fit. This development implies that Sweden, like many other countries, risks developing a two-tier healthcare system, a public system for the large majority and a private one for those with higher incomes. In Chapter Four, Fernando De Maio, Raj Shah, and Kerianne Burke present a case from the United States, on what happens when community needs assessments are mandated. Importantly, this chapter focuses our attention away from the usual analyses of the US healthcare system as totally private and draws attention to the processes at the institutional level in the US public system. It demonstrates an alternative way of understanding health inequities in the United States, as not-for-profit institutions engage with mandated reporting requirements. Again, at the institutional level, Hugh Armstrong and Pat Armstrong in Chapter Five provide an exemplar of private aged care, and the issue of contracting-out of care-related services, providing a reminder that the provision of care occurs across the whole healthcare experience, not just in relation to nursing and medical services. These authors powerfully point to the implications for quality care when services are contracted out to private providers. The role of gatekeepers in the healthcare system is the focus of Fran Collyer’s work in Chapter Six. Collyer’s chapter examines how the habitus of gatekeepers and their ‘world view’ varies according to their location in the public or private sectors of healthcare, while their orientation towards either public or private (which can be either beneficial or problematic) is shaped by their location in the healthcare field. Similarly, in Chapter Seven, Vid Calovski and Michael Calnan examine decisionmakers in the United Kingdom, and provide evidence about how the notion of ‘contracting-out’ of care in the healthcare market can privilege private provision. Privatisation, when it has occurred in the United Kingdom, has appeared only within the scope of certain services rather than supplanting or becoming an alternative to existing public providers. The most effective characterisation of this process would be ‘passive privatisation’, where services which have been allocated to the private sector are those in which the treatment of patients is possible outside hospital settings. Such analyses echo Clark’s (2004) conclusion that neoliberalism is a contested and uneven terrain.

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The following three chapters take the perspectives of healthcare professionals in the context of change. In Chapters Eight and Nine, the argument is made that the growth of private medicine must be understood from the perspective of those who work in the various systems. In Chapter Eight, Trudy Rudge and Luisa Toffoli demonstrate how nursing work changes in the private healthcare context, pointing out that the main customers in the private hospital setting are in fact medical doctors, rather than patients. Without doctors supporting the hospital through referrals and continued practice, the livelihood of the hospital is threatened. Thus, nurses in this setting must work around and ‘tinker with’ the exigencies of private care. In Chapter Nine, Tiago Correia focuses our attention on the need for innovative approaches to sociological analysis of health policy given the growth of private medicine. Using a national survey of physicians, Correia examines how a seemingly successful initiative following the 2008 financial crisis results in changes in the care provided. Correia argues that when examining the experiences of physicians, the effects of policy changes become evident in a way not encapsulated in other forms of policy evaluation, which in this case were viewed as indicators of policy ‘success’. Continuing the theme of analysing the perspectives from within the system, in Chapter Ten, Kristian Larsen and Ivan Harsløf demonstrate the significance of the reorientation of healthcare to neoliberal values for the provision of ‘body work’. Significantly, they point to a new alignment of healthcare services and transformations in the field of employment. Their analysis points to the significance not only for those in receipt of healthcare and rehabilitation services, but also for healthcare professionals working in redefined industries. In the final section, the focus is on healthcare patients, consumers, and citizens. In Chapter Eleven, Karen Willis and Sophie Lewis examine the ‘imperative of choice’ in Australian healthcare. Linked with ideas of individual control and personal responsibility, Australians are increasingly urged by government and the media to purchase private health insurance. The focus on choice privileges private healthcare, rather than public. There is little focus on the challenges of navigating a complex healthcare system and the differential capacity to do so for various groups. In Chapter Twelve, Julie Henderson and Eileen Willis examine the impacts of the marketisation of healthcare. The authors critique the move

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towards consumer-directed care and the assumptions about the link between competition and better quality services. They point to the fact that there is little evidence of standards of care being improved through a market approach. With recent policy changes in Australia privileging market forces, there is likely to be an exacerbation of inequality in access to quality care, with those most able to pay able to purchase higher quality. The concluding chapter by Fran Collyer examines the trends in sociological analyses of health and healthcare, the focus of key players who have promoted a neoliberal approach to healthcare, and how the growth of private medicine has transformed healthcare systems. With reference to the various contributors to the book, Collyer discusses the implications for public healthcare when private healthcare is perceived as more efficient, as providing choice, and as being responsive. Increased marketisation of health and private medicine, she states, has implications for the effective governance of healthcare, as the profit motive overrides all other criteria for success. Moreover, regulation becomes less effective and more difficult to implement when medicine is privatised: there is less access to information upon which to judge the quality of healthcare, and, most importantly, private medicine brings a significant threat to the ideals of universality and equity in healthcare.

References Barber, S., Kumar, A., Roubal, T., Colombo, F. and Lorenzoni, L. (2018). Harnessing the private health sector by using prices as a policy instrument: Lessons learned from South Africa. Health Policy, 122(5), pp. 558–564. Birch, K. (2017). What exactly is neoliberalism? The Conversation, 3rd November. Available at: https://theconversation.com/what-exactlyis-neoliberalism-84755. Burke, S.A., Normand, C., Barry, S. and Thomas, S. (2016). From universal health insurance to universal healthcare? The shifting health policy landscape in Ireland since the economic crisis. Health Policy, 120(3), pp. 235–240. Byers, V. (2017). Health care for all in Ireland? The consequences of politics for health policy. World Medical and Health Policy, 9(1), pp. 138–151. Clark, J. (2004). Dissolving the public realm? The logics and limits of neo-liberalism. Journal of Social Policy, 33(1), pp. 27–48.

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Comendeiro-Maaløe, M., Rideo-Lopez, M., Gorgemans, S. and BernalDelgade, E. (2019). Public-Private partnerships in the Spanish National Health system: The reversion of the Alzira model. Health Policy, 123(4), pp. 408–411. Devaux, M. (2015). Income-related inequalities and inequities in health care services utilisation in 18 selected OECD countries. European Journal of Health Economics, 16(1), pp. 21–33. Fotaki, M. (2014). Can consumer choice replace trust in the National Health Service in England? Towards developing an affective psychosocial conception of trust in health care. Sociology of Health and Illness, 36(8), pp. 1276–1294. Lanford, D. and Quadagno, J. (2016). Implementing ObamaCare: the policies of Medicaid expansion under the Affordable Care Act of 2010. Sociological Perspectives, 59(3), pp. 619–639. Mackintosh, M., Channon, A., Karan, A., Selvaraj, S., Cavagnero, E. and Zhao, H. (2016). What is the private sector? Understanding private provision in the health systems of low-income and middle-income countries. The Lancet, 388(10044), pp. 595–605. Martinussen, P. and Magnussen, J. (2019). Is having private health insurance associated with less support for public healthcare? Evidence from the Norwegian NHS. Health Policy. https://doi.org/10.1016/j.healthpol.2019.05.003. Pusey, M. (1991). Economic Rationalism in Canberra: A Nation-Building State Changes Its Mind. Cambridge: Cambridge University Press. Pusey, M. (2017). Economic rationalism in Canberra 25 years on. In: A. Yeatman (ed.) Economic Rationalism in Canberra Twenty-Five Years On. Working Papers in the Human Rights and Public Life Program No. 5, May 2015. The Whitlam Institute, within the University of Western Sydney. pp. 10–15. Rice, T., Unruh, L., Ginneken, E., Rosenau, P. and Barnes, A. (2018). Universal coverage reforms in the USA: From Obamacare through Trump. Health Policy, 122(7), pp. 698–702. Tynkkynen, L.K., Alexandersen, N., Kaarbøe, O., Anell, A., Lehto, J. and Vrangbaek, K. (2018). Development of voluntary private health insurance in Nordic countries – an exploratory study on country-specific contextual factors. Health Policy, 122(5), pp. 485–492. Yu, H. (2015). Universal insurance for 1.3 billion people: What accounts for China’s success? Health Policy, 119(9), pp. 1145–1152. Wendt, C., Kohl, J., Mischke, M. and Pfeifer, M. (2010). How do Europeans perceive their healthcare system? Patterns of satisfaction and preference for

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state involvement in the field of healthcare. European Sociological Review, 26(2), pp. 177–192. World Health Organization (WHO). (2019). Health Financing. Available at: https://www.who.int/health_financing/universal_coverage_definition/en/ [Accessed 20 May 2019].

Part I About the System: Universalism and Privatisation

Chapter Two: Universalism in Healthcare and Social Citizenship in Chile, Uruguay and Costa Rica Monica Budowski

Introduction Universal healthcare is considered a means to reduce the inequities and inequalities in health, to which healthcare systems contribute (Navarro and Shi 2001; World Health Organisation [WHO] 2013). The WHO states that ‘all people [should] obtain the health services they need—prevention, promotion, treatment, rehabilitation and palliation—without risk of financial ruin or impoverishment, now and in the future’ (WHO 2013: 6). Established understandings of universalism in healthcare generally refer to universal insurance or population coverage; however, the issue might be more complex. While access to health services has come to be conceived as a right of citizenship (Frenk 2015), universal healthcare systems vary in terms of organisation, public and private mix, financial arrangements, and entitlements.

M. Budowski (*) Department of Social Work, Social Policy and Global Development, University of Fribourg, Fribourg, Switzerland e-mail: [email protected] © The Author(s) 2020 F. Collyer, K. Willis (eds.), Navigating Private and Public Healthcare, https://doi.org/10.1007/978-981-32-9208-6_2

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Universalism is a term broadly analysed and debated (e.g., Stefánsson 2012; Schmidt et al. 2015; see also Chapter Three of this book). Kildal and Kuhnle (2005: 5) suggest this ‘may partly be due to the different dimensions it contains’. Universalism may be understood in regard to specific policies, benefits and services, to a whole population or some population groups, or to a specific field (e.g., healthcare). Marshall (1950) conceptualised universalism from a social citizenship perspective and saw it ‘not … an end in itself, [but] rather as a means to an end of the objective of integration’ (Powell 2002: 233). Universalism in this sense refers to the equal status of individuals in terms of access to benefits and participation according to the accepted standards of societies. Universalism provides a common and shared experience of cash, kind and service benefits, and entails ‘a profound effect on the qualitative aspects of social differentiation’ (Marshall 1950: 57) in an equalising way, ‘conferring on everybody a badge of citizenship, eliminating any public distinction between the social classes, between rich and poor, the eligible and the non-eligible’ with regard to access, quality and reception of such benefits when in need (Powell 2002: 232). From within this framework, a universal approach must provide a level of public services or benefits available to all: a level that is consistent with accepted standards of societies, available to a majority of the population, and use or reception which does not stigmatise. Such a level and quality of universal services and benefits will result in ‘greater equality in manners and texture of social life’ (Powell 2002: 232). To realise universalism in healthcare, ‘solidarity in provision and financing’ (Mackintosh and Koivusalo 2015: 90) are necessary. Universalism can be considered a ‘distributive principle … [that] is associated with some kind of equity and redistribution’ (Kildal and Kuhnle 2005: 5). Codified social rights are one way to achieve equal status. On the global level, the ‘right to means for adequate health’ (e.g., through healthcare services) is codified in the 1948 Universal Declaration of Human Rights (UDHR) (article 25). The 1966 International Covenant on Economic, Social and Cultural Rights (ICESCR) (article 12) specifies that this right refers to ‘the highest attainable standard of physical and mental health’. On the country level, some states have formulated access to healthcare as a social right while others have not (for information

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about the constitutions of various countries, see Constituteproject.org. 2019). Constitutionally, codified access to healthcare (‘de jure universalism’) may not be put into practice due to economic or political constraints, and codification need not ensure increased resources to meet the population’s healthcare needs, nor equally recognise the healthcare needs of all social groups, even if healthcare rights may be legally claimed. Some healthcare systems provide universal access to healthcare in practice (‘de facto universalism’): they do not dispose of an explicit right to health in the constitution (Smith-Nonini 2006) and suggest there are functioning institutions in place, despite lack of codification. The term social citizenship refers both to social rights—codified or not—and to practice, participation and struggle. Social citizenship seems to be a question of degree or properties; ‘the right to a modicum of economic welfare and security’, when its level is low, is ‘compatible with a limited type of social citizenship’, whereas the ‘right to share to the full in the social heritage and to live the life of a civilised being according to the standards prevailing in the society’ presents the ‘maximalist part of the citizenship range’ (Powell 2002: 234). Minimal social rights provide the foundation for universal benefits, yet may not result in equal status due to social stigma or assumed inferiority (Powell 2002: 234). Social citizenship, as practices and struggles, points to the importance of institutions, norms and identities, and highlights participation in as well as the institutionalisation and appropriation of collective benefits or services (Isin and Turner 2002: 4). Given the wide variation in the institutional mix and structure across societies, it is not clear whether all universal healthcare systems are, in fact, providing similar levels of service: the same access, the same packages, range and quality of provision. This chapter scrutinises the notion of ‘universalism’ in three Latin American countries which each claim to have universal healthcare, by focusing on variations in institutional arrangements. The next section offers the rationale for selecting the countries according to the welfare regime typology, followed by a section presenting the constitutive dimensions of healthcare systems. After clarifying the ‘variety of universalism’ featured in each of these countries’ healthcare systems, the final section discusses some of the implications of the analysis for social citizenship.

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Welfare Regimes and Country Selection Welfare regime theory provides a theoretical frame within which to compare institutional arrangements. Welfare regimes refer to country groups with dominant institutional patterns, policy logics and principals, and it is assumed that the organisation of welfare in specific fields varies according to the rationale or principles of the welfare regime (Lundberg et al. 2015). The study of regimes reveals the interplay of responsibilities between state, markets, communities/non-profit organisations and  households/individuals, which together enable welfare provision. Each welfare regime is indicative of a specific state-citizen relationship and a way of according social rights and status; it contains a discrete understanding of (social) citizenship (Isin and Turner 2002). The three countries with universal healthcare examined in this chapter were selected according to Esping-Anderson’s typology of welfare regimes (Esping-Andersen 2015), which Filgueira (1999, 2007) applied to the Latin American context: Chile accords to the liberal type, Uruguay to the conservative type and Costa Rica to the social democratic type. Liberal welfare regimes (Chile) build on the rationale of individual provision and responsibility and rely on markets to allocate social rights. Benefits, transfers, redistribution and solidarity are minimal, suggesting that the variety of universalism is residual, that is, at a low level and limited. Social citizenship does not refer to rights of equal status, but rather is dependent on market success or income (Isin and Turner 2002) and therefore stratified. This brings with it the risk that beneficiaries of welfare may be considered inferior and are stigmatised (because they are not successful in the market). Conservative welfare regimes (Uruguay) follow the rationale of corporate or institutional partnerships, or of social groups. Social rights are important, but not universal (Isin and Turner 2002). Welfare provision is differentiated according to status, and benefits are aimed at status maintenance. Social rights are based on employment (and family circumstance). Benefits, transfers, redistribution and solidarity tend to be more generous than in liberal regimes. Universalism refers to institutional arrangements for specific social or population groups. Welfare receipts may stigmatise beneficiaries, and social citizenship may be segmented or stratified.

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Social democratic welfare regimes (Costa Rica) are state-oriented and egalitarian. Social rights are important to ensure equity and enhance equality. Policies are oriented towards the whole of the population and welfare benefits are comprehensive and of similar quality for all. This institutional arrangement is universal without stigmatisation; it enables full social citizenship in terms of equality of status. Social democratic regimes are the best at guaranteeing universalism in healthcare in terms of benefits and services, social rights, equity and social citizenship. Liberal regimes guarantee universalism least, given that social citizenship is stratified according to an individual’s purchasing power and thus capacity to access welfare (and healthcare). Conservative regimes grant conditional rights, with solidarity anchored in groups, so universalism and social citizenship are segmented. Healthcare systems of conservative regimes stand somewhere in between the social democratic and liberal regimes with regard to social rights, solidarity and the level of welfare benefits and equal status.

 onstitutive Dimensions of Healthcare C Systems for Universalism and Social Citizenship Londoño and Frenk’s (1997) framework enables analysis of how well a healthcare system responds to a population’s health needs, by classifying healthcare systems according to two key dimensions: (1) population access to healthcare, and (2) the integration or separation of a healthcare system’s three functions—stewardship, financing and delivery (Frenk and Gómez-Dantés 2018). The framework also provides a structure for comparing healthcare systems, clarifying the form of universalism present, and the type of social citizenship it enables. Stewardship, financing and delivery address the three functions of healthcare systems that expose variations in the institutional features of universal healthcare in terms of legal framework, entitlements, the ­package of services, quality, timeliness and affordability. They provide insight into the extent of solidarity with regard to the contributions of different stakeholders for healthcare. In brief, these can be described as follows.

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The stewardship function establishes, implements and monitors the ‘rules of the game’; it defines the strategic orientation for the healthcare system. It regulates, organises and coordinates the responsibilities of the state, market, communities/non-profit organisations and individuals towards healthcare and the solidarity of different stakeholders in healthcare. Legally codified social rights reflect claimable entitlements and lay out the framework for participation and equal status. Thus, stewardship covers: (1) the right to health in the constitution, and/or (2) an existing rights-based approach to healthcare, and (3) the participation structure of stakeholders for the healthcare system’s strategic orientation. The financing function refers to the way resources are generated and made available for healthcare. Universalism in healthcare requires broad support in financing and solidarity-based financing. Broad support is achieved through the contributions of various stakeholders and solidarity-­ based financing by contribution modalities. Pooling resources separately within different sectors of a healthcare system or selecting more affluent or healthier individuals, and pricing out high-risk individuals, indicates inequity and unequal status, and stratifies or segments access. The following aspects are indicative of the extent to which financing is universal: (1) modalities of contribution between different stakeholders (the state, markets and individuals); (2) modalities to achieve solidarity-based financing, such as proportional or progressive contribution rates according to an individual’s income, or the financial magnitude of public and private employers, or by tapping into various state resources (general and specific consumer taxes), financial and health risks pooling; and (3) the level of public financing in proportion to total financing in healthcare (as an indicator of the importance of health as a public good). The delivery function refers to the way the delivery of healthcare is organised. Three aspects of delivery enable assessment of the variety of universalism and the extent of stakeholder participation: (1) healthcare sectors that serve different population groups with different packages, quality or timeliness of healthcare indicate that the healthcare system is segmented and stratified; (2) the structure of operational decision-­making informs whether different sectors and/or healthcare schemes are integrated and coordinated, and have the institutional opportunity to address inequalities or inequities within the healthcare system and across its sec-

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tors; and (3) the percentage of the population that each sector serves reveals its importance within the whole system. The integration of the three functions dimension indicates the leeway a healthcare system has for solidarity and support for universal healthcare (Frenk and Gómez-Dantés 2018). Solidarity and support are limited if the functions are vertically integrated within each sector only; that is, stewardship, financing and delivery are organised to service discrete population groups or are restricted to the public or private sector. Solidarity and support are enhanced when the same function is integrated horizontally across the public and private sectors. This dimension indicates whether the ‘variety of universalism’ in healthcare is segmented and/or stratified, integrated/coordinated or unified. It also indicates the extent to which the healthcare system enables social citizenship in terms of (claimable) social rights, participation in stewardship and access to equal healthcare regardless of ability to pay. The population access dimension refers to whether, and which, social or population groups are channelled into different sectors or can choose among alternative healthcare providers. It also refers to access to the range, quality, timeliness and affordability of healthcare packages. Segmented healthcare systems segregate different populations or social groups into different sectors (e.g., public and private, or occupational groups). They may achieve universal coverage and enable universal access, yet provide qualitatively different packages, and are conditional on ability to pay or type of medical condition (Londoño and Frenk 1997).

 hile, Uruguay and Costa Rica’s Healthcare C Systems Chile’s Healthcare System Chile’s fragmented healthcare delivery was expanded and centralised in 1948, leading to the creation of a public healthcare system financed by contributions from public servants and private formal sector employees (Barrientos 2002). This national public healthcare system was replaced in 1979 with the National Health Fund (FONASA). In 1981, in line with

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neoliberal reforms (less government involvement, competition, decentralisation and public subsidisation of the poor), a healthcare system with freedom of choice between public and private providers was introduced. By establishing a private healthcare sector for Private Health Institutions (ISAPRES), healthcare became subject to principles of market orientation (Gottret et al. 2008; Missoni and Solimano 2010; Erazo 2011). In 2005, the rights-based Universal Care with Explicit Health Guarantee (AUGE) was implemented to remedy the growing healthcare inequities and inequalities noticeable since the 1980s (Cecchini and Martínez 2012). Today, AUGE provides access to about 80 listed medical conditions that cover around 60 per cent of the health burden (Frenk and Gómez-Dantés 2018). This structure of the healthcare system, alongside the occupational health services for The Armed Forces (CAPREDENA) and The Police (DIPRECA), established in the early 1900s, exists today. Stewardship: Chile’s strategic and regulatory agency is the state’s Ministry of Health (MINSAL). Its legal framework defines regulatory elements, such as benefits packages, protection rights for the insured, affiliation rules or institutional requirements for healthcare financing and delivery for the public sector (Bitrán et al. 2008). The state is responsible for coordinating and controlling health-related services, and ensuring the right to choose between private and public healthcare (article 19 of the constitution constituteproject.org 2015). The Superintendancy of Health (SIS)  regulating the ISAPRES was authorised in 2005 to also regulate healthcare in the public sector (Bitrán et al. 2008: 172). In the same year, the rights-based approach to health—AUGE—was implemented. As a means to strengthen MINSAL’s stewardship and stakeholder participation, advisory councils for healthcare in the public sector and a Complaints and Suggestions Office were introduced in 2008 (by the Ministry of Health Law no. 19937; Chile’s Ministry of Health 2008) (Missoni and Solimano 2010), but no substantial structural changes were made. Financing: Chile’s public healthcare services are financed by mandatory payroll contributions, individual  co-payments for treatments and service fees and, to a smaller extent, by public resources from general and specific consumer taxes (Missoni and Solimano 2010). The FONASA contains various solidary components in financing and subsidies for defined and legally certified citizens (Bitrán et al. 2008). FONASA enrols

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everyone, including those priced out of the private sector, leading to a concentration of health risk and low-income groups in the public sector. For example, 90 per cent of the elderly are in FONASA (Erazo 2011). Mechanisms of financial solidarity to counterbalance these risks are scant. Health insurance—either public or private—is mandatory. Beneficiaries’ premiums in the public sector vary and the percentage of co-payment increases according to FONASA’s classification into income categories. The solidary component  consists in cross-subsidises from higher-income to lower-income insured (Frenz et al. 2014). It is complemented by public budget transfers for state-subsidised beneficiaries. The amount available for subsidiarisation does not depend on the population’s needs but the annual governmental decision of a total lump-sum. FONASA enables choice through two insurance modalities that depend on income category: Institutional Care (MAI) provides access to public sector healthcare for all citizens and Free Choice Care (MLE) is available to FONASA’s higher-income groups. MLE provides access to public and private facilities and requires higher individual co-payments for (public or private) healthcare services and fees. The ISAPRES (private insurances) are financed by mandatory payroll contributions, additional premiums and voluntary employer contributions (Bitrán 2013). Rights-based care (AUGE) is financed mainly through consumer tax (Missoni and Solimano 2010), a 1 per cent mandatory AUGE premium from the ISAPRES and (capped) co-payments for all beneficiaries. Lack of the public sector’s capacity to meet AUGE demands requires the purchasing of (more expensive) services from the private sector (Bitrán 2013). The public and private sectors pool their financial resources and health risks separately; there is a separate pooling arrangement for state-subsidised beneficiaries. Chile had a ratio of 49 per cent of public health as total health expenditure in 2014 (World Bank Indicators 2019). Delivery: Chile’s healthcare is delivered in two large and not well-­ integrated healthcare sectors: the public and the private healthcare sectors. FONASA purchases the majority of its services from the ministry of public hospitals and centres, covers a ‘basic, but broad package of services’ and is complemented by various additional schemes (e.g., for particular population groups, such as the poor, people with mental disabilities, victims of human rights violations, people needing emer-

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gency care or high-cost diagnostics) (Heredia et al. 2015). Legally certified indigent citizens and unemployed have the right to free coverage in the public sector (Bitrán 2013). Quality of the public healthcare package varies according to selected access modality (Institutional MAI or Free Choice Care MLE). The MLE modality enables the use of facilities and services from registered, privately run providers by means of (public sector) vouchers in combination with individual  co-payments and fees. Fully subsidised beneficiaries receive a basic but limited package of healthcare services from the public healthcare facilities. FONASA is accessible to all citizens, but delivery of healthcare varies according to income category (Bitrán 2013). The ISAPRES purchase services mainly from a network of private providers. They must provide a minimum basic package of services (Urriola 2006; Bitrán 2013), yet select the people they insure. AUGE healthcare is independent of insurance affiliation or ability to pay (Frenk and Gómez-Dantés 2018). Private and public healthcare providers (FONASA and ISAPRES) are required to guarantee the same services in terms of access and eligibility, maximum waiting times, maximum co-payments and deductibles and quality of care for AUGE-listed medical conditions. As public providers’ resources are limited and AUGE-listed medical conditions are given priority, an (implicit and maybe not justified) ‘solidarity between medical conditions’ takes place, meaning medical conditions that are not AUGE-­listed ones tend not to be given immediate or comparable quality treatment. Integration of the three functions: Stewardship is sector-oriented, although the law prohibits the Chilean healthcare system from integrating financing and delivery vertically (Bitrán 2013). As FONASA has to—by law—purchase most services from MINSAL, in practice a rather strong vertical integration of stewardship, financing and delivery exists within each sector and horizontal integration is weak. Financing is separate within each sector (FONASA and ISAPRES). AUGE has led to a larger financial engagement by the state by tapping into general and consumer taxes (Erazo 2011), and by introducing proportional yet capped co-payments. Nonetheless, due to a concentration of the high health risk, low-income population and high AUGE demand in the public sector, resources remain scant. The public sector is required to purchase services from private providers (Bitrán 2013). The AUGE did not change the

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structure of healthcare system but led to a further separation of functions consolidating the public-private sector divide (Erazo 2011). Access to healthcare is available to all, yet choice of provider is not. All providers are responsible for identifying potential beneficiaries for subsidisation and enrolling them in FONASA. Access to healthcare is stratified by purchasing power in the public and private sector, although the AUGE-listed medical conditions are exempt from stratification. As private insurance is optional, ISAPRES may apply health risk, price-adjusted, individual insurance plans despite receiving the insured individual’s obligatory contributions (Bitrán 2013). Various laws and bilateral agreements are pending or have been accepted to reform migrants’ access to healthcare in terms of basic social rights for immigrants (Voorend 2014). Access to quality varies: public providers’ healthcare quality is lower (Gideon and Alvarez Minte 2016), and public healthcare has long waiting lists (also interpreted as rationing) (Frenz et al. 2014). Everyone has access to the ‘basic, but broad package of services’ except citizens who are fully subsidised; these receive a limited package of services only. From 2019 onwards, all migrants unable to pay receive healthcare at the same conditions as the fully subsidised Chilean citizens (MINSAL 2019). The delivery modalities for AUGE-listed medical conditions are the same for everyone. Chile’s healthcare systems’ organisational features channel the lowand middle-income population into the National Health Fund (FONASA) (around 78 per cent of the population) and the higher-income population into the Private Health Institutions (ISAPRES) (around 17–18 per cent). The additional two sectors, consisting of The Armed Forces (CAPREDENA) and The Police (DIPRECA), cover 3–4 per cent combined (in 2011) (Class et al. 2014). The distribution of services and facilities are uneven across the country, leading to regional disparities in access to healthcare. Summing up, Chile’s healthcare system is segmented (effectively public and private) and stratified (OECD 2017a). The public and private sectors function independently in terms of stewardship, financing and the delivery of healthcare services, and they service different population groups according to the ability to pay and medical conditions. Universal coverage is limited and residual in Chile for those who are fully subsi-

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dised, and it depends on purchasing power for the others, with the exception of AUGE-listed medical conditions where there is universal access.

Uruguay’s Healthcare System Prior to 2005, Uruguay’s strongly stratified and segmented healthcare system was one of the most complex in Latin America (Fernández Galeano and Benia 2013/2014). Most of the population received care from autonomously functioning, private, non-profit Collective Medical Care Institutions (IAMCs), the poor were serviced by the Health State Services Administration (ASSE) and the wealthy by for-profit private insurance. The 2005 reforms changed this structure. Uruguay’s healthcare system today consists of the public sector’s Health State Services Administration (ASSE), the private healthcare sector with Collective Medical Care Institutions (IAMC) (i.e., non-profit mutual societies and medical cooperatives), a small for-profit private insurance sector and The Military and Police Health Services (Bellomo and Naranija 2016). All healthcare institutions that are voluntarily associated with the National Healthcare System (SNIS) deliver the same package, quality and affordability of healthcare to all. Stewardship: The reforms in 2005 substantially strengthened the state’s stewardship and stakeholders’ participation, integrated stewardship and financing across healthcare sectors, and regulated healthcare delivery and access modalities by means of standards. The Ministry of Health sets the strategic direction, whereas the National Board of Health (JUNASA), consisting of representatives of many stakeholders (such as ministries, employers, employees, unions, medical professionals and organisations, insurance agencies, users of health services, etc.) (Aran and Laca 2013), administers, oversees, plans and regulates the National Health Fund (FONASA) and the National Healthcare System (SNIS) (Setaro Montes de Oca 2014) and implements the Comprehensive Health  Care Plan (PIAS) (Aran and Laca 2013). With its extensive competences and responsibilities, JUNASA increases public control, limits market competition and promotes cooperation and the complementarity of services between the systems (Setaro Montes de Oca 2014).

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Financing: The FONASA is a mandatory, pooled, public fund for all public and private organisations affiliated to the SNIS. It is financed in a solidary way by the state, public and private enterprises and formal and informal employees (Aran and Laca 2013; Fernández Galeano et  al. 2015). In the Uruguay system healthcare insurance is voluntary. Individuals’ insurance contributions are progressive depending on income level and family composition (Bellomo and Naranija 2016; Rivas et al. 2017). Informal low-income workers and the unemployed may actively claim exemption from contributions. Individuals with disabilities, older individuals with low income and victims of state terrorism are eligible for subsidies. All individuals may choose amongst SNIS-affiliated public or private providers (Fernández Galeano et al. 2015), except fully subsidised beneficiaries (serviced by ASSE). FONASA pays age- and sex-adjusted ‘health quotas’ per beneficiary as well as for subsidised beneficiaries (the latter financed with governmental contributions) to SNIS-affiliated public healthcare providers, mutual societies (IAMC) and for-profit enterprises. Individual payment capacities allow for purchasing complementary services or insurance from IAMCs or for-profit insurance enterprises. State contributions vary according to population needs to enable benefits at all levels of complexity that the Comprehensive Health Care Plan (PIAS) covers. FONASA has the capacity to redistribute resources and ensure solidarity between all organisations that have voluntarily joined the SNIS (Setaro Montes de Oca 2014) by integrating, centralising and pooling contributions from state, public and private enterprises and formal and informal employees; providing incentives for complementary cooperation and sharing healthcare facilities; and financing healthcare according to health quota for the defined package of healthcare. In 2014, public healthcare expenditure as a percentage of total health expenditure amounted to 71 per cent of public health (World Bank Indicators 2019). Delivery: The SNIS integrates the public ASSE and other public healthcare providers as well as private non-profit mutual societies (IAMC). Only a few for-profit private insurances have voluntarily affiliated to the SNIS. The National Board of Health (JUNASA) defines the comprehensive healthcare package of preventive, curative, rehabilitative and palliative care that the Comprehensive Health Care Programme

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PIAS is to deliver. The IAMCs and the for-profit private providers offer additional services or treatments. The National Healthcare System (SNIS) has integrated the three functions by centralising stewardship and financing across the public and private sectors for all SNIS-affiliated health providers. Uruguay has enhanced civil participation by including many stakeholders in the National Board of Health (JUNASA), contributing to the healthcare system’s strategic orientation. Access is guaranteed by constitutionally codified social rights (Law 18.211) and a legal framework for Uruguay’s National Healthcare System (SNIS) that considers health a public good. All citizens have access to, and choice of, SNIS-affiliated public or private healthcare providers, with the exception of the fully subsidised, who are served by the Health State Services Administration (ASSE). Migrants have the same rights as Uruguayans (IMPO 2019). Everyone receives the same quality healthcare package at all levels of complexity. The health reform of 2005 reduced the segmentation that was dominant before the reform as most health care providers voluntarily chose to affiliate to the SNIS and increased the mobility of beneficiaries across SNIS-affiliated healthcare providers. The ASSE serves 37 per cent of the population; the mutual societies (IAMCs) serve 56 per cent. The non-SNIS-affiliated private forprofit institutions cover about 2 per cent of the population, the Military and Police Health about 5 per cent (percentages for 2009, Aran and Laca 2013). Despite these reforms, stratifying elements exist with regard to the possibilities for purchasing services for greater convenience or additional treatments. The healthcare system is segmented due to the Military and Police Health and a small number of for-profit private healthcare services. Restricting fully subsidised to ASSE may stigmatise the beneficiaries in terms of provider, although healthcare packages or quality are equal to those of other public and private providers. Facilities are uneven across the country. Summing up, universalism in healthcare in Uruguay is realised through a strong horizontal integration underpinned by the rights-based framework, with a strong and participatory stewardship structure. Public healthcare institutions and non-profit mutual associations (IAMCs) from the private sector have voluntarily affiliated to the National Healthcare

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System (SNIS), and centralising resource generation and distribution through the National Health Fund (FONASA). Choice of healthcare is possible for all citizens, except the fully subsidised beneficiaries who are limited to ASSE services. IAMC’s additional insurance stratifies and reinforces the traditional dividing line between public and private healthcare providers, stigmatising the use of public healthcare (Antía et al. 2013). Although universalism is somewhat limited by components of segmentation, the SNIS is moving towards encompassing universalism and full social citizenship in healthcare.

Costa Rica’s Healthcare System The Costa Rican Social Security Agency (CCSS) was created in the early 1940s as an autonomous institution. Healthcare was originally implemented as an inclusive social insurance system to cover low-paid urban wage workers (Rosenberg 1981). Insurance coverage steadily expanded to other population groups and includes around 95 per cent of the population today (OECD 2017b: 49). Instead of privatising during the 1980s, as many Latin American countries did, most prominently Chile, Costa Rica reformed its public model (Clark 2014). The private sector is weakly developed, but growing. Healthcare consists of ‘an almost complete, universal coverage, both financial and geographical, an achievement that is sustained in a financing strategy based upon the contributions of workers, employers, and the State’ (del Rocío Sáenz et al. 2010: 6). Stewardship: The CCSS autonomy is established by law (article 73 of the Constitution), and the ‘Constitution and the CCSS Creation Law state that social insurance is universal, solidary and compulsory’ (OECD 2017b: 48). The CCSS defines and implements everything in healthcare from strategic planning to funding, procurement of pharmaceuticals, medical utilities and technologies, organisation and delivery of services, education of medical and health personnel, contracting private service providers and more. The Board of Directors of the CCSS is a participatory body. Specified groups from industry, agriculture, commerce and cooperatives, solidarity movements and labour unions elect the representatives of employees, employers and the governmental institutions as

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board members. Participation is implemented at different levels of decision-­making with an underrepresentation of beneficiaries (Cercone and Pacheco 2008: 60–61, 90–91). The Costa Rica’s Constitutional Chamber of the Supreme Court has become a player in stewardship, as it imparts the final decision when beneficiaries challenge the strategic orientation or services (not) provided or financed (Norheim and Wilson 2014). Financing: Healthcare financing relies on contributions of all stakeholders (employers, employees, state and self-employed). Affiliation to the CCSS is mandatory and unconditional on ability to pay. There are various insurance modalities such as  the contributory and non-­ contributory. The contributory modality consists of direct insurance for employed and self-employed independent workers (accounting for about 65 per cent of the population), and the non-contributory, indirect insurance (about 35 per cent) covers pensioners, family dependents and the state-insured (OECD 2017b: 68). The tripartite direct contributions are differentiated according to formal and informal employment. In formal employment, employees, employers and the state contribute a fixed percentage of the employee’s income. Self-employed individuals contribute according to income level, and the state complements this to reach 12.25 per cent. Dependent family members (parents and children) are indirectly insured and those unable to pay may request state insurance, for example, indigenous people or people with disabilities. There is also a ‘not insured modality’ for the population with capacity to pay yet deliberately choosing not to insure. The CCSS pools all health risks and finances. Subsidised healthcare beneficiaries are financed by per-beneficiary payments from another state institution. Although growing, the small private system has not yet fragmented, segmented or threatened health and financial risk pooling. Costa Rica has a ratio of 73 per cent of public health as total health expenditure in 2014 (World Bank Indicators 2019). Delivery: Costa Rica provides integrated healthcare with comprehensive benefits from primary to high-complexity, open-ended healthcare (Clark 2015) for everyone insured. ‘Integrated’ means that the CCSS delivers the same package of services regardless of type of insurance, that is, insurance guarantees the same access and services for everyone insured.

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Everyone else has emergency access to CCSS healthcare, including individuals with the ‘not insured’ modality. Decentralised government organisations identify individuals eligible for subsidisation through house visits and enrol them automatically for insurance in the CCSS.  The CCSS delivers acceptable quality healthcare from its own facilities to everyone, including those in remote and scarcely populated areas (Cercone and Pacheco 2008). In this service there is no choice of provider, although the CCSS contracts a few private providers (OECD 2017b). Delivery from a small private sector encompassing private medical services, insurance companies, cooperatives and self-managed companies and the number of private hospitals is increasing. Integration: Costa Rica’s healthcare system since 1948 has fully integrated the three functions in the CCSS (Costa Rican Social Security). A broad range of stakeholders participate as Directors of the Board of the CCSS, and the Board has considerable power across the field of public healthcare. The CCSS disposes of a country-wide and comprehensive network of facilities and personnel. Access: Costa Rica’s constitution does not have an explicitly formulated, fundamental right to health or healthcare (Norheim and Wilson 2014), yet the Constitutional Chamber has acknowledged the state’s responsibility for health (article 21, article 50, LGS 5395, article 1) (Cecchini and Martínez 2012: 68), and considers population health a public good (LGS 5395, article 1). All citizens have access to healthcare at CCSS facilities, regardless of type of insurance (Cercone and Pacheco 2008), with the exception of the insurance modality ‘not insured’. Migrants, also irregular ones, formerly had access to healthcare (Cercone and Pacheco 2008: 91). This has been restricted by the Migration Law in 2009 that connects healthcare insurance and access to healthcare with regular migratory status. Once migrants achieve legal status their access to healthcare is the same as for nationals (Voorend 2014). The General Migration Law 8764, article 3 passed in 2010, obliges the state to include immigrants, ensure their well-being and respect their rights. Summing up, Costa Rica’s variety of universalism is comprehensive and enables (full) social citizenship with equal status in healthcare. Its functions are fully integrated. The CCSS has not changed its objectives nor the way it functions substantially since 1948; it has functioned reli-

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ably and stably over the past 70 years, and improved its model gradually. The private sector is weakly developed and small. The CCSS remains the most trusted and approved institution in Costa Rica (Cercone and Pacheco 2008).

Comparison, Discussion and Conclusion The debate on ‘varieties of universalism’ in healthcare in Latin America suggests that population coverage or access is not sufficiently clarified: What entity or population group does universalism refer to (e.g., the employed, citizens, residents)? Does universalism refer to coverage (in terms of entitlement of access through insurance, subsidies, rights) or to access (in terms of availability, eligibility for healthcare, quality, timeliness and affordability of healthcare package)? Do coverage and access vary in terms of the recognition of health needs (i.e., equal status), or do they provide grounds for stigma and inferiority? Social rights, as codified in the 1948 Universal Declaration of Human Rights and the International Covenant on Economic, Social and Cultural Rights ICESCR (article 12), call for universal access to healthcare with equal status according to needs from a social citizenship perspective. The chapter’s deliberations on the ‘varieties of universalism’ takes Marshall’s (1950) conceptualisation of universalism as the reference point: his conceptualisation is linked to social citizenship and addresses social differentiation between population groups. Universalism refers to access and participation with equal status (through social rights) according to the accepted standards of democratic societies, regardless of ability to pay. This understanding corresponds to (full) social citizenship. Chile’s healthcare system reveals various lines of division, reflected in the characteristics of its variety of universalism: it is stratified and purchasing power enables choice of (private or public) provider and quality of healthcare provision; it is segmented due to a lack of solidarity within the healthcare system, between the private and public sectors and  in terms of healthcare affordability, packages, provision, timeliness and quality. Universalism is therefore basic, according to Tobar’s (2006) definition. While it provides rights-based equal access and quality, regardless

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of ability to pay, and protects from financial consequences for defined AUGE-listed medical conditions only, it is residual with regard to all medical conditions not listed. This complex, stratified and segmented healthcare system has elements of rights-based healthcare, and many lines of division. These division lines  structure the properties characterising social citizenship in healthcare; access to healthcare (sector and package)  depends on purchasing power, so the type of social citizenship is stratified, segmented and residual. As access also  depends on medical condition, social citizenship is fragmented. One’s purchasing power and medical condition are the key to obtaining healthcare from Private Health Institutions (ISAPRES); one’s income group classification structures the opportunities of choice of provision in the public sector (FONASA) and one’s medical condition structures access and quality of healthcare, as well as access to rights-based healthcare (AUGE). Purchasing power and medical condition characterise the dominant features of the ‘variety of universalism’. Summing up, Chile’s type of social citizenship is segmented, stratified and fragmented. Uruguay’s healthcare system is not consistent with the conservative welfare regimes’ expectations (although it was more consistent before the major reforms of 2005). Based on a social rights framework, an encompassing variety of universalism exists within the strongly integrated National Healthcare System (SNIS). This framework includes a (voluntarily maintained) dividing line, segmenting healthcare between the large and strongly regulated SNIS-affiliated providers (serving the majority of the population) and those not wanting to affiliate (serving 2 per cent of the population), and the occupational-based healthcare services (police and military, about 5 per cent). This division points to a segmented variety of universalism. A further line of division seems to be due to a legacy from the former healthcare system, as fully subsidised beneficiaries have no choice and are restricted  to ASSE healthcare services only. ASSE healthcare  therefore risks being  stigmatised as a ‘service for the poor’, even though it provides the same regulated quality of healthcare package and services today. This ‘variety of universalism’ is stratified in that purchasing power provides access to additional services and insurances. The recently elaborated SNIS provides (almost full) social citizenship, but still has stratifying and segmented elements.

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Costa Rica’s healthcare system is universal today, with compulsory insurance, solidary in financing (through contributions of individuals, employers and the state) and delivery of healthcare (the same provider and services for all), according to needs at all levels of complexity. Although not built on an explicit right to social healthcare, the Costa Rican system is consistent with the expectations according to the welfare regime type and fosters (full) social citizenship. Its ‘variety of universalism’ is encompassing. A comparison of the three healthcare systems reveals some important points: 1. Universalism in healthcare refers to many different elements and is implemented in different ways. 2. Healthcare systems reveal various properties of universalism with respect to healthcare that  are not exclusive; they often overlap and intersect (e.g., ‘stratified’ and ‘segmented’ universalism). 3. ‘Encompassing’ universalism with equal status in healthcare is possible in differently structured healthcare systems; for instance, integrating public and private providers into the National Healthcare System in Uruguay, and through a unified, single public provider in Costa Rica. In Uruguay, equal status is rendered possible through regulated, socially acceptable standards of healthcare and access to provider of  choice (i.e., not conditional on purchasing power or medical ­condition) for all individuals and public and private providers participating in the National Healthcare System (SNIS). Costa Rica integrates everyone, even—however for certain services only—those individuals who have opted out of the CCSS by choosing the insurance modality ‘not insured’. 4. The comparison between Chile and Uruguay suggests that universalism requires strong stewardship through horizontal integration, regulating access and standardising healthcare packages and delivery. Horizontal integration with the broad participation of varied stakeholders—in contrast to vertical integration of healthcare according to sector or population served—provides a powerful framework for a national healthcare system to set rules to ensure equal status in access and provision and to  institutionalise a shared vision of universalism across public and private providers and different stakeholders (Uruguay, Costa Rica). In Costa Rica, horizontal integration has a long tradition.

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Uruguay replaced vertical integration by implementing horizontal integration with the National Healthcare systems (SNIS). In Chile, vertical integration remains despite disposing of a rights-­based universal access to healthcare for a list of AUGE-defined medical conditions that does not integrate but rather consolidate existing division lines and adds a further one, namely, according to medical condition. In conclusion, unpacking the ‘varieties of universalism’ renders visible marked and more subtle division lines produced by institutional arrangements between population and social groups that remain veiled when universalism in healthcare is represented by some statistic of coverage or access. The ‘varieties of universalism’ highlight the complexity of ‘the texture of social life’ (Powell 2002: 232) in terms of equity and integration (Marshall 1950; Powell 2002: 233) beyond satisfying a medical need or economic necessity. The term ‘varieties of universalism’ hints at power relations in political negotiations about the  strategic orientation and the horizontal integration of the important functions of the healthcare system, highlighting where there is (or not) a political commitment to achieving ‘encompassing’ universalism. Relating universalism to social citizenship directs the focus from healthcare ­system-­oriented issues of universalism to social positions structured by unequal and inequitable ability to meet healthcare needs. Limits of this research lie in the strict focus on the organization of the  functions of the healthcare system, leaving aside  institutional  practices. Future research could pursue issues of the healthcare systems’ functioning at the micro level and their  relevance for the  social texture for individuals’ lived experience of ‘varieties of universalism’.

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Bellomo, F. and Naranija, M. (2016). Sistema de salud en el Uruguay 2007–2015. Análisis de los cambios recientes. Montevideo, Asesoría General en Seguridad Social Comentarios de Seguridad Social No 53 (3er trimestre). Bitrán, R. (2013). Explicit Health Guarantees for Chileans: The AUGE Benefits Packages. Washington, DC, UNICO Study Series no. 21. Bitrán, R., Muñoz, R., Escobar, L. and Farah, C. (2008). Governing a hybrid mandatory health insurance system: the case of Chile. In: W.D. Savedoff and P.  Gottret (eds.) Governing Mandatory Health Insurance: Learning from Experience. Washington, DC: The World Bank. pp. 161–181. Cecchini, S. and Martínez, R. (2012). Inclusive Social Protection in Latin America: A Comprehensive, Rights-Based Approach. Santiago de Chile: ECLAC. Cercone, J. and Pacheco, J. (2008). Costly success: an integrated health insurer in Costa Rica. In: W.D. Savedoff and P. Gottret (eds.) Governing Mandatory Health Insurance: Learning from Experience. Washington, DC: The World Bank. pp. 69–100. Chile’s Ministry of Health. (2008). Law No. 19937; Modification of Law No. 2.763 of 1979. Santiago de Chile: Biblioteca del Congreso Nacional de Chile. Clark, M.A. (2014). The final frontiers of healthcare universalisation in Costa Rica and Panama. Bulletin of Latin American Research, 33(2), pp. 125–139. Clark, M.A. (2015). The meanings of universal health care in Latin America. Journal of Health Politics, Policy and Law, 40(1), pp. 221–226. Class, D., Cavagnero, E., Rajkumar, A.S. and Ferl, K. (2014). Health Financing Profile – Chile. Washington, DC, Country Profile no. 38340. Constituteproject.org. (2015). [online]. Chile’s Constitution of 1980 with Amendments Through 2015. [online]. Available at: https://www.constituteproject.org/constitution/Chile_2015?lang=en [Accessed Jan. 2017]. Constituteproject.org. (2019). [online]. The World’s Constitutions to Read, Search, and Compare. Texas: Comparative Constitutions Project, University of Texas. Available at: https://www.constituteproject.org/?lang=en [Accessed previous version Jan. 2017]. Del Rocío Sáenz, M., Bermúdez, J.L. and Acosta, M. (2010). Universal Coverage in a Middle Income Country: Costa Rica. Geneva, World Health Report 2010 (Background Paper) No. 11. Erazo, Á. (2011). La protección social en Chile. El plan auge: avances y desafíos. Santiago de Chile, Serie financiamento del desarollo no. 238. Esping-Andersen, G. (2015). The Three Worlds of Welfare Capitalism. Cambridge: Polity Press. Fernández Galeano, M. and Benia, W. (2013/2014). Salud. Montevideo, Nuestro Tiempo no. 17.

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Fernández Galeano, M., Levcovitz, E. and Olesker, D. (eds.). (2015). Economía, política y economía política para el acceso y la cobertura universal de salud en Uruguay. Montevideo: Organización Panamericana de la Salud. Filgueira, F. (1999). Tipos de welfare y reformas sociales en América Latina: eficiencia, residualismo y ciudadanía estratificada. In: M. De Barreto Campelo and A.  Marcus (eds.) Reforma do estado e mudanca institucional no Brasil. Recife: Editora Massangana. pp. 123–158. Filgueira, F. (2007). Past, Present and Future of the Latin American Social State: Critical Junctures and Critical Choices. Montevideo, Colección Estudios Comparados no. 7. Frenk, J. (2015). Leading the way towards universal health coverage: a call to action. The Lancet, 385(April), pp. 1352–1358. Frenk, J. and Gómez-Dantés, O. (2018). Health systems in Latin America: the search for universal health coverage. Archives of Medical Research, 49, pp. 79–83. Frenz, P., Delgado, I., Kaufman, J.S. and Harper, S. (2014) Achieving effective universal health coverage with equity: evidence from Chile. Health Policy and Planning, 29(6), pp. 717–731. Gideon, J. and Alvarez Minte, G. (2016). Institutional constraints to engendering the health sector in Bachelet’s Chile. In: G.  Waylen (ed.) Gender, Institutions, and Change in Bachelet’s Chile. Basingstoke: Palgrave Macmillan. pp. 147–170. Gottret, P., Schieber, G. and Waters, H.R. (eds.). (2008). Good Practices in Health Financing. Lessons from Reforms in Low- and Middle-Income Countries. Washington, DC: The World Bank. Heredia, N., Laurell, A.C., Feo, O., Noronha, J., González-Guzmán, R. and Torres-Tovar, M. (2015). The right to health: what model for Latin America? The Lancet, 385(9975), pp. 35–37. IMPO, Centro de Información Oficial. (2019). [online]. En Uruguay existe una ley que reconoce la igualdad de derechos de los extranjeros migrantes con los uruguayos. Ley N° 18.250 de 6/1/2008. Ley de Migraciones. Montevideo, Uruguay: Centro de Información Oficial, IMPO. Available at: https://www.impo.com. uy/migracion/ [Accessed Dec. 2018]. Isin, E.F. and Turner, B. (2002). Citizenship studies: an introduction. In: E.F.  Isin and B.  Turner (eds.) Handbook of Citizenship Studies. London: Sage. pp. 1–10. Kildal, N. and Kuhnle, S. (2005). The Nordic welfare model and the idea of universalism. In: N. Kildal and S. Kuhnle (eds.) Normative Foundations of the Welfare State: The Nordic Experience. London: Routledge. pp. 13–33.

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Smith-Nonini, S. (2006). Conceiving the health commons: operationalizing a ‘right’ to health. Social Analysis: The International Journal of Social and Cultural Practice, 50(3), pp. 233–245. Stefánsson, K. (2012). What is in a word? Universalism, ideology and practice. In: A. Anttonen, L. Häikiö and K. Stefánsson (eds.) Welfare State, Universalism and Diversity. Cheltenham: Edward Elgar. pp. 42–68. Tobar, F. (2006). ¿Qué es universalismo básico en salud? In: C.G. Molina (ed.) Universalismo básico. Una nueva política social para América Latina. Washington, DC: Banco Interamericano de Desarrollo Editorial Planeta Washington, DC. pp. 283–292. Urriola, R. (2006). Chile: Social protection in health. Pan American Journal of Public Health, 20(4), pp. 273–286. Voorend, K. (2014). Migration and social policy in Costa Rica: a discussion on universalism, migration control and access to social policy. Transnational Social Review. A Social Work Journal, 4(2–3), pp. 207–225. World Bank Indicators. (2019). [online]. Available at: https://data.worldbank. org/indicator/ [Accessed Sept. 2018]. World Health Organisation (WHO). (2013). Research for Universal Health Coverage. Geneva.

Chapter Three: Privatisation and Marketisation Within a Healthcare System: The Swedish Experience Paula Blomqvist

Introduction The Swedish healthcare system is tax-based, universal and state-­ dominated. Ever since the foundation of the first public hospitals in the sixteenth century, the state has had a strong involvement in the provision of health services. When the modern healthcare system was developed after 1945, ideas about universalism, that welfare services should be accessible to all citizens on equal terms, played an important role. During this period, private health insurers and care providers were not seen as desirable and gradually disappeared from the system. Instead, the state, through its local branches, became wholly responsible for providing health services to the population, including within the primary care sector (Heidenheimer and Elvander 1980; Immergut 1992).

P. Blomqvist (*) Department of Government, Statsvetenskapliga Institutionen, Uppsala universitet, Uppsala, Sweden e-mail: [email protected] © The Author(s) 2020 F. Collyer, K. Willis (eds.), Navigating Private and Public Healthcare, https://doi.org/10.1007/978-981-32-9208-6_3

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During the 1980s, in Sweden, as in many other countries, the view of the state began to change. Neoliberal ideas proclaimed the state provision of public services to be ineffective and oppressive, and this eventually resulted in the enactment of a series of market-orienting reforms in healthcare and other welfare areas. One element of the reforms were the gradual privatisation of healthcare provision, mostly in the primary care sector. Despite these changes, the ideal of universalism remained strong. This meant that along with promoting competition and private entrepreneurship, efforts were also made to try to preserve policy values such as solidarity in financing and more equitable access. The outcome has been a new mix of public and private elements in Swedish healthcare, where funding remains largely public while provision is carried out by a diversity of public and private providers. In this chapter, I review Swedish attempts to strike a balance between the political goals of efficiency through marketization and universalism in healthcare in recent decades. In the first part, I introduce the concept of universalism and how this relates to the goal of social equity in healthcare. Then, I turn to the Swedish case and the market-orienting reforms enacted in the healthcare system between 1993 and 2010. The third part of the chapter discusses how these reforms have affected the system’s ability to sustain universalism in the healthcare sector. The main conclusion is that they have weakened the universal aspects of the system, particularly with regard to access to care, which has become more uneven. This finding indicates that it is difficult to introduce, or strengthen, private elements in a healthcare system without undermining the goal of social equity, even if the funding of the services remain public and the reforms are explicitly designed to prevent such effects.

Universalism and the Nordic Healthcare Model The concept of universalism can be understood as a value or ethic that applies to all individuals in a society, regardless of culture, religion, class, race, nationality or sexual orientation. In health policy, it relates broadly to a way of arranging health services provision so that all members of a

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society, or citizens, have access according to need (see also Chapter Two of this book). In 1999, the WHO declared that universalism in healthcare should be a goal for all countries (WHO 1999). Exactly what is implied by ‘universalism’ and how this value should be achieved in health policy is, however, not always clear (Anttonen et al. 2012; Béland et al. 2014). At the most basic level, universalism in a health policy context has been taken to mean that all citizens of a country have access to at least a minimum level of insurance against health risks. This implies either that there is far-reaching public regulation of private health insurance markets or that the state itself provides health insurance for lowincome groups. Universal access to some basic form of insurance against health risks thus suggests, even at the lowest level of coverage (for instance, against acute or life-threatening injuries), that the public sector plays a significant role in regulating and subsidising private markets for health services. Taking  a pragmatic approach, the WHO has presented the concept of a ‘new universalism’, which refers to a strategy for achieving universal health insurance coverage in low- and middleincome countries through partnerships between government and the private insurance sector. The idea is to create a patchwork of insurance solutions for different income groups within countries so that all citizens get basic health insurance coverage, even the poorest. This was also the strategy pursued by the American Obama administration, when launching the Patient Protection and Affordable Care Act in 2010 (subsequently known as Obamacare), which sought to extend health insurance coverage to previously uninsured American citizens. The reform mandated all Americans under 65 years of age (after which age they are covered by the publicly funded insurance programme Medicaid) to obtain basic health insurance. It also prohibited private insurance companies from denying individuals the right to sign up for insurance, even when they have known health risks (Béland et al. 2014). Within the OECD, nearly all countries have national healthcare systems which could be defined as universalistic, in the sense of providing access to at least basic health insurance for all citizens. The US stands out as the only industrialised nation where a substantive share of the population continues to lack basic health insurance. Within the academic

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literature, a distinction is usually made between countries where there is nationwide public health insurance for the whole population and countries where there are different insurance schemes, typically displaying a mix of public and private elements, for various occupational or income groups. This division corresponds roughly to the two main types of national healthcare systems identified in the literature; social insurance-­ based and tax-based healthcare systems (Freeman 2000; Saltman et  al. 2004). Social insurance systems are based on independent insurance agencies which receive funding from the state and employers and offer access to healthcare services through predominantly private healthcare providers. In such systems, there are usually different insurance alternatives for different groups, depending on income or employment. It is also common to complement publicly funded insurances with voluntary, market-based insurance to obtain more extensive coverage. In tax-based systems, citizens are automatically insured through the same public system and care providers are often predominantly public (ibid.). Tax-based systems are typically understood as having a higher degree of universality in that all individuals (at least citizens or permanent residents) are insured through the same public health insurance and thus have the same coverage against health risks. Voluntary health insurance providing coverage to services not included in statutory healthcare systems is less common (Sagan and Thomson 2016). Hence, tax-based healthcare systems typically offer a higher degree of redistribution between the better-off and those with lower incomes, as all pay into the same system on the basis of their income but receive services in accordance with their medical needs, regardless of how much they have contributed (Wagstaff and van Doorslaer 2000). Tax-based healthcare systems thereby also imply that the public sector plays a larger role in the regulation  provision and financing of healthcare services than in social insurance-based systems. Social insurance-based and tax-based healthcare systems should be understood as ideal types: in reality most national healthcare systems display a mix of elements, even if they are more similar to one of the models (Wendt 2009). This also implies that national healthcare systems are neither universal nor non-universal, but display different degrees of universalism depending on (a) the extent to which publicly regulated

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health insurance provides equitable coverage for all citizens, and (b) to what extent they offer coverage for all types of health risks.

The Nordic Healthcare Model As we have seen, ‘universalism’ in health policy most often refers to the features of financing and access to care within a healthcare system. In the Nordic countries, however, the concept of universalism has assumed a broader meaning, incorporating also the mode in which health services are provided. The Finnish researcher Anneli Antonnen has identified five traits which make social services in the Nordic countries universal: tax-­ based financing; a formal, legislated, right to services; equal access to services for all with equal needs; the same entitlements for all, irrespective of income; and uniform benefits (Anttonen 2002). The first two of these characteristics conform to the regular  model of a tax-based healthcare system. The final three are more distinctive of Nordic healthcare systems, particularly those of Sweden and Norway. Equal access to healthcare for all with equal need is a principle implying that healthcare resources should be distributed solely on the basis of medical need, rather than ability to pay or the type of insurance held by the patient. This rules out the possibility of various occupational groups having different levels of access through differing social insurance schemes, or better-off groups being able to complement public health insurance with voluntary insurances to get faster access to care. Equal benefits signals that there should be no qualitative difference between services in different parts of the system, nor should the better-off be able to purchase services of higher quality through private means. Uniform benefits imply, lastly, that care services are provided foremost through the public sector, thereby ensuring that all health services within the system have the same orientation and content.  The notion that all health and welfare services should have the same content and quality can be seen as reflective of the social egalitarianism which characterized much of Nordic political thought in the postwar era, but also as a strategy for preventing stratification within the welfare sys-

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tems (Rothstein 1998; Kildal and Kunhle 2004). A residual welfare state, where the public sector caters foremost to the needs of the poor, while other groups rely on the private sector, was a model rejected by Scandinavian policy-makers when modern welfare systems were created. Instead, there was an insistence on equal social rights, meaning equal education, healthcare and social protection for all. Hence, public provision came to be seen as a way to ensure universality because this could guarantee all individuals access not only to needed services, but to the same services. As noted by Anttonen (2002), the Nordic model of universalism is based on the notion that all citizens, or at least the large majority, shall actually use public services rather than turn to private markets even when they can afford to. For this to happen, however, the public services have to be of high quality. This political strategy, which led to extensive public investment in the social services in Sweden  and other Nordic countries, has been described as the ‘high-quality standard solution’ (Rothstein 1998). High quality, uniformity and a dominant public sector came to be seen to be the best way to promote universalism and social equality, both in healthcare and in other welfare services (Kautto et al. 2001; Vrangbæk et al. 2007). The background to the political push for universalism in the Nordic countries can be found in the influential role of labour movements in the region during most of the twentieth century (especially Sweden, Norway and Denmark), together with a historical tradition of statism, where governments have long played an important role in providing basic social services and poor relief to the people. The absence of a strong church after the reformation in the sixteenth century contributed to governments, rather than churches or voluntary organisations, taking a leading role in addressing social problems such as poverty and ill health in the eighteenth and nineteenth centuries. In the mid-twentieth century, the state further expanded its involvement in healthcare in the Nordic countries. Systems for financing healthcare shifted, following the example of the British National Health Service (NHS), from social insurance-based to tax-based. In contrast to the NHS, where hospitals were nationalised, the Nordic hospitals were already under public ownership, but after 1950 extensive new public investments were made in the hospital sector. In the 1960s and 1970s,

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the state’s role expanded again as new public systems of primary care were created in Sweden, Norway and Finland. Based on community-oriented public health centres, these systems replaced, wholly or partially, previous systems of self-employed primary care physicians. The political goal behind their creation was to further equalise access to basic care services for all groups within the population. The public health centres were also given the task of working proactively to promote social equality in health outcomes through preventive measures within their local areas of responsibility. In Sweden and Norway, the primary care reforms led to the virtual elimination of private healthcare providers, as they turned healthcare provision into an almost wholly public affair. In Denmark, primary care providers remained predominantly private, whereas Finland developed a mixed system. Finally, the Nordic version of universalism in health that developed in the post-war period also involved an active role for the state in health planning, where the distribution of resources was based on regional and local assessments of health needs. This form of state involvement can also be related to the goal of promoting social equity in health outcomes, which became increasingly important in all Nordic countries after 1960. In sum, it can be concluded that universalism has become a salient goal in health policy, even though the meaning of the concept is sometimes ambiguous. Drawing on the reasoning above, three main dimensions of health policy can be identified through which universalism can be promoted and assessed: access to healthcare, financing of healthcare and systems for providing health services. In the access dimension, universality can be assessed by asking: ‘what differences in access to care exist within a national healthcare system?’ In the financing dimension, a system’s universality can be determined by asking: ‘to what extent is healthcare financing a public responsibility, and are health risks pooled within the population?’ In the provision dimension, universality can be determined through the question: ‘who provides the services and do all groups and individuals receive services of the same quality?’ While it has so far been most common in health policy debates to focus on the first two dimensions, the Nordic countries stand out in that universalism has also been seen as related to care provision. As a result, states in the region were given a prominent role in the post-war era in the development of public,

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uniform systems for health service provision for all, while also tasked with actively reducing health differences between groups. This policy orientation, where a virtually monopolistic public sector for health service provision is seen as essential for achieving equity in healthcare, was especially prominent in Sweden.

 he Shift from Statism to Privatisation T in Swedish Healthcare The state’s involvement in healthcare in Sweden started after the reformation in the mid-sixteenth century. The reformation led to the confiscation of all the Catholic church’s property, including the monasteries, where early forms of healing had been practised. The new Lutheran church was weak and did not involve itself with caring for the sick in the same way. Instead, it was the Crown that enacted the first hospitals in the sixteenth century, and it later mandated the provinces to build more (Anell and Claesson 1995: 16). Since that time, hospitals in Sweden have been owned and operated primarily by provincial governments, known as county councils. Generally, the low density of the largely rural population in pre-industrial Sweden provided poor market conditions for private healthcare providers, including self-employed physicians (Ito 1980: 54). Therefore, following a royal decree in 1671, out-patient care in the countryside was provided by a nationwide system of district-based, publicly employed doctors supervised by the state (Heidenheimer and Elvander 1980). The first voluntary sickness insurance for workers emerged in Sweden at the end of the nineteenth century. This was later extended to include costs for basic health treatments, and the state gradually increased its financial contribution to, and regulation of, the various sickness funds. In 1953, a national, mandatory system of publicly regulated and financed health insurance was finally enacted. Subsequently, the social democratic party, which governed Sweden between 1932 and 1976, continued the transition to a British, NHS style system, by replacing the pre-existing sickness funds with a system of tax-financed services, organised at the local level by the county councils. This meant that a comprehensive

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public healthcare system was created, where both the financing and the provision of care services were consolidated at the county level. All health services became funded by county income tax, and modern institutions for care provision were either transferred to the counties from the state (e.g., the mental hospitals) or set up by the counties with the help of state funding. The political motive behind this shift, which gradually strengthened the role of the state (including its local branches) and, in effect, made redundant pre-existing private institutions such as insurance funds or private care providers, was the vision of an egalitarian system where all citizens should enjoy access to high-quality care services with the same conditions, regardless of income, employment or residence (Heidenheimer and Elvander 1980). A further important step towards a more coherent and integrated public healthcare system was taken in 1959, when the counties were also given the responsibility for out-patient health services. A rapid expansion of health services followed in subsequent decades, guided by the ideals of public planning (Gustafsson 1987). In 1968, a system of public, community-based health centres was created which offered services to the entire population on the basis of residence. During this period, the concept of health needs, as opposed to demands, was established as a central guiding principle for the distribution of health services—a principle later formalised in the 1982 Healthcare Act. The primary care health centres were mandated to not only provide services to those who sought help, but also actively investigate the health needs of the population and work to reduce health differences between social groups. As part of the strategy to eliminate the last financial barrier to care for low-income groups, patient fees within the new primary care system were set at the low level of seven Swedish crowns (less than one euro). This led to the virtual disappearance of the few remaining self-­ employed physicians within the system (Immergut 1992; Serner 1980).

Critique and Reform After 1990 Towards the end of the 1980s, the Swedish economic situation deteriorated as the high growth levels of previous decades  decreased and inflation increased. During the same period, political attitudes towards

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the welfare state began to change, particularly in relation to public services, which were criticised by Right wing groups for being ‘inefficient, bureaucratic and user-unfriendly’ (Blomqvist and Rothstein 2000; ­ Mellbourn 1986). This critical debate also included the healthcare system, which was portrayed as wasteful, hostile to patients and with notoriously long waiting periods for care  (Dahlgren 2008). Some of these criticisms were acknowledged by the governing Left, which sought during the 1980s to make the system more ‘democratic’ and cost-efficient, for instance, by decentralising management, introducing performancerelated payment systems and creating more opportunities for provider choice for patients. These early reforms, which were inspired by the socalled New Public Management (NPM) doctrine (Hood 1995; Pollitt and Bouckaert 2011) were, however, confined to the public sector. The political scene in Sweden changed in 1991 when a Centre Right government took power and began to introduce reforms to open the public healthcare sector to private competition. A string of reforms were introduced, notably the 1992 Personal Doctor Reform (Husläkarlagen), which enabled private GPs to compete for patients and public funding, and the so-called Free Establishment Rights (Fria etableringsrätten) in 1993 for private specialists. Another important legal change in 1992 authorised the county councils to contract out hospitals to private firms (Blomqvist 2004; Green-Pedersen 2002). During the same period, experiments with quasi-markets and new modes of governance were introduced in many  county councils, even if the pace of reforms varied significantly between them. As a result of these reforms, the share of private providers grew steadily within the system, reaching about 7 per cent in the hospital sector and 25 per cent in primary care by 2010 (Anell 2011). In the hospital care sector, the privatisation process slowed down during the early 2000s due to a lack of interest among both the counties and private actors. In the primary care sector, there was more interest from private investors, but developments were slowed by the fact that the county councils had regained the right in 1994 to control private establishments. In 2009, a second step towards privatisation was taken in the primary care sector with the introduction of the 2009 Primary Care Choice Act which, again, made it compulsory for the county councils to allow the free establish-

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ment of private care providers, even if they could set the terms through local regulation of reimbursement fees and listing conditions (Fredriksson et al. 2013). The political motives behind the reform, introduced by a Centre Right government, were to increase opportunities for choice on the part of patients, stimulate private entrepreneurship and improve access to care by increasing the supply of primary care services. The Primary Care Choice Reform (PCCR) stipulated that all county councils must introduce so-called choice systems whereby private care providers could establish and compete on equal terms for patients and public funding if they fulfilled certain basic quality criteria. For patients, the choice systems implied that they had to choose between  public and private health centres and that funds within the system would be distributed on the basis of their choices. Like the Personal Doctor Reform, the PCCR was politically controversial when enacted. The Left wing opposition was highly critical of what was seen as an attempt to force privatisation upon the county councils and deprive them of control with regard to the allocation of resources for primary care. It was also seen as detrimental to the idea of district-­ based responsibility for the health of the population and opportunities to work preventively on the part of the county councils. A specific concern was that the establishment of new private providers would be uneven between areas and parts of the country, leading to the undermining of the goal of equity in access in geographical terms (Isaksson et  al. 2016; Kullberg et al. 2018). Evaluations of the PCCR have shown that it led to a 20 per cent increase in the share of private primary care providers in this sector, albeit with great local variation between the county councils. In this sense the reform represents a further step towards the privatisation of care provision within the Swedish healthcare system. The vast majority of the new private providers were for-profit firms, in many cases owned by large chains. The reform also led to a significant increase in the number of patient visits in the primary care sector (Rehnberg et al. 2014), indicating that it did improve access to care, at least for some groups. A persistent critique of the PCCR has been that the improvement in access has been confined foremost to patient groups living in urban settings, as the new private health centres have been primarily established in such areas (Swedish National Audit Office 2014). Recent studies have also revealed

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that private establishments have been more common in areas with higher income levels and fewer unemployed (Isaksson et al. 2016). A year prior to the introduction of the PCCR, a similar reform was introduced in the municipal nursing home care sector through the 2008 Act on System of Choice in the Public Sector. The 2008 reform—which, in contrast to the 2009 PCCR, was voluntary in its implementation—also provided a legal framework for introducing choice systems in specialist healthcare. In 2017 this had been introduced in nine county councils in medical specialities such as hip and knee replacement surgery, cataract surgery and psychiatric services. Taken together, the market-orienting reforms introduced in Swedish healthcare between the years 1990 and 2010 have led to a restructuring and value reorientation within the system, even though they cannot be said to have constituted radical change. First and foremost, they did not concern either the financing side of the system or its basic organisation of decentralised democratic governance through the county councils. What they did was alter the provision structure in the primary care sector, which went from a virtual public monopoly (or, rather, 21 local monopolies) to a mixed system of public and private providers. The reforms also transformed governance in the hospital sector, as hospitals, even though the majority remained publicly owned, became governed more independently while budgetary systems became more closely tied to performance. The reforms also led to patients being given new opportunities to choose among care providers, both in the in-patient and in the out-patient care sectors. Another result of the marketisation reforms has been the increased establishment of private specialist care providers outside the hospitals. This has led to a form of quasi-market also for such services, where patients can seek care freely from privately practising specialists receiving reimbursement from the county councils. The specialists are authorised by the county councils and receive payments on the basis of a national fee schedule. Alongside this publicly financed market, however, there has also developed fully private markets for specialist care outside the public system, where patients pay the full cost for the treatment themselves either out of pocket or, more commonly, through voluntary  private health insurance. Together with increased opportunities for patient choice, this has led to a distinctly more consumerist healthcare sector in

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Sweden, where providers advertise for customers and patients shop around for care services. This culture is so far largely confined to cities and bigger towns, as the countryside and smaller towns have received virtually no new private care providers. Given the fact that there has been a marked increase also in the number of private health insurance holders in Sweden in recent decades, this development points to a tendency for the marketisation reforms, which retained public funding, to “spill over” in fully private healthcare markets. This is a new development in Sweden, as voluntary private health insurance was unusual prior to 1990. In 2016, the number of private insurance holders had increased by several 100 per cent since the mid-1990s, but was still only about 800,000—less than 1 per cent of the population (Lapidus 2017). Studies show that voluntary private health insurance is obtained from for-profit insurance companies primarily by white-collar workers through their employers (Alexandersen et al. 2016; Kullberg et al. 2019). Typically, such insurance offers supplementary benefits such as faster access to care among private care providers and care coordination, thus helping insurance holders to escape waiting lines in the public healthcare system. The growth in private insurance holders signals that there has been a shift in the perception of health services in Sweden, as these have come to be seen as more of a private, and less of a public, good.

 rivate Care Providers and Universalism P in Swedish Healthcare It has been argued in this chapter that universalism can be understood as a value in health policy that can be promoted in several dimensions of a healthcare system, such as access, financing and provision. In the Swedish health system that developed after WWII, universalism was a central policy goal, promoted in all three dimensions through active state involvement. It was believed by a large political majority that social equity in healthcare demanded that health services should not only be financed collectively but also have the same content and quality for all. When marketisation reforms were introduced in the system in the late 1980s and early 1990s in the form of internal markets, contracting and increased

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opportunities for private establishment, it was stated, on the part of both social democratic and Right wing governments, that this would not affect the universal characteristics of the system. This has been an argument put forward also by proponents of quasi-market reforms in other countries. In the UK, one of the first countries to introduce such reforms in mid-­ 1989, it was argued that this mode of governance in welfare services did not undermine social equity, as the funding remains public, thereby guaranteeing that all citizens have access to the same services, just as they did in the old bureaucratic model (Le Grand 2006). Others, however, have refuted such claims, arguing that the introduction of competitive dynamics within public healthcare systems still risks undermining social equity because it creates a mechanism for patient selection and makes it harder for patients with a low education to use the opportunities of their new rights in the same manner as the better-educated (Dixon et  al. 2010; Vrangbæk et al. 2007). This implies that healthcare systems introducing marketisation reforms—such as quasi-markets and patient choice— would become less universal in character. So far, this discussion has not been fully resolved, partly because there have been different understandings in the literature of how implications for social equity and universalism should be assessed (see, for instance, Goul Andersen 2012; Thompson and Hogett 1996). In the Swedish case, it can be argued that the marketisation reforms undertaken between 1993 and 2010 did affect the universal traits of the system, as least if we adopt the understanding of universalism that has been predominant in the Nordic countries. The effects are not strong, but rather subtle; in fact, the most significant implications of the reforms may not be their actual effects but the value reorientation they represent. First, with regard to access to care, it can be noted that, formally, there has been no change in Swedish health policy in this area following the marketisation reforms. The statutory Health Services Act from 1982, which states that all citizens have the right to quality healthcare services ‘on equal conditions’, is unchanged. Neither did the reforms reduce access to care for any groups by raising fees or reducing the supply of services; on the contrary, their goal was to improve access to care and they did have some positive effects in this regard, primarily through a marked increase in the number of out-patient care givers. Yet, it can be argued

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that the reforms affected the access dimension of universality in that they led to improved access for some groups rather than others, thereby negatively affecting the principle of equal access to care. As most of the new establishments of private care givers have taken place in urban areas and areas with higher income levels, access to care has been improved mainly for those residing in such areas. This also implies that the new opportunities to choose freely between different providers are available largely to these groups. This is especially true in the case of specialist care, where residents of the larger cities enjoy the freedom of a diverse supply of care givers, while others have little choice other than the nearest public hospital, where waiting periods can be several months. In this sense, access to care has become more unequal. Another observation that can be made regarding the implications for access is that the reforms did not solve the most pressing problem in Swedish healthcare: the waiting periods, especially for specialist treatment. This has continued to be a problem in the system, related to the inability of the largely public hospital sector to respond to the growing demand for care services. Furthermore, after the marketisation reforms, with the growth in private care providers in the system, the waiting periods in the public sector have given rise to a new dynamic as they have led individuals and employers to purchase health services on the private market in order to get faster access. The increased tendency of better-off groups to turn to the private care market for faster access to care undermines the policy of needs-based distribution of resources and thereby the principle of equal treatment of all individuals within the system. With regard to the financing of care services, the Swedish system retains its large measure of solidarity in that health services are still funded almost exclusively through income taxation. The private share of healthcare financing constituted less than 5 per cent in 2017 (except in the area of dental care, where co-payments are notably higher), and private health insurance uptake remains very low by international standards. The fact that the system offers automatic health insurance to all citizens, and also has an element of geographical redistribution of resources among the county councils, implies that health risks are still pooled within the whole population. The high level of solidarity in the financing structure of the Swedish healthcare system is also preserved by the fact that voluntary

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private health insurances are only supplementary to this system while the willingness to pay taxes to contribute to the public system is still high, also among private insurance holders (Kullberg et al. 2019). Finally, in the case of the provision of health services, the marketisation reforms in Swedish healthcare have had a more notable effect. The provision system was transformed during the 1990s from a virtual public monopoly of health services provision by the county councils to a mixed market system, where public and private care providers compete for both patients and public contracts. This has led to care services no longer being uniform, and probably also to having greater quality differences, even if this has not yet been systematically evaluated. Most importantly, the new mixed care provision system, together with wider opportunities for choice on the part of patients, has led to healthcare being transformed from a public service, allocated on the basis of need alone, to a service where individual patients can ‘shop around’ and seek care feely from different providers as they see fit. This new consumerist freedom is clearly appreciated by many, but there are also signs that it is used predominantly by the more resourceful groups who can more easily find information about different care providers and have better knowledge of their rights. The provision dimension of care services is also affected by the increased establishment of private care providers who cater largely to the growing private healthcare market, where individuals holding voluntary health insurance can seek care services that either are perceived to be of higher quality or can be accessed faster. This development implies that Sweden, like many other countries, risks developing a two-tier health care system: a public system for the large majority and a private one for those with higher incomes whose employment benefits include voluntary private health insurance. If this development continues, the universalism of the Swedish healthcare system has clearly been undermined.

Conclusions The main question posed at the outset of this chapter was how the marketisation reforms introduced in Sweden after the late 1980s have affected the system’s universal character. As we have seen, universalism

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can be defined in a narrow way, as access to basic healthcare services for all citizens, or in a fuller sense, as all citizens enjoying access to needed health services on equal terms. This latter model of universalism is a policy goal in most national healthcare systems based on tax funding, where all citizens are insured against health risks through the state. In the Nordic countries, the notion of universalism became linked during the post-war era to an extended role for the state in healthcare, as it was believed that a fully universal healthcare system could be achieved only if the state itself delivered health services. Such a system would ensure that all services would have the same quality and content and that the allocation of resources would be based on medical need alone. In contrast to, for instance, the British NHS, this vision of the state as the sole provider of health services was extended also to the primary care sector in Sweden with the reforms in 1970 which replaced previously selfemployed GPs with a universal system of publicly owned and operated health centres. One effect of the marketisation reforms is that health services are no longer uniform or provided solely by the state, or local governments, but by a mix of public and private care providers. Another effect is that access is determined to a greater extent by residence and the ability on the part of individuals themselves to identify and choose appropriate health services within the new mixture of care providers. In addition, a fully private sector has begun to develop along with the public system. None of these developments are unusual in an international context, but they represent a new policy departure in Sweden where the vision of sameness and uniformity with regard to welfare services has long held sway, and where the public sector has been seen as the natural guardian of these values. In this sense, the partial privatisation of healthcare provision in Sweden, even if it is still confined mainly to the outpatient sector, signals a distinct shift in attitude to the public sector among both political elites and the public at large. Where it was previously taken for granted that the public sector offered medical services of the highest quality to all, many citizens now prefer private care providers. The public sector, rather than being, as before, symbolic of a Swedish dream of commonality and social equality, has become one care provider among many.

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References Alexandersen, N., Anell, A., Kaarboe, O., Lehto, J., Tynkkynen, L. and Vrangbaek, K. (2016). The development of voluntary private health insurance in the Nordic countries. Nordic Journal of Health Economics, 4(1), pp. 68–88. Anell, A. (2011). Hälso- och sjukvårdstjänster i privat regi. In Konkurrensens konsekvenser Studieförbundet Näringsliv och samhälle. Anell, A. and Claesson, R. (1995). Svenska sjukhus förr och nu: ekonomiska aspekter på struktur, politik och framtida förutsättningar. Lund: Institutet för hälso- och sjukvårdsekonomi (IHE). Anttonen, A. (2002). Universalism and social policy: a Nordic-feminist revaluation. NORA: Nordic Journal of Women’s Studies, 10(2), pp. 71–80. Anttonen, A., Häikiö, L., Stefánsson, K. and Sipilä. (2012). Universalism and the challenge of diversity. In: A. Anttonen, L. Häikiö and K. Stefánsson (eds.) Welfare State, Universalism and Diversity. Cheltenham: Edward Elgar Publishing. Béland, D., Blomqvist, P., Andersen, J., Palme, J. and Waddan, A. (2014). The universal decline of universality? Social Policy Change in Canada, Denmark, Sweden and the UK. Social Policy and Administration, 48(7), pp. 739–756. Blomqvist, P. (2004). The choice revolution. Privatization of Swedish welfare services in the 1990s. Social Policy and Administration, 38(2), pp. 139–155. Blomqvist, P. and Rothstein, B. (2000). Välfärdsstatens nya ansikte. Stockholm: Agora. Dahlgren, G. (2008) Neoliberal reforms in Swedish primary health care: for whom and for what purpose? International Journal of Health Services, 38(4), pp. 697–715. Dixon, A., Robertson, R., Appelby, J., Burge, P., Devlin, N. and Magee, H. (2010). Patient Choice—How Do Patients Choose and How Do Providers Respond? Report. London: The King’s Fund. Fredriksson, M., Blomqvist, P. and Winblad, U. (2013). The trade-off between choice and equity: Swedish policy-makers’ arguments when introducing patient choice. Journal of European Social Policy, 23(2), pp. 192–209. Freeman, R. (2000). The Politics of Health in Europe. Manchester: Manchester University Press. Goul Andersen, J. (2012). The concept of universalism and its operationalization in a mixed economy of welfare. Paper presented at CCWS seminar, Aalborg University, October 31, 2012. CCWS working paper nr. 2012-81.

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Green-Pedersen C. (2002). New public management reforms of the Danish and Swedish welfare states: the role of different social democratic responses. Governance, 15(2), pp. 271–294. Gustafsson, R. Å. (1987). Traditionernas ok. Den svenska hälso-och sjukvårdens organisering i historie-sociologiskt perspektiv. Doctoral Dissertation, Department of Economic History, Stockholm University. Solna: Esselte studium. Heidenheimer, A.J. and Elvander, N. (eds.) (1980). The Shaping of the Swedish Health System. London: Croom Helm. Hood, C. (1995). The ‘new public management’ in the 1980s: variations on a theme. Accounting, Organizations and Society, 20(2), s. 93–109. Immergut, E.M. (1992). Health Politics: Interests and Institutions in Western Europe. Cambridge: Cambridge University Press. Isaksson, D., Blomqvist, P. and Winblad, U. (2016). Free establishment of primary health care providers: effects on geographical equity. BMC Health Services Research, 16(28), pp. 1–10. Ito, H. (1980). Health insurance and the medical services in Sweden and Denmark 1850–1950. In: A.J.  Heiderheimer and N.  Elvander (eds.) The Shaping of the Swedish Welfare System. London: Croon Helm. Kautto, M., Fritzell, J., Hvinden, B., Uusitalo, H. and Kvist, J. (2001). Nordic welfare states in the European context. London and New York: Routledge. Kildal, N. and Kuhnle, S. (2004). The principle of universalism: tracing a key idea in the Scandinavian welfare model. In: G.  Standing (ed.) Promoting Income Security as a Right: Europe and North America. London: Anthem Press. Kullberg, L., Blomqvist, P. and Winblad, U. (2018). Market-orienting reforms in rural health care in Sweden: how can equity in access be preserved? International Journal for Equity in Health, 17(1). Kullberg, L., Blomqvist, P. and Winblad, U. (2019). Health insurance for the healthy? Voluntary health insurance in Sweden. Health Policy, 123(8), pp. 737–746. Lapidus, J. (2017). Private health insurance in Sweden: fast-track lanes and the alleged attempts to stop them. Health Policy, 121(4), pp. 442–449. Le Grand, J. (2006). Equality and choice in public services. Social Research: An International Quarterly, 73(2), pp. 695–710. Mellbourn, A. (1986). Bortom det starka samhället: socialdemokratisk förvaltningspolitik 1982–1985. Stockholm: Carlsson. Pollitt, C. and Bouckaert, G. (2011). Public Management Reform: A Comparative Analysis-New Public Management, Governance, and the Neo-Weberian State. Oxford: Oxford University Press.

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Rehnberg, C., Janlöv, N. and Andersson, F. (2014). Konkurrens, kontrakt och kvalitet – hälso- och sjukvård i privat regi. Stockholm: Ministry of Finance. Rothstein, B. (1998). Just Institutions Matter: The Moral and Political Logic of the Universal Welfare State. Cambridge: Cambridge University Press. Sagan, A. and Thomson, S. (2016). Voluntary health insurance in Europe: role and regulation. Observatory Studies Series, 43. Saltman, R., Busse, R. and Figueras, J. (2004). Social Health Insurance Systems in Europe. London: Open University Press. Serner, U. (1980). Swedish health legislation: milestones in reorganization since 1845. In: A.J.  Heiderheimer and N.  Elvander (eds.) The Shaping of the Swedish Welfare System. London: Croon Helm. Swedish National Audit Office (Riksrevisionen). (2014). Primärvårdens styrning – efter behov eller efterfrågan? Rapport RIR 2014: 22. Thompson, S. and Hogett, P. (1996). Universalism, selectivism and particularism. Towards a postmodern social policy. Critical Social Policy, 16(46), pp. 21–42. Vrangbæk, K., Østergren, K., Okkels Birk, H. and Winblad, U. (2007). Patient reactions to hospital choice in Norway, Denmark and Sweden. Health Economics, Policy and Law, 2(2), pp. 125–52. Wagstaff, A. and van Doorslaer, E. (2000). Equity in health care finance and delivery. Handbook of Health Economics, 1(part B), pp. 1803–1862. Wendt, C. (2009). Mapping European health care systems: a comparative analysis of financing, service provision and access to healthcare. Journal of European Social Policy, 19(5), pp. 432–445. WHO (1999). Making a Difference. The World Health Report 1999. Report, The World Health Organization.

Part II Institutions of Health

Chapter Four: ‘Looking Outside Their Walls’: Exploring Community Health in Chicago Hospitals Fernando De Maio, Raj C. Shah, and Kerianne Burke

Introduction The majority of hospitals in the United States are designated not-for-­ profit organisations (American Hospital Association 2019). As such, they are exempt from many federal, state, and local tax obligations. The financial implications are substantial—the latest national estimate values the tax exemption at almost $25 billion per year (Rosenbaum et al. 2015). Historically, tax-exempt status was an acknowledgement of the ‘community benefit’ provided by the hospitals (Herring et  al. 2018). Yet, over F. De Maio (*) Department of Sociology, Center for Community Health Equity, DePaul University, Chicago, IL, USA e-mail: [email protected] R. C. Shah Department of Family Medicine, Rush Alzheimer’s Disease Center, Center for Community Health Equity, Rush University Medical Center, Chicago, IL, USA K. Burke Ruth M. Rothstein CORE Center, Cook County Health, Chicago, IL, USA © The Author(s) 2020 F. Collyer, K. Willis (eds.), Navigating Private and Public Healthcare, https://doi.org/10.1007/978-981-32-9208-6_4

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time, controversy developed over how hospitals defined community benefit, and whether their activities were sufficient to justify their favoured tax status (Young et al. 2013). At the core of this controversy is the link between the public and the private—between the state, private institutions (not-for-profit hospitals), and the communities they serve. Recognising the value of collaboration between public health agencies and hospitals, the United States’ 2010 Patient Protection and Affordable Care Act (ACA) requires that not-for-profit hospitals conduct a community health needs assessment (CHNA) every three years (Prybil et  al. 2016). These assessments represent a critical opportunity for hospitals to better understand the patterns of community health in their service areas. This is particularly important in the United States, given the country’s reliance on private financing and private delivery of health services (Budrys 2011). By focusing on identifying the needs of the community as a whole, CHNAs can be used to push back against the dominant philosophy of seeing poor health as a personal trouble, and access to care as a commodity governed by the rules of the market. CHNAs call for hospitals to gauge the health of the population at large. By design, the ACA-mandated CHNAs are meant to not only describe patterns of community health, but provide plans for improving health over time. Under the ACA requirements, hospitals are required to develop an implementation plan addressing the needs observed in the CHNA, or provide reasons for not addressing the identified needs in their community (Martin 2013). CHNA reports, therefore, offer an important perspective on the state of health equity in the United States, and in particular on how not-for-profit hospitals conceptualise their relationship with the community they serve. As described by the Chicago Department of Public Health (CDPH), ‘through the CHNA processes, hospitals are looking outside of their walls and focusing on the broader communities that comprise their service areas’ (CDPH 2014: 3). Prybil et al. (2016) describe this as a ‘paradigm shift’ in US healthcare, noting that it represents a new kind of collaboration between public health and private institutions. Our analysis examines how this process has unfolded in Chicago, Illinois, through an analysis of two generations of CHNA reports. We are particularly interested in what CHNA reports indicate regarding how

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hospitals conceptualise ‘community’ and how these reports frame the causal pathways, or ‘root causes’, of health inequities. Previous research examining CHNA reports in the United States found great heterogeneity in their content (Pennel et al. 2015). Previous reports also reflected different approaches for engaging with underserved populations (Lightfoot et  al. 2014; Grant et  al. 2015; Mathews et  al. 2015). ACA-mandated CHNAs also showed varying levels of collaboration between hospitals and local public health departments (Wilson et  al. 2014; Beatty et al. 2015; Laymon et al. 2015). Most critically, current research is now examining the potential of CHNAs to affect patterns of population health and health equity (Begun et  al. 2017; Singh et  al. 2018; Powell et al. 2017), asking the most important question of all: do these reports make a real difference? The extent to which current CHNA practices account for the social determinants of health is an open question. There is the potential for CHNA reports to play an important role in identifying health inequities and for assessing the effectiveness of equity-promoting programmes, and enabling analyses of changing patterns of community health over time. Yet some concern has been raised in the literature over how this might actually work in practice. For example, Pennel et al. (2015) analysed 95 CHNA reports from hospitals in Texas, and concluded: hospitals struggled to include issues and strategies that reflected and accounted for broader social determinants of health. Hospital reports also performed poorly in identifying evidence-based strategies to address health issues, considering local contextual factors, and examining contributing causes to problems (Pennel et al. 2015: e9).

Similarly, in an analysis of 15 CHNA reports from Philadelphia-area hospitals, Powell and colleagues observed that the reports focused predominantly on access to care and health behaviours (Powell et al. 2017)— and while these are of course important, they are part of a larger chain of causal factors linked to underlying structural and social determinants of health. Both Pennel et  al. (2015) and Powell et  al. (2017) found that hospitals focused primarily on individual behaviour change at the expense of a broader, more structural understanding of the drivers of community

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health. The implications are significant. According to Pennel et al., ‘If we are to hope for population health improvement through these methods [CHNAs], hospitals cannot continue to do what they are doing’ (Pennel et al. 2015: e9). Building on the work of Pennel et al. (2015) and Powell et  al. (2017), we examine how hospitals in Chicago have approached their CHNA responsibilities, contrasting the first and second wave of reports published under the ACA. Our chapter is divided into four main parts. First, we provide a brief profile of Chicago, outlining some of the social divisions in the city. Second, we examine the first wave of CHNA reports in the city (2012–2013), focusing on how hospitals conceptualised ‘community’ and how these reports framed the causal pathways, or ‘root causes’, of health inequities (e.g., focusing on access to care and individual-level behaviour change versus underlying structural and social determinants of health). Third, we examine the more collaborative second-wave reports published in 2015–2016. Fourth, we conclude the chapter with suggestions for carrying out CHNAs in the future, with the goal of maximising their potential for generating improvements in community well-being.

Profile of Chicago Chicago is the third largest city in the United States, with a population of 2.7  million (with nearly 10 million people in the surrounding ‘Chicagoland’ area). In 2015, it had a per capita income of $32,000—but with significant inequities by race/ethnicity. African Americans in Chicago had a per capita income of just $19,000, while non-Hispanic Whites had a per capita income of more than $55,000. These data reflect inequities in other socio-demographic characteristics, including unemployment and educational outcomes (see Table One). These socio-economic characteristics map on to deep-rooted inequities among the 77 community areas in the city. Research has repeatedly described Chicago as one of the most highly segregated cities in the United States (Coates 2014; Massey and Denton 1989; Massey 1990). In turn, these socio-economic inequities drive the well-known health statistics of the city (see Table Two for a selection of key indicators).

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Table One  Socio-demographic profile of Chicago, by race/ethnic group (selected indicators, 2015) in US dollars African American Per capita income $19,268 Unemployment 18.7 per cent High school 84.5 per graduation cent College 19.2 per graduation cent

Asian

Hispanic

NonHispanic White

$36,892 6.8 per cent 86.9 per cent 56.8 per cent

$17,391 9.4 per cent 65.6 per cent 15.0 per cent

$55,395 $31,641 4.1 per cent 9.5 per cent 95.2 per 84.1 per cent cent 60.8 per 36.6 per cent cent

Total

Notes: Per capita income—per capita income is the mean income computed for every man, woman, and child in a particular group. It is derived by dividing the aggregate inflation adjusted income of a particular group by the total population in that group. Unemployment—percentage of adults aged 16 years and over in the civilian labour force who were unemployed among the total population of adults aged 16 years and over in the civilian labour force. High school graduation—percentage of adults aged 25 years and older with a high school diploma or equivalency among all adults aged 25 years and older. College graduation—percentage of adults aged 25 years and older with a college degree or higher among all adults aged 25  years and older. Source: https://www. chicagohealthatlas.org

There are profound health inequities in Chicago (De Maio et al. 2019). Life expectancy and infant mortality vary significantly by race/ethnicity, as do critical indicators such as obesity (both for adults and for children) and tobacco use. On average, we see a seven-year gap between African Americans and non-Hispanic Whites across the city. For international comparison, this is approximately the same gap observed in the United Kingdom between the lowest and highest classes of the National Statistics Socio-Economic Classification (Office for National Statistics 2015). Yet, if one takes a community-level perspective and examines differences in life expectancy across the 77 communities of Chicago, the gap is even greater: 15 years, from a low of 68.2 to a high of 83.3 (Hunt et al. 2015). Access to hospital care in the city has historically been highly influenced by socio-economic inequality, structural racism, and other forms of ‘structural violence’ (Ansell 2017; Abraham 1993). In 2014, 18.7 per cent of Chicagoans had no health insurance (Dircksen et al. 2016), and

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Table Two  Health profile of Chicago, by race/ethnic group (selected indicators, various years)

Life expectancy at birth (2015) Infant mortality (2014) Adult obesity Childhood obesity (6th grade; 2012–2013) Adult smoking (2016)

African American

Non-Hispanic Asian Hispanic White Total

72.0

83.0

81.0

79.0

77.0

10.8 17.6 26.7

4.8 37.9 17.4

5.5 35.5 33.9

5.0 19.6 18.3

7.1 29.3 –

7.5

26.6

17.5

14.5

18.4

Notes: Adult obesity—estimated number of adults (18  years and older) who reported a height and weight that yield a body mass index of 30 or greater. This number is weighted to represent the population from which the sample was drawn, the household population of adults 18 years of age and older who reside in the City of Chicago. Childhood obesity—percentage of Chicago Public School students with valid data elements on the Illinois Child Health Examination form whose BMI is equal to or greater than the 95th percentile on the CDC BMI-forage growth charts (for either girls or boys) adjusted for non-response through logistic regression. Adult smoking—estimated number of adults (18 years and older) who report that they’ve smoked at least 100 cigarettes in their life, and report that they now smoke cigarettes every day or some days. Source: https:// www.chicagohealthatlas.org

while over 75,000 residents enrolled in ACA Marketplace health plans for 2015, and over 200,000 residents enrolled in Medicaid expansion plans, significant inequities in access to care remain within the city (Illinois Health Matters 2015; Illinois Department of Healthcare and Family Services 2015). In 2016, Chicago launched a new public health strategic plan, Healthy Chicago 2.0, which advances the explicit goal of achieving health equity in the city (Dircksen et al. 2016). Hospitals are key partners in that project. Healthy Chicago 2.0 has a clear vision: ‘a city with strong communities and collaborative stakeholders, where all residents enjoy equitable access to resources, opportunities and environments that maximise their health and well-being’ (Dircksen et al. 2016: 1). Hospital CHNAs can play a vital role in realising that vision by presenting community-level data on health inequities, nurturing collaborative ties with community organisations, and building consensus that health equity is an achievable goal.

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First-Wave Reports The first wave of CHNA reports from Chicago-area hospitals were published in 2012–2013. An original list of 39 Chicago-area hospitals obtained from the Illinois Department of Public Health was used as the basis for an Internet-based search for CHNA reports. CHNA reports were located for 24 of these hospitals; the remaining hospitals included for-profit institutions, as well as other hospitals not mandated to conduct their own CHNA (e.g., hospitals in the Veteran Affairs system). Once the initial CHNA for a hospital was found, an additional search was carried out for companion reports. These included documents such as Community Health Profiles or Community Input Reports that were used to inform the CHNA, or Implementation Strategies that detailed a hospital’s plans concerning CHNA results. All CHNA-related documents for each hospital were considered in the analysis. Our analysis also draws on a report summarising Chicago-area CHNAs published by the Chicago Department of Public Health and Health and Disability Advocates (CDPH 2015). Scanning across the first wave of reports, attention was paid to three particular issues: mental health, access to care, and obesity. These were identified as priorities by a majority of hospitals in the first wave of CHNA reports (see Table Three). Seventeen hospitals (out of 27, or 63 per cent) identified mental health as a top priority. This choice was driven, in part, by analysis of hospital admissions data which revealed that mental health-related conditions were among the leading causes of hospitalisation in the city. Access to care was also identified as a top priority by 63 per cent of hospitals, recognising that even with advances from the ACA, significant gaps remain in the US healthcare system. Access to mental, oral, and vision services remains fragmented. Critically, the ACA contains no provisions to support access to care for ‘undocumented’ immigrants (e.g., individuals who entered the United States without inspection or who overstayed their visas)—a population estimated at 11.8  million, barred from even purchasing health insurance under ACA health insurance exchange (Zuckerman et  al. 2011). Obesity (together with nutrition, physical

Advocate Health Care Christ Hospital (Oak Lawn) Illinois Masonic Medical Center Trinity Hospital Ann & Robert H. Lurie Children’s Hospital Jackson Park Hospital & Medical Center La Rabida Children’s Hospital Little Company of Mary (Evergreen Park) Mercy Hospital & Medical Center Northwestern Memorial Hospital Norwegian American Hospital Presence Health Resurrection Medical Center Saint Francis (Evanston) Saint Joseph Saints Mary & Elizabeth Medical Center Rehabilitation Institute of Chicago RML Specialty Hospital—Chicago Rush University Medical Center Saint Anthony Hospital

Hospital

x x

x x x

x

x x

x

x

x x

x

X X

X

x

x x x x

x x

x x x

x

x x

X

x

x x

x

x

x x

x

x

X

x

x

x x

x

x x

x

x

x

x

x

x

x

x x x

x

x

(continued )

Social determinants Heart Respiratory disease Diabetes health Violence of health

x

x

x

Mental Access health to care Obesity

Table Three  CHNA priorities, by hospital, first wave

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17

x x

x x

x

17

x x

x x x

x

15

x

x x x x x

Mental Access health to care Obesity

12

x

x

x x

x

10

X X

X X

X

10

x X

x

x

9

x

x

x

6

Social determinants Heart Respiratory disease Diabetes health Violence of health

Adapted from CDPH 2015. Chicago Hospitals and the Affordable Care Act: More Opportunities for Prevention. Chicago, IL: Chicago Department of Public Health. This analysis includes the three suburban Cook County hospitals which serve significant numbers of Chicagoans

Saint Bernard Hospital & Health Care Center Shriner’s Hospitals for Children Sinai Health System Holy Cross Hospital Mount Sinai Hospital Schwab Rehabilitation Hospital Swedish Covenant Hospital Thorek Memorial Hospital & Medical Center University of Chicago Medicine University of Illinois Hospitals & Health Sciences System Total number of hospitals

Hospital

Table Three (continued)

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activity, and weight control) was identified by 15 out of 27 hospitals (56 per cent). This was driven, in part, by analysis of childhood obesity data that revealed a striking prevalence of obesity among elementary school students (see Table Two). Only six hospitals explicitly identified priorities associated with the social determinants of health (including poverty, employment, homelessness, housing security, and neighbourhood safety). This is congruent with the findings of Pennel et al. (2015) in Texas, and Powell et  al. (2017) in Philadelphia. We now turn to some qualitative detail from the CHNA reports to examine this in more detail.

Conceptualising the ‘Community’ An important element of the social determinants of health framework is the idea that ‘place’ matters, that ‘communities’ matter. Many hospitals acknowledged the unique characteristics of the communities they serve in this sample of CHNA reports. Holy Cross Hospital, for example, emphasised that ‘each community in Chicago has a unique history that contributes to its health and well-being. Thus, it seems only natural that we begin this report with a description of the communities’. More strongly, Mount Sinai Hospital’s CHNA report stated: It is absolutely essential to realise that a community is more than just a geographically delineated area in which residents share common resources. A community has a history and an historical memory. Both of these contribute to the essence of the community and in this case help shape its health and well-being.

Mount Sinai Hospital went on to describe their definition of community, comprising 13 community areas, where 80 per cent of their patients reside.1 Mount Sinai’s report stands out in this sample as the most concerned with the history of the community, with long sections devoted to the history of North Lawndale, a Chicago community which experienced profound demographic and economic shocks in the 1950s and 1960s. This period saw ‘White flight’ from the area, a dramatic loss of employment opportunities, the legacy of institutionalised racist mortgage-­

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lending policies (‘redlining’) and riots in the wake of the assassination of Martin Luther King Jr. (see Ansell 2017). Mount Sinai emphasises: ‘We believe it is critical to remember this past when thinking about current problems’. Schwab Rehabilitation Hospital, part of the Sinai Health System, included the same material. In contrast, most other hospitals gave technically precise definitions of their community areas (usually by zip code rather than the name of the community area or neighbourhood), but with little background, context, history or justification.

F raming the Issue: Thinking of Causal Pathways or ‘Root Causes’ Along with recognising and understanding the particular history of the communities they serve, hospital CHNA reports shed light on how institutions conceptualise the root causes of health inequities. Many reports start their framing of the causal pathway with modifiable risk factors such as diet, physical activity, and tobacco use. For example, Trinity Hospital’s report states: Trinity Hospital’s total service area data indicates a heart disease, cancer and stroke death rate of 56 percent, a heart disease death rate that is 17 percent higher than the Chicago rate and a stroke death rate that is 66 percent higher than the Chicago rate in some communities. High rates of obesity (70 per cent) exist within the total service area as compared to the Chicago rate of 58 percent and the state rate of 56 percent. These disparities indicate the need to provide prevention programmes that offer behaviour modification for nutrition and physical activity. The Council agreed that the root cause of obesity involves lack of exercise and poor eating habits, and that these preventable risk factors significantly impact heart disease and stroke.

In this case, the framing of causation was limited to the behaviour of individuals (‘lack of exercise and poor eating habits’ as the root cause of obesity), with little recognition of how community characteristics may constrain those behaviours. And while true that lack of exercise and poor eating habits can increase the risk of obesity, this is only part of the larger,

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structural story than the ‘causes of the causes’ framework would suggest (Marmot 2017). The root cause of obesity involves lack of exercise and poor eating habits—but those behaviours themselves are not the root cause; they, in turn, are caused by the quality of a community’s built environment, its level of safety, the quality of public amenities, food security, and a range of other deep-lying social determinants of health (Dircksen et al. 2016). Similarly, the reports of Mercy Hospital, University of Chicago, Saint Anthony, and other hospitals note: Behaviour patterns represent the single-most prominent domain of influence over health prospects in the United States. The daily choices we make with respect to diet, physical activity, and sex; the substance abuse and addictions to which we fall prey; our approach to safety; and our coping strategies in confronting stress are all important determinants of health.2

Other hospitals showed a wider conceptualisation of causation. For example, instead of starting at individual behaviours, Saint Bernard Hospital’s report recognises the social determinant of socio-economic status, but relatively quickly moves on from it as a focal point of analysis: The most prominent contributors to mortality in the United States in 2000 were tobacco (an estimated 435,000 deaths), diet and activity patterns (400,000), alcohol (85,000), microbial agents (75,000), toxic agents (55,000), motor vehicles (43,000), firearms (29,000), sexual behaviour (20,000), and illicit use of drugs (17,000). Socio-economic status and access to medical care are also important contributors, but difficult to quantify independent of the other factors cited.

Going further, the Sinai Health System hospitals included structural factors beyond those that characterise individuals or their families. For example, the Mount Sinai Hospital report explicitly names structural factors as the fundamental causes of poor health: Poor health is caused by many factors ranging from less than optimal habits (e.g., smoking, lack of physical activity), to inadequate access to healthcare (e.g., no health insurance, lack of healthcare providers), to structural fac-

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tors in society (e.g., inadequate housing, failing schools), to what have been called the fundamental causes of poor health (e.g., poverty, lack of education, segregation, racism).

The Schwab Rehabilitation Hospital also provided an in-depth background on the causes of each health issue in its report, noting that the gender imbalance in certain neighbourhoods is attributed to institutional discrimination and high incarceration rates for African Americans in Chicago. Description of structural or institutional causal factors were missing in reports from other hospitals. Focusing on individual behaviour change at the expense of a broader, more structural, framework for understanding causality is a particularly salient problem for Chicago, a city well-known for long-standing patterns of race/ethnic segregation (De Maio et al. 2019). Taking the example of the Sinai Health System hospitals, we can set out a model to describe the differences between hospitals with respect to the framing of causality (see Figure One). There is broad agreement on outcomes, with heart disease, cancer, stroke, diabetes, and chronic respiratory diseases well established as the leading causes of death in Chicago (Harper-Jemison et  al. 2009). The question is how far upstream the causal framework used in these CHNA reports was extended. Most hospitals stopped with common modifiable risk factors—diet, physical activity, tobacco use—and thereby focused on Underlying social / structural determinants of health Community hardship, institutional discrimination, segregation, housing conditions, food insecurity, lack of safety

Common modifiable risk factors Unhealthy diet, physical inactivity, tobacco use

Non-modifiable risk factors

Intermediate risk factors

Health outcomes

Raised blood pressure, raised blood glucose, abnormal lipid levels, overweight / obesity

Heart disease, stroke, cancer, chronic respiratory diseases, diabetes

Age, heredity

Traditional perspective focused on individual behavior change

Broader conceptualization of social determinants of health, including structural factors

Figure One  The ‘causes of the causes’ in Chicago

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individuals, the domain of traditional risk-factor epidemiology (Krieger 2011). In contrast, what advantages could health systems (and communities) gain if they expanded the causal frame to include underlying social/ structural determinants of health? Following the social determinants of health model, this would generate a more accurate and honest assessment of the drivers of community well-being. It would also shift intervention efforts from behaviour modification towards systems, environments, and the policies that shape communities. Overall, the first wave of ACA-mandated CHNA reports suggests a very narrow conceptualisation of causal pathways, reflective of what Pennel et al. (2015) describe as the biomedicalisation of the social determinants of health. With some exceptions (most notably the reports from the Sinai Health System hospitals), the first wave of CHNA reports in Chicago emphasised individual behaviour as the focal explanatory point for health inequities. As a result, the argument is that community health needs can be solved by interventions in the behaviour of individuals. However, the social determinants of health paradigm calls for us to examine not only the behaviour of individuals but the social context in which individuals’ actions are shaped (Marmot and Wilkinson 2006; De Maio et al. 2013). It is that paradigm that shaped the second wave of CHNA reports in Chicago.

Second-Wave Reports The majority of hospitals in the Chicago region approached the first wave of CHNA reports as individual activities, writing their own reports (often with the aid of an external consulting agency). The traditional model was that one hospital would work with one or more local health departments along with a set of community stakeholders to develop one CHNA and one Community Health Implementation Plan (CHIP). Unfortunately, in a dense urban environment like Chicago, where hospital catchment areas overlap, each hospital was approaching the same community representatives and developing the same priorities with slightly different approaches. It was an inefficient system that put a strain on community groups.

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A more collective approach emerged with the second wave of CHNA reports. Federal regulations changed and encouraged hospitals to collaborate whenever they shared a catchment area. In February 2015, under the direction of the Chicago Department of Public Health and the Cook County Department of Public Health, in addition to the Illinois Public Health Institute (IPHI), a not-for-profit public health organisation, a meeting about a collective model approach was held with leaders of hospitals serving Chicago and the surrounding Cook County. The rationale for collective action was presented as a shared investment in a process for coordinated impact on health outcomes for all in the region, as one hospital by itself could not fully achieve such broad impact. There was also a desire to maximise involvement and coordination of health departments and stakeholders without overwhelming these with duplicating requests and having to choose one hospital to work with rather than all hospitals in the region. Also, community engagement could be broadened by combining unique community relationships of hospitals serving the same catchment area. A Letter of Agreement codifying terms of engagement and responsibilities was signed with the key deliverable being a comprehensive CHNA for the Chicago and surrounding Cook County region that could be adapted by each hospital. Hospitals could agree to join for an annual membership fee that would fund the collective work. An early decision was made to make membership dues on a hospital level—even if some health systems had multiple hospitals—and discounts were provided to safety net hospitals so as to ensure that financial burden was not a reason for non-participation. In the end, 26 hospitals joined the effort launched as the Health Impact Collaborative of Cook County (HICCC). The IPHI served as the backbone/coordinating organisation and over 100 community stakeholders contributed to the work. Stakeholder partners represented government, business and industry, healthcare, education, built and social environment, and community services. Governance of HICCC was provided by a shared Steering Committee with working groups in three regional geographic areas (south, west, and north—there is no east as Lake Michigan is the eastern boundary of the region). The goal was to develop a shared CHNA with aligned priority actions for Community Health Implementation Plans with shared community mea-

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Table Four  Original health systems and health department partners in the Health Impact Collaborative of Cook County Health systems

Health departments

Presence Health

Cook County Department of Public Health Chicago Department of Public Health Village of Skokie Department of Public Health Oak Park Department of Public Health Village of Stickney Public Health District

Advocate Health Care Rush University Medical Center Roseland Community Hospital NorthShore University Health System Loyola University Health System

City of Evanston Public Health Department

Mercy Hospital and Medical Center Norwegian American Hospital Cook County Health & Hospitals System RML Specialty Hospital

sures for collective impact. See Table Four for a listing of the key health systems and health departments involved in the HICCC. Soon after hospitals agreed to work together, an adaptive governance structure was developed. This was to help shift the institutions from the ‘compete and co-exist’ part of the collaboration spectrum into the ‘cooperate, coordinate, collaborate, and integrate’ part of the spectrum, where tight engagement and trust are developed for greater impact. Mindset shifts for collective impact included having to move to adaptive solutions to problems rather than technical solutions to problems, a focus on evidence and relationship rather than just evidence alone, content and context expertise rather than just content expertise, a realisation that no magic bullet would be found for solving complex problems, and—importantly—that credit for any success would need to be shared. The hospitals agreed that collective impact could be achieved through the establishment of a common agenda, shared measurement, mutually reinforcing activities, and continuous communication facilitated by backbone support. The common agenda included a shared vision for change, common understanding of the problems and a joint approach to solving the problem through agreed-upon actions. Shared measurement included all organisations achieving consensus on key measures that

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would be reported, utilising common indicators for learning and improvement, and building a learning culture where commitment to continuous improvement is fostered. Mutually reinforcing activities included diverse stakeholders coordinating a set of differentiated activities and the utilisations of a mutually reinforcing plan of action. All stakeholders engage in frequent and structured open communication that builds trust, assures mutual objectives, and creates common motivation. The independent, funded staff dedicated to guiding the vision and strategy provide backbone support. The IPHI acted as process facilitators for advancing the work defined by a Steering Committee, which in turn was made up of members of hospitals and public health departments. The Steering Committee and the IPHI oversaw the work of three regional dyads of a hospital/health system leadership team and a stakeholder advisory team. Stakeholder advisory teams in each region had about 25 members each. Participants were asked to attend eight to ten meetings between May 2015 and August 2016 to develop the Collaborative’s vision and values, provide input on the design of assessments, facilitate participation of community members to provide input through surveys and focus groups, review assessment data to identify priority strategic issues, and participate in action planning for implementation efforts. All the work was supported by a data committee. Collaborative mission, vision, and values were developed by the regional teams and the Steering Committee (see Figure Two). The development of the vision was driven by the Center for Disease Control and Prevention’s ‘Health Impact Pyramid’ where socio-economic factors such as poverty, education, housing, and inequity were viewed as foundational, and where the most impact could be achieved for improving health outcomes. Also, there was a clear appreciation of equality and equity as different terms, and that the focus for communities in the region and for the collaborative work should be equity, supporting the agenda set forth in the city’s Healthy Chicago 2.0 campaign (Dircksen et al. 2016). The HICCC implemented a public health system assessment based on recent reports completed by health departments in the region, a community health status assessment based on available community-level data from the American Communities Survey and other resources, a community themes and strengths assessment, and a forces of change assessment.

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Mission The Cook County Collective Health Impact Collaborative will work collaboratively with communities to assess community health needs and assets and implement a shared plan to maximise health equity and wellness. Vision Improved health equity, wellness, and quality of life across Chicago and Cook County. Values 1. We believe the highest level of health for all people can only be achieved through the pursuit of social justice and elimination of health disparities and inequities. 2. We value having a shared vision and goals with alignment of strategies to achieve greater collective impact while addressing the unique needs of our individual communities. 3. Honouring the diversity of our communities, we value and will strive to include all voices through meaningful community engagement and participatory action. 4. We are committed to emphasising assets and strengths and ensuring a process that identifies and builds on existing community capacity and resources. 5. We are committed to data-driven decision-making through implementation of evidence-based practices, measurement and evaluation, and using findings to inform resource allocation and quality improvement. 6. We are committed to building trust and transparency through fostering an atmosphere of open dialogue, compromise, and decision-making. 7. We are committed to high quality work to achieve the greatest impact possible.

Figure Two  Health Impact Collaborative of Cook County—mission, vision, and values. Source: Health Impact Collaborative of Cook County

Community-level data included running 23 focus groups to hear from groups in the region with specific needs that may be missed in survey samples. In particular, participants from diverse immigrant communities (Arab American, Polish, Korean, Chinese, Puerto Rican, Mexican, and Central American immigrants), veterans, formerly incarcerated, individuals with mental health conditions, homeless and transitional housing residents, individuals with disabilities, and seniors and caregivers were contacted. Quantitative data were also collected from residents (N = 5200). The survey questions included questions not always covered in broader public health surveys, including adult education and job training, barriers to mental health treatment, childcare and education programmes for youth, perceived discrimination, food security, health insurance coverage, personal safety, and stress. This work led to the selection of four overarching goals for the collaborative CHNA: 1. Reducing inequities caused by the social, economic, and structural determinants of health

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2 . Improving mental and behavioural health 3. Preventing and reducing chronic disease risk factors 4. Increasing access to care and community services Data systems and policy advocacy were viewed as cross-cutting resources needed to promote impact for the four overarching goals. With the CHNA developed, each hospital utilised the information in a way that their Board of Directors would approve. Some institutions created their own version of a Community Health Needs Assessment Report for their communities and showed alignment with the HICCC CHNA by adding the report as an appendix. Others tailored an executive summary to report on local progress since the first-wave CHNA and to highlight special community and hospital circumstances, and others submitted the Health Impact Collaborative CHNA report as their institution’s report with an appendix highlighting progress from the past CHNA. Enabling flexibility was key in matching the HICCC CHNA to the needs of hospitals and health systems. These goals were to be further developed for CHIPs by each health system and by collaborative implementation work by the HICCC. The key areas of focus for collaborative work were on mental health/substance use and the social determinants of health. Both areas were seen as complex problems requiring resources and engagement broader than any one hospital or a small group of hospitals. Access to care and prevention of chronic conditions were left to individual hospitals (and to new collaboratives that had been developing in the Chicagoland area).

Discussion Chicago’s experience with CHNAs reflects an important tension, between seeing health inequities as the sum of poor choices made by individuals and recognising the deep-lying structural and social determinants that constrain people’s capacities to make healthy choices. The former privileges individual behaviour and targets interventions to change that behaviour. The latter, while recognising the importance of behaviour, situates that behaviour in a more intricate and layered causal pathway,

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one where intervention points are not as immediately recognisable. In the language of sociology, this entails a shift towards the fundamental causes of poor health (Phelan et al. 2010; Link and Phelan 1995). CHNAs offer an important lens through which to understand the links between the public and the private—between the state, private institutions (not-for-profit hospitals), and the communities they serve. Our analysis of how CHNAs have worked in Chicago is not only a descriptive story of one city, but also an analytical story about the US healthcare system, particularly as remodelled under the ACA. The first wave of CHNA reports in Chicago focused primarily on three particular issues: mental health, access to care, and obesity. These issues were clearly identifiable from the public health indicators of the city. Yet the first wave of reports, at least for most hospitals, conceptualised these issues in a very narrow way, reflecting what Pennel et  al. (2015) describe as the biomedicalisation of the social determinants of health. By the second wave of CHNA reports, many hospitals in Chicago expanded their framing of the issue, placing ‘social, economic and structural determinants of health’ at the top of the agenda. This second wave of reports was written in a very different and more collaborative way. While the underlying health needs of the communities in question did not change in any significant epidemiological way between the first and second wave of CHNA reports, there is a clear signal that healthcare institutions were beginning to change how they understood the problems at hand. An increased level of public health and hospital collaboration is arguably at the root of that transition, illustrating what Prybil et al. (2016) have described as an ongoing ‘paradigm shift’ in US healthcare. CHNA reports are an important vehicle through which to understand health inequities in the United States. They represent a snapshot of institutional priorities, and signal opportunities for collaboration and change. At their best, CHNAs offer the potential for meaningful discussion with community residents who have often been marginalised and left out of prioritysetting work (McKnight 1980; Lightfoot et al. 2014; Grant et al. 2015). Yet the real challenge remains: will communities see any improvements in living conditions, any improvements in health, and any reductions in

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health inequities? Will CHNAs from hospitals reduce the life expectancy gap which now burdens the population of Chicago? Future research should examine CHNA reports from other cities. It may be that there are systematic differences between different parts of the country or between different cities, as well as differences between urban, suburban, and rural places. It may be that health systems serving more affluent communities approach their CHNA responsibilities in ways that differ from health systems serving marginalised communities. Future research could also examine how CHNA reports change over time, as health systems adapt to new regulations, engage with new partners, and learn from communities themselves. Lastly, research is needed to examine if ACA-mandated CHNAs actually lead to policy-level changes in health systems, and, most importantly, to real improvements in community health. Acknowledgements  We are grateful to David Ansell, Maureen Benjamins, Fran Collyer, Marty Martin, John Mazzeo, and Karen Willis for helpful comments on early drafts of this work.

Notes 1. Under the Internal Revenue Service (IRS) guidelines for CHNA reports, a hospital may define its own community boundary: ‘a hospital facility may take into account all of the relevant facts and circumstances, including the geographic area served by the hospital facility, target population(s) served, and principal functions. However, a hospital facility may not define its community to exclude medically underserved, low-income, or minority populations who live in the geographic areas from which the hospital facility draws its patients’ (Internal Revenue Agency 2014). In practice, this has meant that hospitals are largely free to define their own community areas—some hospitals claim the entire city, others a smaller geographic section. Differences may also exist between community hospitals and larger academic health centres, since the former will have higher utilisation rates in local communities than the latter. 2. These reports were written by the same consulting agency, which used identical text in the various reports.

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References Abraham, L.K. (1993). Mama Might be Better Off Dead: The Failure of Health Care in Urban America. Chicago: The University of Chicago Press. American Hospital Association. (2019). AHA Hospital Statistics. Chicago: American Hospital Association. Ansell, D. (2017). The Death Gap: How Inequality Kills. Chicago: The University Of Chicago Press. Beatty, K.E., Wilson, K.D., Ciecior, A. and Stringer, L. (2015). Collaboration among Missouri nonprofit hospitals and local health departments: content analysis of community health needs assessments. American Journal of Public Health, 105(2), pp. S337–S344. Begun, J.W., Kahn, L.M., Cunningham, B.A., Malcolm, J.K. and Potthoff, S. (2017). A measure of the potential impact of hospital community health activities on population health and equity. Journal of Public Health Management Practice, 24(5), pp. 417–423. Budrys, G. (2011). Our Unsystematic Health Care System. Lanham: Rowman and Littlefield. CDPH. (2014). Chicago Hospitals and the Affordable Care Act: New Opportunities for Prevention. Chicago: Chicago Department Of Public Health. CDPH. (2015). Chicago Hospitals and the Affordable Care Act: More Opportunities for Prevention. Chicago: Chicago Department Of Public Health. Coates, T.N. (2014). The case for reparations. The Atlantic, 313(5), pp. 54–71. De Maio, F., Shah, R.C., Mazzeo, J. and Ansell, D. (eds.) (2019). Community Health Equity: A Chicago Reader. Chicago: The University Of Chicago Press. De Maio, F.G., Mazzeo, J. and Ritchie, D. (2013). Social determinants of health: a view on theory and measurement. Rhode Island Medical Journal, 96, pp. 15–19. Dircksen, J.C., Prachand, N.G., Adams, D., Bocskay, K., Brown, J., Cibulskis, A. and White, M. (2016). Healthy Chicago 2.0: Partnering to Improve Health Equity. Chicago: City of Chicago. Grant, C.G., Ramos, R., Davis, J.L. and Lee Green, B. (2015). Community health needs assessment: a pathway to the future and a vision for leaders. Health Care Management, 34(2), pp. 147–156. Harper-Jemison, D., Thomas, S. and Woldemichael, G. (2009). Leading Causes of Death in Chicago. Health Status Index Series. p. Xviii. Herring, B., Gaskin, D., Zare, H. and Anderson, G. (2018). Comparing the value of nonprofit hospitals’ tax exemption to their community benefits.

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Chapter Five: Contracting-Out Care: Nursing Homes in Canada Pat Armstrong and Hugh Armstrong

Introduction From a neoliberal perspective, governments should steer and not row, markets are said to provide effective, quality services as a result of competition and individuals should take responsibility for much of their own health. These assumptions provide the basis for privatisation, a process that takes multiple forms that are often complicated and difficult to see. More of the costs of services and more of the labour are shifted to individuals and families; management in the public services follows practices imported from the for-profit sector; more services are handed over to the for-profit sector while those that remain partly public are often managed by for-profit firms. P. Armstrong (*) York University, Toronto, ON, Canada e-mail: [email protected] H. Armstrong Carleton University, Ottawa, ON, Canada e-mail: [email protected] © The Author(s) 2020 F. Collyer, K. Willis (eds.), Navigating Private and Public Healthcare, https://doi.org/10.1007/978-981-32-9208-6_5

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This chapter focuses on one aspect of this for-profit provision, namely the contracting-out of services. Our starting point is feminist political economy, which assumes that politics, economics, discourses and ideas are integrally related and operate on multiple levels from the intimate to the global. These interconnected parts are shaped but not determined by the dominant means of providing for food, clothing, shelter, jobs and joy, as well as for the next generation. The search for profit profoundly influences how we live, work, talk, reproduce and play but so do the actions of individuals and collectives. Feminist political economists insist that social reproduction on a daily and intergenerational basis must be central to the analysis, making the gendered construction of social relations and the interconnections between paid and unpaid labour critical to our understanding of how things work. The usual criteria for evaluating public policy, most notably in services, are three: quality, cost effectiveness and accessibility (see, for example, Fox and Poirier 2018). These criteria are broadly parallel to the US reform agenda known as the ‘Triple Aim’ of improving the health of the community and the patient’s experience while saving the health system money (Berwick et al. 2008). This chapter is framed around these criteria, using them as a way to assess the consequences of contracting-out care in nursing homes. It begins by outlining various forms of privatisation and the extent to which these forms meet the criteria. This serves as the background for examining the particular form of contracting-out services.

Forms of Privatisation It has become increasingly common in high-income countries to look to the for-profit sector and especially to the corporate sector to provide services (see also Chapters Three, Six, and Seven of this book). Such moves are justified in terms of competitive mechanisms that are assumed to provide better quality at lower cost. Although it is generally imprudent to make definitive claims that apply in all circumstances, the evidence assembled by us and others is clear: corporate for-profit provision most often means higher cost and lower quality. Devereaux et al. (2002a, b), Harrington et al. (2001, 2017), Tanuseputro et al. (2015), McGregor and Ronald (2011), McGregor et al. (2011, 2014), Ronald et al. (2016) and Armstrong et al. (2016), to name only some, have documented the lower

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quality that tends to accompany corporate provision of care services. Others such as Woolhandler et al. (2003), Woolhandler and Himmelstein (2004), Armstrong (2001) and Devereaux et  al. (2004) have demonstrated the higher costs associated with large, for-profit services. On access, the focus is more on private payment than on private provision, and the most prominent case is of course that of the United States. Even with the enactment (and survival) of the Affordable Care Act, or Obamacare, about 27 million Americans remain uninsured for healthcare and thus unable to access it (Dickman et al. 2017), mainly because they cannot afford it. Many more are underinsured. Although Canadians do not pay individually for hospital or doctor care, an estimated 23 per cent of Canadians fail to take needed prescription medications because of costs (Angus Reid 2015). Thus, the quality and cost studies are focused primarily on ownership of facilities such as nursing homes, while the access studies are focused primarily on payment regimes. It is important to observe, however, that privatisation can take other forms as well and that these forms often overlap (Armstrong et al. 1997). New and renovated facilities can be financed, designed, built and operated by private consortia under public-private partnership (P3) arrangements, or private finance initiative (PFI) mechanisms as they are labelled in the United Kingdom. Private companions can be hired to meet care needs left unmet by publicly funded hospitals and nursing homes. ‘Beds’ can be cut in both relative and absolute terms from publicly funded hospitals and nursing homes, and replaced by a combination of assisted living and supportive housing arrangements, which are usually privately owned and mainly paid for by individuals. With the move to day surgeries and ‘aging in place’, more care is paid for privately at home. Indeed, home care brings to mind a second usage of the publicprivate dichotomy, with care in the private home provided on an unpaid basis by family members, usually women, and the concept of public enlarged to include both the state broadly defined and the formal economy. Contracting-out is a particular form of privatisation that is also about ownership. For-profit entities can be contracted to take over the development of policy in government and the management of public or non-­ profit facilities. They may also be contracted to deliver part of a public service such as cleaning. However, payment for services may still be from the public purse. Both clinical and support care services may be contracted-­

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out, although the contracting-out of the full range of clinical services to a private company has been attempted on a large scale in only the United States and the United Kingdom. In the United States, this took the form of the now-discredited HMOs, or Health Management Organisations. In England, contracts of this sort have been found in all their complexity and centrality to be very difficult to monitor and enforce. The ‘commissioning’ bodies lack the detailed knowledge to discern when contracted services are being delivered in full. These bodies have on occasion themselves resorted to contracting-out the monitoring of clinical contracts, adding yet more transaction costs in their effort to identify when and where the large private contractors are finding ways to cut corners. The contracting bodies are also reluctant to enforce clinical contracts out of fear of ‘exacerbating the financial situation of providers’, and thus leaving patients and residents in the lurch. The organisation known as Clinical Commissioning Groups, a major commissioning body in England, spent £700 M in recent years on 15,000 contracts in which poor performance was detected, only seven of which were terminated (CHPI 2015). By contrast, support services are more commonly contracted-out, in part because they are commonly deemed to be less important to care. Hence the widespread use, at least in North America, of the term ‘ancillary’ services—even labelled ‘hotel’ services (Armstrong et  al. 2008). Another reason is that these services are easier to specify, to fragment and to measure in concrete time and place. The results can more readily be treated as products or deliverables, and thus as commodities with price tags. Because privatisation can take so many forms beyond the private ownership of entire services or facilities, it is often difficult to identify. This difficulty is exacerbated by the uncontested use of practices and language drawn from the arena of business. Total Quality Management, Lean Production, Cost/Benefit Analysis, Pay for Performance, Request for Proposals mechanisms and so on are often imported from business, typically with only a specific service or facility in mind and without regard for the larger contexts within which these practices are placed. When public funding is involved, these practices are often brought together under the neoliberal label of New Public Management (NPM). Questions of ‘efficiency’ for what and for whom are seldom asked under this rubric (Stein 2001). Similar questions could also be posed about the ‘flexibility’ that is promoted for both the work and the worker. Self-employment is one

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form such flexible contracting takes, and another is hiring people through employment agencies or on hourly, irregular contracts. The consequence is more precarity for workers, and especially for women with the negative effects of flexible paid labour on domestic labour (Coyle 2005: 74–75). Such flexibility can also undermine the continuity that is critical to care relationships. The result of NPM is too often one of privatisation by stealth, with the processes largely invisible to many. Secrecy is often justified in terms of the exigencies of competitive advantage, with privatisers arguing that citizens do not care who provides the care they need so long as it is paid for out of the public purse. Both these practices and the avoidance of troubling questions concerning them are reinforced by the everyday use of business terms like bottom-­ line, product line, business plan, value added and profit centre. The assessment (and creation) of demand for care services by corporations replaces the assessment of care needs by citizens and their direct providers. We are increasingly targeted as consumers and customers, rather than treated as patients or residents. We are viewed as taxpayers rather than as citizens.

The Case of Nursing Homes The lack of scrutiny of privatisation practices becomes even more troubling when the care is provided to, and received by, some of the most vulnerable members of the population. This is particularly the case for nursing home residents, who are typically elderly, suffering from a variety of complex health issues and are disproportionately female, and for the poor who receive their care in the private household. It is also the case for those who provide the paid and unpaid care there as most of whom are female, low paid and often from immigrant/racialised groups. This lack of scrutiny must be compared unfavourably with the research and ­political attention devoted to hospitals and to the physicians who work in and around them. The data presented here have been drawn primarily from a research project entitled ‘Re-Imagining Long-Term Residential Care: An International Study of Promising Practices’. The study has been designed to address the relative lack of research and political attention bestowed on

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nursing homes and on the vulnerable people who live, work and visit there. An international study involving researchers from six countries and over a dozen academic disciplines, this project has concentrated on what is termed ‘rapid site-switching ethnography’ with week-long observation and transcribed interviews at nursing homes in Germany, Norway, Sweden, the United Kingdom, the United States and four Canadian provinces. The details of this methodology can be found in our book Creative Teamwork: Developing Rapid, Site-Switching Ethnography (Armstrong and Lowndes 2018a). These ethnographies have been accompanied by studies of financing, approaches to care, work organisation and accountability mechanisms, studies that employ a wide variety of methods. One of the themes emerging from this research concerns the practice of contracting-out, or outsourcing, specific services. Contracting-out can be narrowly defined as ‘the private delivery of publicly financed services through a contractual agreement between a public sector organisation and a private sector company’ (Hodge 2000 in Vrangbæk et al. 2013). A central assumption in this project is that care needs to be understood as a relationship—one that involves the actions, values and perceptions of both providers and recipients. We argue that the conditions of work (both paid and unpaid) are the conditions of care. In the nursing home context, social care as well as medical care need to be considered, and considered together. Our ethnographic approach enables us to focus on care relationships and on care contexts in all their diversity. It helps us see beyond so-called objective factors, with their temptations to draw seemingly objective comparisons based on standardised measurements. It helps us to analyse alignments and contradictions between rhetoric and realities. In our semi-structured interviews and direct observations, and in the field notes derived from them, we pay close attention to stories.

Contracting-Out Specific Services The highlight of the day for many, if not most, nursing home residents is meal time. Good food and drink, taken in the company of others, can be a source of pleasure. Safe food and drink also, of course, constitute a social determinant of health. Their nutritional and other benefits can, however, be diminished by contracting-out, which typically involves off-­site, indus-

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trialised meal preparation with delivery at tightly prescribed times of day. Under such conditions residents lose some control over what to eat and drink when, and with it they lose a degree of autonomy. They are often required to be up and at their tables at a set time for breakfast, whatever their preferences, in order to accommodate the contracted corporation workers’ time. The start and finish of later meal times are also pre-determined, and menus geared to the private firms’ calculations of efficiency and cost, often with little attention to the availability of fresh local produce or the wishes of residents. The instance we saw of a staff member and a resident heading out to a local market in Sweden to buy some of the food for their unit is incompatible with contracted-out food services of this sort. At some homes with contracted-out food, the dietary staff employed by the contractor arrive to distribute entire meals on plastic trays. They have no time to chat with residents or with other staff. There is thus no opportunity for teamwork, or to consider care as a relationship. In one Canadian home with contracted-out food, the isolation of the dietary staff was made very clear by a sign saying ‘Please do not talk to the kitchen staff’. This is a far cry from homes where meals are prepared on site, often right within the unit where cooking smells and sounds can stimulate appetites. With contracted-out food, staff are much less likely to be able to make coffee, tea and toast, set out jam, cheese and cold meat and prepare bacon and eggs in a leisurely fashion while chatting to residents who appear for breakfast at different times, as we saw in homes that prepared their own food. At such homes, residents may be involved in meal preparation (e.g. slicing vegetables or rolling out pizza dough) and clean-up (e.g. loading dishwashers or sweeping floors). These activities can promote their sense of belonging and of home. They were a particularly pronounced practice in one of the German homes we visited (Lowndes and Müller 2015: 47–50). (It must be added, however, that some residents have told us that nursing home life is attractive precisely because they are now free from domestic work.) Less prominent than meals, at least to outsiders, is laundry. Clothes are one of the few indicators of personal identity available to residents once they enter nursing homes (Armstrong and Day 2017). Linens (sheets, pillow cases, towels, table cloths, even bibs) can, and probably should, be sent off for industrial cleaning with its bulk loads, high temperatures and harsh detergents, but mum’s favourite sweater merits delicate treatment

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by someone who cares. Her clothes need to be sorted, folded and returned to the proper places in her room, preferably without the benefit of a name tag having been added. At one Canadian home where the laundry was sent out, long racks of clothes were wheeled into common areas in the unit, to be delivered by staff to individual residents. The busy staff did not have time to deal with the clothes immediately and, as one daughter told us, residents think these are racks in Walmart and select something they find attractive. We heard many stories of clothes lost or damaged by the contracting company. At the other end of the spectrum, we saw stackable washer/dryer appliances in the en-suite bathrooms of some Swedish residents. Care workers could load personal items into these machines, adjusting the temperature and soap to accommodate delicate fabrics, and ensure that no clothes were lost or cross-contaminated. At the same time, this system meant that no worker had to lift heavy bags of soiled or wet laundry. In between contracting-out and laundry appliances in individual resident rooms is the practice in a Canadian home that employs its own laundry staff. The manager ensures that the staff member does not remain isolated in a humid laundry room. Instead, the worker personally delivered the laundry to each resident and stopped to chat as she put the clothes away. This meant that not only could she vary her work but also she could respond to the individual preferences of residents. Laundry done on the premises can also provide meaningful work for the residents, as we saw in a home where residents sort the socks that come out of the dryer. Other support services can also be contracted-out. A frequent candidate for contracting-out is cleaning services, or housekeeping services as they are often called. Like food and clothes, they can appear easy to ­quantify, and thus to commodify. They can also seem to be quite separate from care, even though clean facilities are critical to health. One problem is that the search for profit too often tempts private firms to cut back on how much is cleaned, by workers with insufficient training using inadequate cleaning supplies. Such cutbacks may go undetected until tragedy strikes, with C-difficile and staph infections too often killing the particularly vulnerable residents of nursing homes. Over-diluted bleach disinfectant was found responsible a few years ago for 64 Clostridium difficile infections and 8 deaths during a single period in the related case of a British Columbia hospital (Zuberi and Ptashnick 2011). Contracting-­ out cleaning services in health services has been linked not only to infec-

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tions but also to the undermining of teamwork and to precarity for workers (CUPE 2009, 2013; Dryden and Stanford 2012). The problems for workers were well illustrated by one cleaner we interviewed in Canada. She had been working at the airport before her employer lost the contract and before the nursing home housekeeping staff was fired when the work was contracted-out. The corporation that won the housekeeping contract provided her with three days’ training focused on ‘just housekeeping’, and the only thing she learned about working with the elderly was to make sure she reported any personal items she found to her supervisor so she would not be charged with theft. She was responsible for up to 30 rooms. Even her boss said, ‘This is way too big for one person cleaning. But the company is like that. That’s all the budget that’s there’. She previously had a supervisor who knew about nursing homes’ cleaning, ‘But this one, I don’t know if he knows how to wear the gloves. That’s all I can say. I mean we have to tell him what to do’. This supervisor is in charge of multiple contracts that take him to many homes, leaving the housekeeping staff without a supervisor much of the time. The housekeeper went on to say, ‘But anyway, there’s no reason of complaining now because this company is going. We are just okay, let’s go, keep working until the end when the other company comes [laughs]’. When we left her, she had no idea if she would find another job when the contract goes to another firm. An additional problem with contracted-out cleaning stems from what we term the ‘regular irregularity’ of healthcare, including in nursing homes. We can predict that bodily fluids, along with food and drink, will find their way onto nursing home floors, chairs and beds, without knowing just when and to what extent. For health and safety reasons they should be cleaned up quickly, but this promptness is hampered if the home’s own staff are not allowed to immediately ask cleaners for help with an accident, but must report it to the cleaning firm which then directs the cleaners on site. All this takes time and may be further delayed because the corporation’s supervisor is not available. Meanwhile, tensions can grow between the contracted staff and employees of the nursing home. To contract-out specific housekeeping services is to fragment care, with negative effects on the care itself and on care workers (see also Munford and Sanders 2001: 50–52).

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At one Ontario home we noticed a cleaner pushing a resident in a wheelchair instead of pushing a broom. One of us sought him out for an interview, learning that he was commended, not criticised, by the home’s management for taking time to have a chat and some coffee with a resident. It was part of his job, taking up an estimated 20 per cent of his time and giving him considerable job satisfaction. He had worked there for 17 years and intended to remain until retirement. More social care and less worker turnover meant better quality for resident and worker alike, as well as lower long-term costs for the home. Other contracting-out areas include drawing on for-profit agencies for some staff, which almost inevitably means less worker familiarity with residents and vice versa, less context-specific staff training and less teamwork. Regular employees have to spend time telling these contracted workers about residents, processes and resources. The result is unhealthy for both residents and workers. In contrast, one Canadian home has its own part-time and casual staff who regularly fill in when full-time employees are away or retired. New hires are recruited from this list. The success of this strategy is evident in the very low turnover rate in this home. Most common in the North American homes we studied, private companions are part of the grey economy. Although the hiring of private companions, whether from agencies or not, may ease the workload of regular staff as well as make life better for the residents involved, the regular staff may have to take time to train and monitor them, and may perceive that the companions are spying on them for the families involved. Staff may not know when these companions will show up or what they will do when they do arrive. The work is necessarily precarious, and the families seldom provide even statutory benefits or even minimum wage. This unhealthy work is, moreover, largely invisible to and unsupervised by facility management, which means that quality protections that stem from standards and job descriptions are seldom to be found (Daly et al. 2015). And of course the private hiring of personal companions offends the principle of equitable access. Not only can clinical and support services be contracted-out, but so can management services. This is an aggressive activity undertaken by some of the largest nursing home chains in North America, as they purport to introduce innovation and efficiency to public and non-profit homes. Extendicare Assist is one of the largest such management opera-

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tions. On its website, this ‘proven solutions partner’ notes that ‘a myriad of expectations, reporting requirements and competing priorities’ face nursing homes, and promises to ‘clear away the layer of administration and management’ so that the partner home can focus on its vision. Extendicare Assist is active in over 80 Canadian long-term care homes, helping to provide care and services to residents ‘while maintaining a close eye on [each home’s] bottom line’. It also offers to link its partner homes to separate Extendicare divisions that provide homecare services and purchasing services (Extendicare REIT 2017). Most of the examples cited here are set out in greater detail in one or more of the four ‘bookettes’ produced for popular consumption out of our project (Baines and Armstrong 2015/2016; Armstrong and Braedley 2016; Armstrong and Day 2016; Armstrong and Lowndes 2018b), but let us mention another. In one Canadian case we observed, the for-profit management team that was brought in deemed it efficient to eliminate soup at the noon meal since it was offered at the evening meal. Most of the residents, some of the staff and the entire board of directors at this home were of Italian heritage. Great controversy ensued, and the cost-­ cutting decision was quickly reversed. At the same home, however, the management also determined that it was inefficient to sort the waste to be composted from that which was destined for the garbage dump. Leaving aside its long-term ecological effect, this change meant heavier garbage bags and more soft tissue injuries among staff. It was still in place at last report, despite being inefficient both for society as a whole and for workers and thus residents at the home in question.

Conclusions Markets do not work well, if at all, in healthcare. In his lengthy assessment of marketisation in health services, economist Thomas Rice (1997: 423) concluded over 20 years ago that assuming market forces are ‘superior to alternative policies’ can mean policy-makers ‘blind themselves to policy options that might actually be best for enhancing social welfare, many of which fall out of the conventional, demand-driven competitive model’. Patients and residents typically lack genuine choices of the sort assumed in markets, and power imbalances are especially obvious in

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terms of healthcare needs and knowledge. Yet marketisation has continued in spite of the empirical evidence demonstrating that it fails the quality, cost and access criteria. As Annemarie Mol persuasively argued in her book, The Logic of Care, ‘Care is not a limited product, but an ongoing process’ (Mol 2008: 14). Care involves much more than medical treatment for specific illnesses, as the feminist literature and the research on the determinants of health make clear. Market failure is particularly highlighted in the contracting-out of nursing home services. In these homes stability is important for the development of the familiarity, trust and collaboration that both residents and staff need, but this is undercut by contracting-out. Moreover, the very services that tend to be contracted-out are those that make life worth living in longterm care. With 70 to 80 per cent of nursing home expenditures devoted to staffing, cost savings must mean some combination of fewer workers, lower staff qualifications, less pay and benefits and less employment security, especially given that some contractor revenue must be diverted to profits. The impacts on quality and, at least over the longer term, on cost are clear. So too are the impacts on accessibility as nursing home services are reduced or replaced in part by private companions. In addition to the impacts on quality, cost effectiveness and accessibility, we identify another effect of the fragmentation that results from contracting-­out. It makes the responsibility for actions, and inactions, difficult to discern (Munford and Sanders 2001: 49–50). Not only are the contracts often secret, leaving the parties to them unaccountable, but the contracts can be simultaneously too short and too long in duration, too short in stability terms while too long for market competition to thrive. Indeed, the private contractor may bid artificially low on its first and successful contract, offering real cost savings, then recoup in subsequent contracts when potential competitors have vanished, along perhaps with on-site kitchens and/or laundry facilities. Which party to the contract is to blame when things go wrong? This difficulty is intensified if, as is often the case, the contracts are declared to be trade secrets, and thus are not open to scrutiny by residents and their families, by staff, and by the general public. Accountability is obscured, giving rise to a fourth criterion for public policy assessment: its impact on democratic control. A US example from our study involves a nursing home that markets itself as being non-profit, with all its revenues spent on the provision of on-site care. The home is part of a larger complex with various levels of

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assisted living and with firm assurances of continuity of care. Individuals were recruited to sell their individual homes and buy assisted living apartments, with the promise that when it came time to sell the apartments back to the complex (at a set reduction in price) the individual was guaranteed a place in the nursing home. This was a sustainable strategy until the owners of the complex’s land and buildings expanded to another state, which became a rust-belt state with rapidly declining real estate values. The rust-belt complex failed to reach a necessary occupancy target, and started being subsidised by the complexes in the original state. This appeared to violate the terms under which residents had been recruited, prompting a court case for fraud. The management of the homes was complicit in this cross-subsidisation, having been contracted-­out to a firm linked to the owners of the land and buildings for the complexes. Other US examples abound. In a recent article originally prepared for Kaiser Health News, Jordan Rau (2018) analysed ‘related party transactions’ between nursing homes and firms in which they have a financial interest or control and that supply a wide range of goods and services. These firms ‘then siphon off higher profits, which are not recorded on the nursing home’s accounts’. According to one source cited by Rau, ‘[r]ental prices to real estate companies related to [Brius, a large California chain] were a third higher than rates paid by other for-profit nursing homes in the same counties’. Further, these ‘corporate webs’ provide to the private corporations involved a measure of legal protection as well, making it harder for families to collect money from lawsuits brought against the outsource firms. His analysis, based on inspection and quality records, concluded ‘that homes that outsource to related organisations tend to have significant shortcomings’ with fewer staff, more injuries and more complaints. It is challenging for judges in several states—the article specifically mentioned New  York, Tennessee and Texas in addition to California—to determine whether ‘all the companies were acting as one entity and that the nursing home could not make its own decisions’. Unions are often the only source with sufficient resources to mount legal actions to pierce the ‘corporate veil’ (Rau 2018). In Canada, the Hospital Employees Union was successful in persuading an adjudicator from the BC Office of the Information and Privacy Commissioner to order a public health authority to provide information on details of a laundry contract to the union. The adjudicator rejected the laundry firm’s

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argument that release of the commercial information would be harmful to its business interests, but the order was based solely on the grounds that the terms of the contract were negotiated rather than being supplied (Fedorak 2010). On the same day, this adjudicator also issued parallel access orders to the health authority with regard to nursing home contracts with outside suppliers of food and cleaning services. In sum, the contracting-out of nursing home services tends to mean lower quality for residents and staff alike, and is likely to raise costs. Lower quality in turn may result in the hiring of private companions to supplement the overburdened staff, with adverse effects on accessibility. In addition to its negative implications for quality, costs and access, contracting-­out entails contracts shrouded in secrecy, leaving their parties unaccountable to residents and their families, to staff and to the public, which foots most of the bill, in general. Contracting-out benefits the private contractors, but it is difficult to identify benefits for anyone else. Acknowledgements  Work on this chapter has been supported by ‘Re-Imagining Long-Term Residential Care: An International Study of Promising Practices’ (Pat Armstrong, Principal Investigator) funded by the Social Sciences and Humanities Research Council of Canada, grant # 412-2012-1004.

References Angus Reid Institute. (2015). Prescription Drug Access and Affordability an Issue for Nearly a Quarter of All Canadian Households. Vancouver: Angus Reid Institute. Available at: http://angusreid.org/prescription-drugs-canada [Accessed 15 Sept. 2018]. Armstrong, H. (2001). Social cohesion and privatization in Canadian health care. Canadian Journal of Law and Society, 16(2), pp. 65–81. Armstrong, H., Armstrong, P. and Connelly, M.P. (1997). Introduction: the many forms of privatization. Studies in Political Economy, 53(1), pp. 3–9. Armstrong, P. and Braedley, S. (eds.) (2016). Physical Environments for Long-­ Term Care. Ottawa: Canadian Centre for Policy Alternatives. Armstrong, P. and Day, T. (eds.) (2016). Exercising Choice in Long-Term Residential Care. Ottawa: Canadian Centre for Policy Alternatives. Armstrong, P. and Day, S. (2017). Wash, Wear, and Care: Clothing and Laundry in Long-Term Residential Care. Montreal and Kingston: McGill-Queen’s University Press.

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Armstrong, P. and Lowndes, R. (2018a). Creative Teamwork: Developing Rapid, Site-Switching Ethnography. New York: Oxford University Press. Armstrong, P. and Lowndes, R. (2018b). Negotiating Tensions in Long-Term Residential Care: Ideas Worth Sharing. Ottawa: Canadian Centre for Policy Alternatives. Armstrong, P., Armstrong, H. and Scott-Dixon, K. (2008). Critical to Care: The Invisible Women in Health Services. Toronto: University of Toronto Press. Armstrong, P., Armstrong, H., and MacLeod, K.K. (2016). The threats of privatization to security in long-term residential care. Ageing International, 41(1), pp. 99–116. Baines, D. and Armstrong, P. (eds.) (2015). Promising Practices in Long Term Care: Ideas Worth Sharing. Ottawa: Canadian Centre for Policy Alternatives. Berwick, D.M., Nolan, T.W. and Whittington, J. (2008). The triple aim: care, health, and cost. Health Affairs, 27(3), pp. 759–769. CHPI. (2015). The Contracting NHS – Can the NHS Handle the Outsourcing of Clinical Services? London: Centre for Health and the Public Interest. Available at: https://chpi.org.uk/wp-content/uploads/2015/04/CHPI-Contracting NHS-Mar-final.pdf [Accessed 15 Sept. 2018]. Coyle, A. (2005). Changing times: flexibilization and the re-organization of work in feminized labour markets. In: L. Pettinger et al. (eds.) A New Sociology of Work? Malden MA: Blackwell. pp. 73–88. CUPE Canadian Union of Public Employees. (2009). Healthcare Associated Infections: A Backgrounder. Ottawa: CUPE Canadian Union of Public Employees. Available at: https://cupe.ca/health-care-associated-infectionsbackgrounder-and-fact-sheet [Accessed 15 Sept. 2015]. CUPE Canadian Union of Public Employees. (2013). Backgrounder on K-Bro Linen Systems: The New Provider of Hospital Linens in Saskatchewan. Ottawa: CUPE Canadian Union of Public Employees. Available at: https://sk.cupe. ca/files/2013/04/Final-K-Bro-Backgrounder-_CUPE_December-17-2013. pdf [Accessed 16 Mar. 2015]. Daly, T., Armstrong, P. and Lowndes, R. (2015). Liminality in Ontario’s long-­ term care facilities: private companions’ care work in the space ‘betwixt and between’. Competition and Change, 19(3), pp. 246–263. Devereaux, P.J., Choi, P.T., Lacchetti, C., Weaver, B., Schünemann, H.J., Haines, T., Lavis, J.N., Grant, B.J., Haslam, D.R., Bhandari, M., Sullivan, T., Cook, D.J., Walter, S.D., Meade, M., Khan, H., Bhatnagar, N. and Guyatt, G.H. (2002a). A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals. Canadian Medical Association Journal, 166(11), pp. 1399–1406.

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Devereaux, P.J., Schünemann, H.J., Ravindran, N., Bhandari, M., Garg, A.X., Choi, P.T., Grant, B.J., Haines, T., Lacchetti, C., Weaver, B., Lavis, J.N., Cook, D.J., Haslam, D.R., Sullivan, T. and Guyatt, G.H. (2002b). Comparison of mortality between private for-profit and private not-for-­ profit hemodialysis centers: a systematic review and meta-analysis. Journal of the American Medical Association, 188(19), pp. 2449–2457. Devereaux, P.J., Heels- Ansdell, D., Lacchetti, C., Haines, T., Burns, K.E.A., Cook, D.J., Ravindran, N., Walter, S.D., McDonald, H., Stone, S.B., Patel, R., Bhandari, M., Schünemann, H.J., Choi, P.T.L., Bayoumi, A.M., Lavis, J.N., Sullivan, T., Stoddart, G. and Guyatt, G.H. (2004). Payments for care at private for-profit and private not-for-profit hospitals: a systematic review and meta-analysis. Canadian Medical Association Journal, 170(12), pp. 1817–1824. Dickman, S.L., Himmelstein, D.U. and Woolhandler, S. (2017). America: equity and equality in health 1. Inequality and the health care system in the USA. Lancet, 389(10077), pp. 1431–1441. Dryden, R. and Stanford, J. (2012). The Unintended Consequences of Outsourcing Cleaning Work. Ottawa: Canadian Centre for Policy Alternatives. Available at: https://www.policyalternatives.ca/publications/reports/unintended-consequences-outsourcing-cleaning-work [Accessed 15 Sept. 2018]. Extendicare REIT. (2007). Extendicare Assist Management and Consulting Services. Available at: http://extendicareassist.ca [Accessed 1 Sept. 2018]. Fedorak, J. (2010). Order F10-28: Vancouver Coastal Health Authority. Victoria: Office of the Information and Privacy Commissioner for British Columbia. Available at: https://www.oipc.bc.ca/orders/1061 [Accessed 15 Sept. 2018]. Fox, A. and Poirier, R. (2018). How single-payer stacks up: evaluating different models of universal health coverage on cost, access and quality. International Journal of Health Services, 48(3), pp. 568–585. Harrington. C., Woolhandler, S., Mullan, J., Carrillo, H. and Himmelstein, D.U. (2001). Does investor ownership of nursing homes compromise the quality of care? American Journal of Public Health, 91(9), pp. 1–5. Harrington, C., Jacobsen, F.F., Panos, J., Pollock, A., Sutaria, S. and Szebehely, M. (2017). Marketization of long-term care: a cross-country comparison of large for-profit nursing home chains. Health Services Insights, 10, pp. 1–23. Hodge, G. (2000). Privatization: An International Review of Performance. Boulder, CO: Westview Press. Lowndes, R. and Müller, B. (2015/2016). Germany: Small Town 1. In: D. Baines and P. Armstrong (eds.) Promising Practices in Long Term Care: Ideas Worth Sharing. Ottawa: Canadian Centre on Policy Alternatives. pp. 47–50. McGregor, M., Cohen, M., Stocks-Rankin, C.A., Cox, M.B, Salomons, K., McGrail, K.M., Spencer, C., Ronald, L.A. and Schulzer, M. (2011).

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Complaints in for-profit, non-profit and public nursing homes in two Canadian provinces. Open Medicine, 5(4), pp. e183–e192. McGregor, M., Abu-Laban, R.B., Ronald, L.A., McGrail, K.M., Andrusiek, D., Baumbusch, J., Cox, M.B., Salomons. K., Schulzer, M., and Kuramoto, L. (2014). Nursing home characteristics associated with resident transfers to emergency departments. Canadian Journal on Ageing, 33(1), pp. 38–48. McGregor, M. and Ronald, L.A. (2011). Residential Long-Term Care for Canadian Seniors: Non-profit, For-profit or Does It Matter? Montreal: Institute for Research on Public Policy. Available at: http://irpp.org/research-studies/ residential-long-term-care-for-canadas-seniors/ [Accessed 15 Sept. 2018]. Mol, A. (2008). The Logic of Care: Health and the Problem of Patient Choice. London: Routledge. Munford, R. and Sanders, J. (2001). The buck stops where? Contracting, service delivery and the challenge to provide responsive services. Social Work in Health Care, 34(1/2), pp. 43–57. Rau, J. (2018). Care suffers as more nursing homes feed money into corporate webs. New York Times. Available at: https://www.nytimes.com/2018/01/02/ business/nursing-homes-care-corporate.html [Accessed 15 Sept. 2018]. Rice, T. (1997). Can markets give us the health system we want? Journal of Health Politics, Policy and Law, 22(2), pp. 383–426. Ronald, L., McGregor, M., Harrington, C., Pollock, A. and Lexchin, J. (2016). Observational evidence of for-profit delivery and inferior nursing home care: when is there enough evidence for policy change? PLoS Medicine, 13(4), pp. 1–12. Stein, J.G. (2001). The Cult of Efficiency. Toronto: Anansi. Tanuseputro, P., Chalifoux, M., Bennett, C., Gruneir, A., Bronskill, S., Walker, P. and Manuel, D. (2015). Hospitalization and mortality rates in long-term care facilities: does for-profit status matter? Journal of the American Medical Directors Association, 16(10), pp. 874–883. Vrangbæk, K., Petersen, O. and Hjelmar, U. (2013). Is contracting-out good or bad for employees? A review of international experience. Review of Public Personnel Administration, 35(1), pp. 3–23. Woolhandler, S., Campbell, T. and Himmelstein, D.U. (2003). Costs of health care administration in the United States and Canada. New England Journal of Medicine, 349(8), pp. 768–775. Woolhandler, S. and Himmelstein, D.U. (2004). The high costs of for-profit care. Canadian Medical Association Journal, 170(12), pp. 1814–1815. Zuberi, D. and Ptashnick, M.B. (2011). The deleterious consequences of privatization and outsourcing for hospital support work. Social Science and Medicine, 72(6), pp. 907–911.

Part III Gatekeepers in the System

Chapter Six: Gatekeepers in a Mixed Private/Public System Fran Collyer

Introduction Decision-making and choice are central features of the operation of the Australian healthcare system, with its mixed provision of public and private services, its universal healthcare insurance scheme (Medicare) and the availability of private health insurance  (PHI). These are central because navigating the healthcare system involves many decisions for participants between public and private services: for patients and their referring doctors, choices must be made about which service the patient should attend, and whether to use private health insurance (if the patient has this); for individuals with the responsibility of managing, designing, funding and planning services, decisions have to be made about the private or public nature of the suite of services to be offered.

F. Collyer (*) Sociology and Social Policy, University of Sydney, Sydney, NSW, Australia e-mail: [email protected] © The Author(s) 2020 F. Collyer, K. Willis (eds.), Navigating Private and Public Healthcare, https://doi.org/10.1007/978-981-32-9208-6_6

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In this chapter, the focus is on the attitudes underlying the decision-­ making of the ‘gatekeepers’—individuals who have a role in managing access to resources, services and information, and thus, in various ways, shaping patients’ experiences of healthcare. Gatekeepers may be general practice doctors (GPs), who have the legislative responsibility to refer patients to specialists (without which no Medicare rebate will be paid to the patient); specialists who choose how much public versus private work they will undertake and whether to provide their patients with access to hospitals and special treatments such as surgery or radiotherapy; nurses or other health workers assisting patients to access services within the community or the hospital (including homecare or social work facilities); or, indeed, managers, policy-makers or administrators who have responsibility for designing, managing, assessing the costs of or organising the funding of the services to be used by the patients. In this latter sense, the gatekeepers build or control the ‘pathways’ of the healthcare system. Although ‘gatekeeper’ is a common term in the literature, it is generally applied as if these individuals were automatons, without individual agency, motivations or concerns. Indeed, in Marxist or political economy analyses of healthcare, the gatekeeper is an agent rather than an actor. A more sociological rendering of the concept envisages the gatekeeper as a fully social being, often in control of scarce public resources, not merely responding to the imperatives of the system but with their own motivations and capacities for action (for a more detailed thesis, see Collyer et al. 2017). In the healthcare field, gatekeeping is one of the more important processes through which the structures or pathways are created, maintained and modified over generational time—pathways that guide, enable and constrain the ‘choices’ made about possible therapies, providers and services, by patients, doctors, health workers, policy-makers, administrators, healthcare executives and managers. The attitudes and perspectives of all gatekeepers are highly influential in policy processes, given the capacity of such individuals to pressure government for reform (Wendt and Naumann 2018), even though, as this chapter will show, some have more capacity to influence policy than others. Moreover, in this era of neoliberalism, marketisation, privatisation of government services (Humphrys 2018; see also Chapters Three, Five, and Seven of this book), and the substantial growth of private

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healthcare in the Australian setting, the attitudes and practices of gatekeepers may be critical determinants of the structure and organisation of the emerging health system. As acknowledged by various Australian ­governments—which have actively supported the strengthening of private healthcare services and private medicine—this growth has brought unintended shifts in the workforce and patient load from the public to the private sector, and put pressure on the training infrastructure of public hospitals (Productivity Commission 2005: 15). Despite such acknowledgements, there has been no detailed investigation of the implications of the growth of private sector medicine, nor of the way this has been brought about through the choices, decisions and practices of key actors in the system. Thus it is both important and timely to address the former in this volume, while this chapter focuses on the latter—the gatekeepers of the healthcare system, and their perspectives and experiences of private and public healthcare services. Attitudes have long been considered important in the shaping of an individual’s decisions and practices, and consequently a significant literature has developed on social attitudes within the broader population. Much of this utilises quantitative data, revealing correlations between attitudes and various features of the population such as age, class, voting preferences and education. A conventional finding in the social sciences has been that attitudes are fundamentally class-based: that there is a struggle between groups with differing interests, experiences and opportunities, and these are associated with diverse attitudes towards the causes of social problems, the appropriate roles of government and the market towards egalitarianism and the redistributive policies of government (Heaton 1987: 612). Indeed, the thesis that subjective attitudes are the consequences of objective status is a central tenet of class analysis (Heaton 1987: 611). Thus, it is assumed class is the main driver of attitudes and motivations, with significant differences between the working and ruling classes, all underpinned by their specific locations in the economic system. These assumptions derive from classical economic theory, which ‘envisions financial self-interest as the cornerstone of free markets’ (Waitzkin et al. 2012: 33). Within such a framework there is the further supposition of homogeneity within classes. For Mills (1957), for example, executive decision-makers work within closely knit, elite networks

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where their financial interests are protected. Individuals in these networks rotate between working in prominent positions in government and business, thus impacting significantly on public policy decisions. Interaction within these networks produces an essential synergy of perspectives between the two groups (Waitzkin et al. 2012: 33). There is much to support this view of a polarisation of attitudes between the working classes and the elite. For example, in the face of a marked escalation in the privatisation and marketisation of government services since the 1990s, and an embedding of these practices within the policy platforms of successive Australian governments (Collyer and White 2011; Collyer et al. 2015; Meagher and Goodwin 2015), there has been increased support for privatisation among the elite, but falling support across the broader population. In 1986, there were about even numbers of people for and against privatisation across the population, but by 2002 only 25 to 30 per cent were in favour (Kelley and Sikora 2002). The lack of support for privatisation among Australians continues, with surveys in 2014 and 2015 reporting that 59 per cent of the population believe privatisation to be a ‘bad idea’ (Meagher and Wilson 2015: 78). With regard to healthcare, levels of support for public provision remain very high, with nearly nine in ten voters showing a clear preference for government delivery (Meagher and Wilson 2015: 75). One of the clearer pictures to emerge is found in Neumann’s comparative, longitudinal study of attitudes across 14 Western European healthcare systems. This was conducted in a context of reform and restructuring, pressure on public funds and the growth in private medicine. The study reveals very little change in the high level of support for public healthcare across these 14 countries (Neumann 2018: 259), and, with regard to class cleavages, reveals very little change in the traditional scenario—whereby the lower the social class, the greater support there is for public provision of health services. Neumann concludes that support for the public provision of healthcare in these countries has remained very stable over time, despite the privatisation of medicine, and any differences in attitudes can continue to be explained in class terms (Neumann 2018: 261). Such findings support the notion that the continuing growth of privatisation, contracting-­out and marketisation by both Federal and state governments1 (and both major political parties) over the past four decades is not

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a trend driven by a demand from voters, but by the elites (Meagher and Wilson 2015: 32; Ebbinghaus and Naumann 2018: 155). Clearly, a difference in attitudes towards privatisation and marketisation exists between the political elites and the broader population, and while evidence of the decisions of the political elites is publicly available in the policy record, far less is known about the gatekeepers working in the healthcare system. Class analysis assists little here as gatekeepers are a heterogeneous group, though ostensibly of a similar class. In the literature on the professions there has traditionally been a focus on doctors, who are generally understood to have a form of socialisation that produces a ‘clinical individualism’, making them largely resistant to managerialism or other ideologies of control (Martinussen and Magnussen 2011). This strong sense of professional autonomy has been found even among medical students, in comparison to law and business students (Wilkes et al. 1998). Martinussen and Magnussen (2011: 194) suggest most studies conclude that doctors in clinical practice are likely to regard ‘managerialist and accounting values as a threat to professional autonomy and clinical values’ (e.g., Dent 1991; Jacobs 1995); and managerialism to be a greater threat than the growing assertiveness of patients (Tousijn 2006: 473). However, following Scott (1982) and Freidson (1985), Martinussen and Magnussen (2011) note a significant differentiation between doctors. They argue that attitudes towards healthcare reform, for instance, differ according to whether the doctors are employed as practitioners, researchers or administrators, and such differences are more marked than those which occur as a result of speciality, prestige or income (Martinussen and Magnussen 2011: 194). These findings of a divergence in values between doctors engaged in clinical rather than administrative or management positions have not gone unchallenged. Correia, among others, argues we should not assume a simple dichotomy between doctors and management, particularly given the blurring of the borders between administrative and professional authorities in contemporary healthcare systems (2013: 255)—after all, many of the management and administrative functions in the healthcare field are now undertaken by health or medical professionals. Taking the view that social actors do not merely respond to perceived constraints and commands, and that they experience the ‘structural properties’ of the

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healthcare system in different ways, Correia’s study suggests a rather diverse range of responses among doctors to managerial directives (2013: 256, 264–265). Thus, in examining responses to managerialism within two diverse medical units, Correia demonstrates the importance of context in the way doctors and managers interpret organisational or institutional directives: Among the medical profession in general and physicians and surgeons in particular, there is no uniform response in relation to managerial expectations. Whereas some are committed to their patients, others respond to financially-driven interests to conduct expensive and high-risk procedures (Correia 2013: 264).

Waitzkin et al.’s (2012) qualitative study of executives in managed care organisations in the USA also suggests a diversity of attitudes, finding that government policy-makers and administrators of major healthcare organisations convey a variety of motivations, ‘in which profit maximisation and financial self-interest comprise only a part’ (2012: 43). Likewise, Humphrey and Russell’s (2004) examination of consultants (specialists in Australian parlance) in the British National Health Service (NHS), who also work in the private sector, challenges the view that attitudes within this group can be simply categorised as either altruistic or profit-oriented. Such findings raise important questions about the healthcare system and the gatekeeping process within this. If these studies are correct, and there are differences among the attitudes of gatekeepers, what are these, are they arbitrary or organised in some way and how are they organised? These questions need to be addressed both theoretically and empirically. In this chapter, I report on an empirical study of gatekeepers in the Australian healthcare system and analyse this using Pierre Bourdieu’s concepts of habitus, field, market and state. These concepts provide a way of thinking about the state and the market, and potentially take us well beyond research which might otherwise offer only a dichotomous view of gatekeepers—as pursuing either economic or non-economic interests. In this I follow Waitzkin et al. (2012: 35) and their use of Bourdieu’s conceptual approach, focusing on how individuals and organisations respond to the social constructions of the market, and the way an individual’s

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practices embody (and reveal) the beliefs and values of their habitus. Analysis is also guided by Clarke’s (2004) theory of neoliberalism as an ideology of valorising the market and devaluing the public provision of services that has not, contrary to most portrayals, been a global, causal, unstoppable, universal force, but a political and policy strategy that is both anti-statist and anti-welfarist, and yet fundamentally contradictory, contested, unfinished, incomplete and uneven. The section directly below describes the methods and aims of an empirical study of gatekeepers. This is followed by an analysis of the views of gatekeepers about private and public healthcare, demonstrating the way their choices and decisions are shaped by experiences within specific locations (the social spaces) of the healthcare field. These locations are shown to be linked to their diverse approaches to equity and social justice, and differing conceptions of the state. The chapter closes with a brief discussion of the implications of the study.

The Gatekeeper Study The gatekeeper study is part of a larger research programme funded by the Australian Research Council (DP130103876) which investigates the navigation of the healthcare system in Australia. Both the gatekeeper study and its companions, the citizen study (reported elsewhere, e.g., Willis et al. 2016; and also Chapter Eleven of this book) and the media study (e.g., Lewis et al. 2018), examine the choices faced by Australians in the healthcare field and analyse these using Bourdieu’s (1993) interlinked concepts of habitus and field. The research program is multi-­method in approach, relying primarily on in-depth interviews for the citizen and gatekeeper studies, and a discourse analysis of newspaper articles for the media study. The aim has been to examine the experience of patients and other actors within the field, and at the same time explore the structures of the social context within which these individuals make choices about health services. A key finding of the citizen’s study is that the socially and economically privileged are more able to effectively navigate the healthcare system (Willis et al. 2016; Chapter Eleven), while a key finding of the media study is that ‘choices’ (and attitudes) are shaped by

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the prevalence of a specific discourse in the media—itself shaped by the social relations of the media field—which denigrates public healthcare, privileges private sector medicine, creates anxiety among those who do not have and perhaps cannot afford private health insurance and commands Australians to ‘choose private’ rather than public services (Lewis et al. 2018). The gatekeeper and the citizen studies drew their participants from the same research sites to ensure the inclusion of individuals: working or living in low, medium and high socio-economic areas; in metropolitan, regional and remote areas; and in three Australian states. This strategy enabled matching of citizen’s stories with their local health services, ensuring some understanding of how local contextual factors might impact on their experiences and attitudes. Participants were selected using internet searches of appropriate sites (such as hospitals and general practices) through theoretical sampling, and invited to participate. Between 2014 and 2015, 43 individuals were interviewed for the gatekeeper study, and these included GPs and nurses in private and public general practices and hospitals; specialists (e.g., Visiting Medical Officers, consultants) in both private and public practice; clinical directors, managers and CEOs in private and public hospitals; executive managers in various health departments; and, from the non-profit sector, representatives from consumer and professional associations, senior managers in community organisations and policy experts from research institutes and universities. All in-depth, semi-structured interviews were transcribed and analysed using the techniques of thematic analysis. Due to the sensitive nature of some of the material discussed, pseudonyms are used to protect identity, and neither the institution nor geographic location of the participant is revealed. Descriptors are provided to give an indication of context, for example, ‘GP, public hospital’.

The Healthcare Field and the Nation State The healthcare system is best described as a social field in the Bourdieusian sense. The concept of field embraces the idea of a space of social action, defined by the unique struggles and forces operating within (Bourdieu

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1993: 30). The field is where capital—both a resource and a deployment of power—is produced and regulated. As a concept, the field must ­necessarily be understood in relation to the habitus, for over time it gives the habitus its structure. While the field is the objective network of relations that is both structuring and structured, the habitus is the subjective element of practice, a set of ‘durable dispositions’ laid down through one’s life experiences, guiding an individual’s choices and future behaviour (Bourdieu 1993: 86; see also Bourdieu and Wacquant 1992). Fields can be distinguished by the nature of their struggles, and by their doxa: their unique sets of rules or unquestioned ‘truths’ (Bourdieu 2000: 11). In the case of the twenty-first century healthcare field, there are two fundamental ‘truths’ at stake. The first concerns the claim that health can be defined by the (bio)medical model of illness (sometimes referred to as scientific medicine), and a second that healthcare is best provided through the private market (Collyer 2018: 121–122). These doxa underlie the major tensions of the field and favour the dominant actors. Both are fundamentally class-based claims to the truth, though only the second of these claims is dealt with in this chapter. Healthcare systems are very much a product of nation states. Their various histories can be seen as sustained political struggles to establish accessible and quality services for the population in the face of professional dominance and the power of the medical industry (e.g., pharmaceutical companies, private hospital owners/corporations and private insurance companies). In Australia, a polarisation of views about the healthcare system has played out historically within healthcare policy. The establishment of Medicare (initially Medibank) as a universal health insurance system paid for through the taxation system was a Labour government initiative whereas policies to promote voluntary insurance and build up the private healthcare industry have been primarily introduced by Conservative/Liberal governments (for a more detailed history, see Collyer et  al. 2015). For the gatekeepers of the healthcare system, the field within which they work has been radically remodelled in the space of only a couple of decades. The encroachment of neoliberalism, and the growing normalisation of market processes within state functions, has heightened previous distinctions between services provided by the public and private sectors. Until the 1990s the private healthcare sector in

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Australia was a small part of the overall system, with small independent clinics run by individual doctors and small independent hospitals— mostly owned and run by religious orders—conducting elective surgery and nursing care. After this time, the healthcare field has seen the entry of larger, for-profit hospital and nursing homes that are not independent but part of national or global conglomerates (Collyer et al. 2015; Collyer and White 2011). This systematic strengthening of the private sector healthcare industry in Australia was produced by government support for the private health insurance sector from 1996, and, together with severe cuts to public sector health services, profoundly bifurcated the field and undermined the capacity of the public sector to maintain its position as the majority provider of services. As such, healthcare has been a site of unconcealed class conflict between Conservative/Liberal and Labour governments, and between Left and Right wing politics: Left parties, mainly representing the interests of the working classes, prefer a strong state and are the main defenders of the welfare state, whereas Right parties want the market to solve social problems and are seen as the opponents of a strong welfare state. Attitudes should thus be structured with respect to social class and the traditional Left and Right in politics (Neumann 2018: 248).

In the Australian context, this Right-Left dimension is reflected in attitudes towards private or public healthcare: On the ‘Left’ are those who stand up for Medicare as a universal, free, tax funded system, while on the ‘Right’ are those who would see private insurance take over the dominant role in funding healthcare (Doggett and McAuley 2013: 1).

These Right-Left, Conservative/Liberal-Labour struggles indicate the state’s fundamental involvement in the creation of the healthcare field. For Bourdieu, the state ‘is the foundation of both the logical and the moral conformity of the social world’. Rather than a neutral site of administration, or indeed a mere tool of capital, the state is the means by which some kind of orthodoxy (a particular logical conformity) and a set

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of rules for the ‘game’ are laid down and imposed on society (Bourdieu 2014: 4). The fundamental centrality of the state to all social life is emphasised by Bourdieu when he states that the ‘state is this well-founded illusion, this place that exists essentially because people believe that it exists … an entity that exists by way of belief ’ (Bourdieu 2014: 10). The product of this ‘well-founded illusion’—the healthcare system, its regulations, procedures, conventions and structures—is the day–to-day, lived experience of the gatekeepers each day of their working lives.

 atekeepers in a Radically Altered Healthcare G Field Many of the gatekeepers interviewed for this study are acutely aware of the changes to the healthcare field, and of the part the state has played in bringing these changes about. While only a proportion are politically active, their reactions can, nevertheless, be characterised as either Left or Right wing. Some, such as Robert, a university statistician, hold a Left, pro-Medicare view. He argues the private insurance industry should not be protected by government (the government gives individuals tax rebates if they hold private health insurance), because it is a ‘voluntary good’ and ‘ought to stand in the market like any other insurer’. Robert is angered by the marketing slogans of Medibank Private (a for-profit insurance company), which state ‘I feel better now’. ‘They’re nothing to do with feeling better, they’re to do with money, its false advertising’, he says. Moreover, Robert sees current health policies that promote private health insurance as ‘ideological’. He rejects the rhetoric that such insurance will ‘take pressure off the public hospitals’, and says, to the contrary: [Private health insurance] stimulates demand and so you get more demand for in-patient services, which everybody says isn’t the way to go, you should be getting people out of hospital. But the health insurance benefits were set up to have you in hospital, not to support you in the community … The private system depends on the public system because if things go wrong, [they] shunt the person off to Intensive Care in the public hospital, [and private hospitals] don’t have to run all that backup stuff.

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Padriac, a GP educator working in a public hospital, is also concerned that the growth of private medicine is damaging public sector medicine. He believes it is allowing governments to withdraw services ‘because there’s this alternative’. And Bruce, a GP educator working in both private practice and a university, echoes similar sentiments: I think there is too much emphasis on the role of private. As a strong leader in universal healthcare I think [private healthcare] should be there as an option but really it’s not a solution to a struggling public system. Yeah, I just think we’ve chronically under-invested in public health and it looks like it’s going to get worse.

Other participants expressed Right wing sentiments, propounding the benefits of private insurance and market-centred medicine, and generally expressing views in synergy with neoliberalism. Alyssa, the CEO of a healthcare peak body, sees PHI as benefitting public sector medicine, reducing waiting times and the number of people using the public hospitals. Likewise, Jarrod, a GP working in both a public and a private hospital, suggests individuals should pay for their medicine so that they ‘appreciate’ it and don’t take ‘unnecessary tests’. He says ‘people should also have responsibility for their own health’. Cleo, the CEO of a private for-profit hospital, says: But everything should be run as a business in order to be able to control costs … [our hospital] is a profit organisation, but that’s not the reason why we’re here, to make a profit. The reason we’re here is to provide a service to the community, but I’m still able to make a profit … the money’s wasted in the public sector … it’s poorly managed … Now if they gave us a budget and said, ‘Here’s your budget. Do what you like with it, but you’re not getting anymore’, I can guarantee we could manage it better than they do and we could get more benefit out of that money for the community than they can … the private sector can run their services for 30 per cent less than the public sector can, and that’s well proven in documents that you can get your hands on. So basically, if we’ve got a waiting list we can do 30 per cent more patients on that waiting list than the public sector can.

Perspectives towards the private, public and non-profit sectors within the gatekeeping group can be understood as a product of the habitus, the

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set of ‘durable dispositions’ emerging from the processes of socialisation and life experiences (Bourdieu 1993: 86). Indeed, early socialisation seems particularly important, given the differences in attitudes previously noted among students enrolled in the various disciplines (Wilkes et al. 1998). Nevertheless, the attitudes and practices of individuals change over time. Socialisation is a continuous process. Bourdieu offers the concept of habitus to explain the durability of dispositions, but explains the potential for development and change over time by fundamentally connecting habitus with the concept of field (Bourdieu 1986: 101). Given that the structuring dynamics of the field, its doxa and the nature of its struggles have the capacity to modify the habitus, the attitudes and practices of individuals can be reshaped throughout an individual’s working life.

Gatekeepers, Location and Social Space One of the study’s findings is that individuals working within the public or not-for-profit sector tend to express support for public healthcare and Medicare, whereas individuals working in the private sector support political views from the ‘Right’, and are likely to be advocates of private health insurance and private medicine. This association between attitudes towards public and private healthcare and location within the healthcare field (i.e., in the public or private sector) is an effect of the field. Although the border between these two groups is to some extent permeable—and should be, given that many experts work in both sectors—it is, nevertheless, evident that ‘location’ matters, and has some capacity to modify early habitus and class dispositions. Bourdieu (1989) speaks of symbolic space, of social space and of geographic space, with these spaces functioning together because, as he argues, we are both social and physical beings. Such spaces are sites where groups interact, where choices are shaped and where individuals tend to share similar dispositions and thus practices. For Bourdieu this is not simply because individuals located in proximity are in interaction with others of similar disposition, but because locations have specific economic and cultural resources attached to them, rewarding individuals in different locations differentially (Bourdieu 1989:

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17–19). Thus, each social space is located within a specific hierarchical order, having specific meanings and implications for its occupants. In other studies, the social spaces within which people live—their regions or suburbs—have been associated with how they perceive and evaluate their local healthcare services (Lewis et  al. 2018). In the gatekeeper study, participants evidently found their working environments to be social spaces with specific social and symbolic meanings. Individuals place importance on the level of resources available to them (relative to expectations about what others in similar occupations or organisations might have), are conscious of their role within the organisation and field of healthcare and also their position within the hierarchy of the organisation and field. Most pertinently perhaps, for our participants, ‘public’ and ‘private’ are pivotal terms, weighty with both symbolic and practical meaning, fundamentally influencing their perspectives of the healthcare field and the value they place on their work. They spoke freely, and often passionately, about the differences between the private and public sectors, and how these shape behaviour and even health outcomes. Differences which may seem ‘merely’ symbolic clearly have material and very real consequences. As Raul, a surgeon working in both a private and a public hospital, noted in relation to the flow of work and waiting lists, ‘In the private hospital, at the end of the day, it’s a business’. If the public hospital closes over Christmas, it ‘saves’ money. In the private hospital, closing means ‘losing money’. For Raul, working in the public sector is a more collaborative way of working, and it means an opportunity to ‘give something back to the community’. The difference is also expressed well by Matthew, an executive administrator in a state health department, when he says that: … people’s perspectives are very different depending on where they work and how they see the world. I see things very differently where I am now to what I did when I was providing care at a local level … I had some discussion with some private hospital operators in a meeting we had just recently, and I was amazed about their view of the world. Very different to my view of the world.

Symbolic/material differences are particularly evident for participants who work in both the private and the public sectors. Frank, a GP who

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works in both the local private and public hospitals, talks at length about the contrasting staffing practices in the two organisations, and says the staff have a sense of ‘ownership’ in the public hospital that is missing from the private, for-profit hospital—and although ‘the standards are probably fairly equal’, the doctors have more ‘commitment’ to their much sicker patients in the public hospital. Bruce, a GP with a private practice but also a GP educator at the university, can also see differences: I think to me there are two real cultures in primary care in Australia, I know this is pretty simplistic but you really have primary care that is motivated for the right reasons, that people are there to really try hard and look after them, and then there’s primary care that really is not, and it’s more commercially driven.

Equity and Justice in the Healthcare System Almost all participants in our study spontaneously brought questions of ethics and social equity into the interviews about the healthcare system, and all claim to be motivated by a concern for the disadvantaged. Further analysis, however, reveals participants have quite different views of whose responsibility it is to provide solutions to the inequalities of health and healthcare. To some extent, as with attitudes towards health insurance, the market and the private/public divide in healthcare, these views are divided according to the participants’ location in the private or public/not-­ for-­profit sector. Many of the private sector participants expressed the belief that individuals should be responsible for their own healthcare: an attitude expected of an individual operating within a Right wing or neoliberal political framework. For instance, Cleo, the CEO of a private, for-profit hospital, states: ‘I feel that there should be a level of responsibility by the public to pay part of their fee going to the doctor, as part of the responsibility for their own health, just like education’. Roland, who also works in the private sector, in this case the director of a pathology company, says ‘Patients don’t want to put their hands in their pocket … People understand the system and realise if they jump up and down to be bulk billed they will be bulk billed generally’.2

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Participants in the study from the public and not-for-profit sectors, on the other hand, tend to reveal less individualistic attitudes towards ethics and social justice, seeing healthcare as a collective good that should be available to all. In discussions with participants about who should take responsibility for healthcare services, it became apparent that such views are embedded in conceptions of the state—an important dimension of the field. Across the broad population, Australians are supportive of state spending on health and family welfare, and large surveys suggest this support is above the OECD average (Wilson et al. 2005: 103, 106). Although there is a class dimension to attitudes, support for state spending on health and family welfare, and endorsement for more government expenditure on health, has continued to increase; in 2007, 90 per cent of Australians agreed we should be spending more on healthcare (Wilson et al. 2012: 116–117). Moreover, Australians show strong support for the public provision of healthcare services, clearly preferring government delivery to that of private businesses, charities or families (Wilson et al. 2005: 116). Participants in the gatekeeper study from the public and not-­ for-­profit sectors show a similar propensity to look towards the state for leadership in healthcare services rather than the individual. Despite a common belief in state support, this group of participants holds varying conceptions of what the state is, and of their relationship to it. A number of participants display attitudes towards the state and their relationship to it that one would expect from those working in the public and not-for-profit sectors. Essentially, they perceive the state as an objective feature of the world, but, nevertheless, regard themselves—as gatekeepers—to be part of the state with some responsibility for its functioning, and this is tied to their strong sense of social justice. Bruce, for instance, a GP university educator, speaks of the disenfranchisement of people with disabilities, of the young and homeless, Aboriginal people, Torres Strait Islanders and refugees, and of his anger at what he sees as the government’s neglect and ‘obscene’ focus on private medicine. Padriac, a GP working in a public hospital, speaks of his anger at government plans to bring in a co-payment (plans which did not eventuate after strong public outcry), which would require individuals to contribute to the ­doctor’s fees at the point of service. His empathy with poor patients is evident. He says, ‘they’ll seek less care but when they do seek care they’ll be

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sicker and they’ll probably end up seeking care in places which are not terribly efficient like the emergency department’. The state in this conception is flawed and fallible, but that is because it is composed of institutions and individuals with differing perspectives, talents and agendas. Pierre, the manager of a not-for-profit organisation, spoke at length about his anger when the government cut funding to community organisations and made many staff redundant: ‘That’s people’s livelihood and mortgages, food on the table … People are out of a job. It’s not right’. Yet, like many of his fellow gatekeepers, he spoke about ‘the public’ and the existence of a ‘public service ethic’ within the state and the not-for-profit sector. He says this ethic shapes people’s practices. For instance, as a commissioner of services for the community, his organisation and others are keen to see not-for-profit providers flourish, and will only commission private providers who won’t charge a ‘gap payment’ (a fee in addition to the Medicare reimbursement). And finally, Austin, an economist and health policy expert, sees the different perspectives and sets of behaviour in the healthcare sector as an ‘understandable’ outcome of the design of the system. For Austin, Medicare has created a specific set of financial incentives, and the medical practitioners have: … established their business models to respond to the financial incentives in the country in which they’re situated. And so, they then defend politically the maintenance of the status quo and that makes it harder for public policy-makers to shift the financial incentives a way in which they ought to be shifted … [it would be] naïve to believe that people shouldn’t respond to the financial incentives that you’ve put in place.

These attitudes stand in some contrast to those of another group of public and not-for-profit sector actors, and was one of the more surprising findings of the study. For these gatekeepers, their role as gatekeepers did not necessitate being involved in the functioning of the state. Regardless of where they were located in the policy process—and thus in their capacity to take a leadership role in policy—they were more able to divorce themselves from state functions. Peter, for example, the director of a specialist unit in a public hospital, while keen to display a sense of social justice with regard to system-wide inequalities of access for patients,

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tells us it is not his role to make decisions about whether a service to which he refers patients is private or public, because there are policy mechanisms and processes in place such as Medicare, Healthcare cards (for low-income individuals), the Pharmaceutical Benefits Scheme and bulk billing. Peter also divorces himself from the responsibility of the functioning of the healthcare system. He says: Personally, I don’t get involved with it [whether a service is private or public]. Our services are free at the point of service delivery. But the charge for a patient—for example, seeing a cardiologist in their private rooms, that’s between them and the cardiologist. If they’ve got financial difficulties, the cardiologist will bulk bill them.

Alyssa, the CEO of a peak body in the not-for-profit sector, expresses similar views about who has the responsibility for ensuring equity. She says we shouldn’t be concerned about private medicine compromising equity, because when contracts are written with the private sector, a set of health outcomes are specified that have to be met: They’re either articulated in the contract or at least in the overarching rationale for commissioning that type of work. And essentially that’s around ensuring that a service is available and affordable and accessible to all Australians … [and] at the end of the day, they do actually share some common goals.

Concluding Thoughts This chapter has described a qualitative study of the attitudes and experiences of a group of gatekeepers within the Australian healthcare field. It has demonstrated the way neoliberalism has become a pervasive feature of the healthcare field, with the market rapidly becoming the accepted way of delivering services. The study has shown a continuation of the historical struggle over the best way to deliver care and a diversity of views about the trend towards market-oriented medicine. This has taken us well beyond the idea of gatekeepers as either anonymous, overly rational, neutral agents or actors responding solely to financial interests. It has

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offered, instead, a view of gatekeepers as key decision-makers, with their choices and decisions drawn from the habitus, and holding diverse conceptions of the healthcare field and their role within it, of social justice, the state and the market. This glimpse into the world of gatekeepers has identified an additional factor shaping the attitudes of doctors and other gatekeepers. Alongside early socialisation, specialisation and employment as either a clinician or administrator, the study has uncovered a relationship between attitudes and one’s location within the healthcare field. Thus ‘social space’ is where the tensions and struggles of the field— between the private, public or not-for-profit sectors—and its doxa impinge on and potentially either strengthen or modify the dispositions of habitus. Much of the evidence, then, points to a distinct boundary between public and private sector gatekeepers, with systematic differences in understandings and perceptions across the public/private divide. Gatekeepers in the public or not-for-profit sector appear less likely to embrace neoliberalism, the market and the values associated with this. These individuals contest the imposition of neoliberal values and practices, indicating support for Clarke’s (2004) insight that neoliberalism is a contradictory, contested and uneven political strategy. A more nuanced view appears among the gatekeepers when issues of responsibility for inequality are raised, with divisions emerging even among the public/not-­ for-­profit sector participants. Here we find some gatekeepers who see themselves as part of the state with some responsibility for its policies, while others, in comparable roles of authority and proximity to the policy process, distance themselves from the state. In this, the latter group show an interesting response to neoliberalism, with individuals regarding the very existence of the state as alleviating them of responsibility, and providing a freedom to act without regard for the inequalities of the healthcare system they work within. It is evident from this study that more investigation is needed into the growth of private healthcare and its implications. As private healthcare continues to gather in legitimacy and dominance across the healthcare field, it becomes imperative to understand how key decisions are made, where the decision-makers are located, how their locations within the field are shaping decisions and practices and how neoliberalism is resisted

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or embraced. It has been argued here that neoliberalism is a class project, that the growth of private medicine is of more benefit to the elites, particularly the financial elites, than it is to members of the working and middle classes. However, this study suggests neoliberalism is not a ‘whole of class’ project, for while gatekeepers may share some class features (such as secure employment and higher education attainment), they are a heterogeneous group with differential access to power within the healthcare system. There is consequently a need for a larger study which will include gatekeepers situated in, or more closely connected to, the field of finance and national development—an admittedly difficult group to access for social research. If achieved, it will allow further insights into the varying capacities of gatekeepers for influencing policy decisions. Such a critical, empirical examination of decision-making in healthcare is increasingly imperative in a global context where the strategies of neoliberalism threaten to replace the ethos of healthcare as a service to the community and the general public, with the alternative—market-driven medicine— as the only viable and possible form for the twenty-first century. Acknowledgements  I would like to acknowledge the participants of the gatekeeper study for their time and thoughtful contribution to this project; the Australian Research Council and the University of Sydney for funding the field work; and colleagues, including Karen Willis and Sophie Lewis, without whom the project would not have been either successful or enjoyable; and Jon Gabe of Royal Holloway, University of London, for his thoughtful comments on the manuscript. Note: Approval for the gatekeeper study was sought from a plethora of ethics committees at a variety of institutions. Primarily this was the Human Ethics Committee (HEC) at the University of Sydney, as well as the various authorities with responsibility for ethical conduct in the public hospital system in each state.

Notes 1. Australia has a federal system of government, meaning that it has a central, federal (or Commonwealth) government and six state governments. Powers and responsibilities are divided between them, and these are set

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out in the constitution. The states have the autonomy to make laws over matters not controlled by the Commonwealth. In Australia, unlike the USA, federal law overrides state law in the case of any contradictions. There are also eight territories, with the largest being the Northern Territory and the Australian Capital Territory. These do not have the full autonomy of the states, and their powers are not defined by the constitution but by Commonwealth law. The division of powers and responsibilities between the Commonwealth and state governments relevant to healthcare are complex (for an overview, see https://beta.health.gov.au/ about-us/the-australian-health-system). 2. Bulk billing is a payment option under the Medicare system of universal health insurance in Australia for medical services occurring outside hospitals, and when it is agreed to by doctors/practices, the patient does not have to pay fees at the point of service. Instead, the doctor/practice accepts the Medicare benefit (between 85 and 100 per cent of the Schedule fee) as full payment for the services rendered, and the doctor/practice recovers the Schedule fee directly from Medicare. Alternatively, doctors accept the Schedule fee from Medicare plus an additional charge from their patients. Not all doctors/practices offer bulk billed services, but incentives are offered (in certain eligible areas) by the government to bulk bill pensioners, healthcare card holders and those aged 16 and under, in an effort to increase access to services across the population and limit the possibility of bad debts.

References Bourdieu, P. (2014). On the State: Lectures at the College de France 1989–1992 (edited by Champage et al., translated by David Fernbach). Cambridge: Polity. Bourdieu, P. (2000). Pascalian Meditations. Stanford: Polity. Bourdieu, P. (1993). Sociology in Question (translated by R. Nice). London: Sage. Bourdieu, P. (1989). Social space and symbolic power. Sociological Theory, 7(1), pp. 14–25. Bourdieu, P. (1986). The production of belief: Contribution to an economy of symbolic goods. In: R.E.  Collins, J.  Curran, N.  Garnham, P.  Scannell, P.  Schlesinger and C.  Sparks (eds.) Media Culture and Society: A Critical Reader. London: Sage. Bourdieu, P. and Wacquant, L. (eds.) (1992). An Invitation to Reflexive Sociology. Cambridge: Polity Press.

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Clarke, J. (2004). Dissolving the public realm? The logics and limits of neo-­ liberalism. International Social Policy, 33(1), pp. 27–48. Collyer, F.M. (2018). Envisaging the healthcare sector as a field? Social Theory and Health, 16(2), pp. 111–126. Collyer, F.M., Harley, K. and Short, S.D. (2015). Money and markets in Australia’s healthcare system. In: G. Meagher and S. Goodwin (eds.) Markets, Rights and Power in Australian Social Policy. Sydney: Sydney University Press. pp. 257–291. Collyer, F.M. and White, K.N. (2011). The privatisation of medicare and the national health service, and the global marketisation of healthcare systems. Health Sociology Review, 20(3), pp. 238–244. Collyer, F.M., Willis, K. and Lewis, S. (2017). Gatekeepers in the healthcare sector: knowledge and Bourdieu’s concept of field. Social Science and Medicine, 186, pp. 96–103. Correia, T. (2013). The interplay between managerialism and medical professionalism in hospital organisations from the doctors’ perspective. Health Sociology Review, 22(3), pp. 255–267. Dent, M. (1991). Autonomy and the medical profession. In: C.  Smith, D.  Knights and H.  Willmott (eds.) White-Collar Work. Houndmills: Macmillan. Doggett, J. and McAuley, I. (2013). A new approach to health funding. D!ssent, 42(Spring 2013). Available at: http://www.ianmcauley.com/academic/dissent/healthfund2013.pdf [Accessed 28 Feb. 2015]. Ebbinghaus, B. and Naumann, E. (2018). The popularity of pension and unemployment policies revisited. In: B.  Ebbinghaus and E.  Naumann (eds.) Welfare State Reforms Seen From Below: Comparing Public Attitudes and Organized Interests in Britain and Germany. Palgrave Macmillan. pp. 155–186. Freidson, E. (1985). The reorganisation of the medical profession. Medical Care Review, 42, pp. 11–35. Heaton, T.B. (1987). Objective status and class consciousness. Social Science Quarterly, 68(3), pp. 611–620. Humphrey, C. and Russell, J. (2004). Motivation and values of hospital consultants in south-east England who work in the national health service and do private practice. Social Science and Medicine, 59, pp. 1241–1250. Humphrys, E. (2018). How Labour Built Neoliberalism. Brill. Jacobs, K. (1995). Budgets: a medium of organizational transformation. Management Accounting Research, 6, pp. 59–76.

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Kelley, J. and Sikora, J. (2002). Australian public opinion on privatisation, 1986–2002. Growth, 50(December 2002), pp. 54–59. Lewis, S., Willis, K. and Collyer, F.M. (2018). Navigating and making choices about healthcare: the role of place. Health and Place, 52, pp. 215–220. Martinussen, P.E. and Magnussen, J. (2011). Resisting market-inspired reform in healthcare: the role of professional subcultures in medicine. Social Science and Medicine, 73, pp. 193–200. Meagher, G. and Goodwin, S. (eds.) (2015). Markets, Rights and Power in Australian Social Policy. Sydney: Sydney University Press. Meagher, G. and Wilson, S. (2015). The politics of market encroachment. In: G. Meagher and S. Goodwin (eds.) Markets, Rights and Power in Australian Social Policy. Sydney: Sydney University Press. pp. 29–96. Mills, C.W. (1957). The Power Elite. New York: Oxford University Press. Neumann, E. (2018). Increasing conflict in times of retrenchment? attitudes towards healthcare provision in Europe between 1996 and 2002. In: B.  Ebbinghaus and E.  Naumann (eds.) Welfare State Reforms Seen From Below. Palgrave Macmillan. pp. 245–271. Productivity Commission. (2005). Australia’s Health Workforce. Research Report, Canberra. Scott, W.R. (1982). Managing professional work. Health Services Research, 17(Fall), pp. 213–240. Tousijn, W. (2006). Beyond decline: consumerism, managerialism and the need for a new medical professionalism. Health Sociology Review, 15(5), pp. 469–480. Waitzkin, H., Yager, J. and Santos, R. (2012). Advancing the business creed? The framing of decisions about public sector managed care. Sociology of Health and Illness, 34(1), pp. 31–48. Wendt, C. and Naumann, E. (2018). Demand for healthcare reform by public opinion and medical professionals. In: B.  Ebbinghaus and E.  Naumann (eds.) Welfare State Reforms Seen From Below. Palgrave Macmillan. pp. 129–152. Wilkes, M., Coulter, I. and Hurwitz, E. (1998). Medical, law and business students: perceptions of the changing health care system. Social Science and Medicine, 47(8), pp. 1043–1049. Willis, K., Collyer, F.M., Lewis, S., Gabe, J., Flaherty, I. and Calnan, M. (2016). Knowledge matters: producing and using knowledge to navigate healthcare systems. Health Sociology Review, 25(2), pp. 202–216.

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Wilson, S., Meagher, G. and Breusch, T. (2005). Where to for the welfare state? In: S.  Wilson (ed.) Australian Social Attitudes: The First Report. Sydney: UNSW Press. pp. 101–121. Wilson, S., Meagher, G. and Hermes, K. (2012). A new role for government? Trends in social policy preferences since the mid-1980s,. In: J. Pietsch and H. Aarons (eds.) Australia: Identity, Fear, and Governance in the 21st Century. Canberra: Australian National University, ePress. pp. 107–131.

Chapter Seven: Creeping Privatisation? Examining Procurement Choices in the ‘New’ NHS in England Vid Calovski and Michael Calnan

Introduction The National Health Service (NHS) is consistently amongst the most popular institutions in the UK (King’s Fund 2017a) and has continued to have strong public support for its tax-based funding and model. While the NHS appears to be resilient to radical changes, it is vulnerable because it is tax funded and subject to continued financial crises which requires central government control, regulation and monitoring (Klein 2018). Hence, governments have felt the need to intervene but have been hesitant to introduce policies which appear to radically reform the NHS, particularly those that suggest privatisation (Calnan 2000; Shaw 2003). Despite this political wariness, numerous reforms have taken place (Tuohy 2018), the latest of which occurred in 2012. These most recent changes proposed a new commissioning framework, which placed General Practitioners (GPs) in new Clinical Commissioning Groups V. Calovski (*) • M. Calnan School of Social Policy, Sociology and Social Research, University of Kent, Canterbury, Kent, UK e-mail: [email protected]; [email protected] © The Author(s) 2020 F. Collyer, K. Willis (eds.), Navigating Private and Public Healthcare, https://doi.org/10.1007/978-981-32-9208-6_7

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(CCGs). In addition to the creation of these groups, the Health and Social Care Act (UK Legislation 2012) included clauses which suggested an enhanced role for the private sector in the delivery of healthcare, increasing public concern about the issue of privatisation (Timmins 2012). Debate about the effect of introducing the Health and Social Care Act (2012) emphasised either continuity or change (Ham et al. 2012), and the focus of debate was the impact of the changes. For some, the Act represented a threat to the fundamental premise of the health service of universal care free at the point of access, by encouraging the increased use of private providers (privatisation) (Pollock and Price 2011a). Opponents viewed it as ‘privatisation by the back door’ (Peedell 2011), with debate about other possible scenarios in which the NHS might become further marketised (Dixon and Ham 2010). On the other hand, those who argued that the reforms were simply an extension of previous Labour neoliberal health policy suggested that it was just ‘a logical, sensible, extension of [changes] put in place by Tony Blair’ (Le Grand quoted in Timmins 2012: 84). These proponents claimed the Act simply expanded the neoliberal principles associated with marketisation laid out by Labour governments, and cited policies such as practice-based commissioning, Total Purchasing, the role of patient choice and the use of private providers to deliver care (Miller et  al. 2016). The previous Labour administration had put an emphasis on developing a partnership between the NHS and the private sector (Shaw 2003), where the mantra was ‘what works counts’, and offered a blurring of boundaries between the public and private sectors rather than distinct divisions between the public and private sectors as reflected in ‘old’ Labour discourse (Mohan 2009). This stands in marked contrast to the Conservatives’ approach in the 1980s, which aimed to expand the private sector outside the NHS (Calnan et al. 1993). This chapter examines the potential effects of the Health and Social Care Act (2012) on the extent and nature of privatisation and marketisation in the NHS.  Privatisation is understood to involve the ‘transfer of assets’ (Saltman 2003) from the public to the private, whereas marketisation occurs when there is the insertion of market principles within public services, but does not involve the private sector (see also Chapters Three, Five, and Six of this book). While not always the case, it is customary for privatisation to be preceded by a period of marketisation. Focusing on the commissioning pro-

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cess in this newly created landscape, the chapter draws on an ethnography of decision-making by the newly created CCGs to explore how the new powers gained by the CCGs might have influenced decisions about the selection of providers. These new CCGs are primarily composed of general practitioners who function as the key decision-makers in these new bodies. They are responsible for spending around 60 per cent of the NHS budget (The King’s Fund 2017a). Under the new commissioning arrangements, in theory, the new commissioning groups were provided with powerful new commissioning tools, allowing them to utilise the market and decommission or fine providers perceived as under-performing. However, the use of these tools may manifest very differently in practice, and this ethnographic study focused on these possible differences—primarily how commissioners use the tools at their disposal on a daily basis and how they select providers. The chapter begins with a brief narrative of the history of commissioning in the NHS, illustrating the extent to which recent reform policies reflect continuity and incremental, rather than radical, change.

 he Socio-Historical Context: NHS T Commissioning 1991–2010 The NHS was established in 1948 as a universal healthcare system free at the point of access. The access point or first port of call for patients was primarily a general practitioner, and patients were referred to hospital-­ based specialist services if and when necessary. Historically, the NHS service supply and organisation was decided upon by local health authorities for their patient populations. Commissioning as a distinct process was introduced in 1991 when the Conservative government (1987–1992) introduced the NHS and Community Care Act, which split the NHS into purchasers and providers of healthcare. In this context, commissioning was the process where the purchasers selected services from mainly hospital providers (The King’s Fund 2015); the purpose being for the NHS to start behaving more like a market. Commissioning was carried out either by GPs or by area health authorities responsible for strategy and capital expenditures. From 1991 to 1997, GPs were organised into GP Fundholding (GPFH) groups and given budgets to purchase non-­

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urgent elective and community care for their local populations (The King’s Fund 2015). The aim of the process was to incentivise GPs to manage costs and increase competition in their local health economies. With the election of ‘New Labour’ in 1997, there were further reforms to the commissioning process. The GPFH schemes were abolished but the purchaser/provider split remained. In their place was a system of Primary Care Trusts (PCTs) which were developed and operational by 2004 (Turner and Powell 2016). These PCTs had a membership of all GPs, which led to the argument that it involved all GPs in some form of commissioning (Klein 2013; Lewis et al. 2003). They would directly contract NHS providers to deliver care for their geographical areas. The PCTs were responsible for commissioning primary, secondary and community services for their local populations. This meant they were responsible for delivering 80 per cent of the NHS budget (Turner and Powell 2016). PCTs also had the ability to commission private and third sector providers and were even encouraged to do so (Klein 2007). Alongside the PCTs, the Department of Health retained control and strategic direction of the NHS through the Strategic Health Authorities. This ensured oversight of the NHS from the Department of Health. The New Labour government encouraged the use of private providers within the NHS, and during the New Labour years (Mohan 2009) private facilities such as Independent Sector Treatment Centres were established to carry out surgery on behalf of the NHS (Naylor 2009)—primarily to reduce waiting lists. This encouraged the development of a mixed economy of care, as these private providers catered exclusively to NHS patients and were funded with public money. Thus, these previous policy changes, as they relate to commissioning, laid the foundation for new legislation in 2012.

 he Health and Social Care Act (2012): New T Clinical Commissioning Decision-Makers Introduced by the incoming Conservative-Liberal Democrat Coalition government, the purpose of the Health and Social Care Act (2012) was to develop primary care-led commissioning. The key reform involved the

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creation of GP Consortia with the responsibility for the commissioning of the major part of the NHS budget (Timmins 2012). These new Consortia would replace the PCTs. In the new Consortia, all GPs would be members, but only some would participate in the executive decision-­ making groups. The initial proposals suggested they would be responsible for the commissioning of ‘£60–£80 billion of the £100 billion NHS budget’ (Timmins 2012: 65). The Consortia would retain geographical boundaries similar to that of the PCTs. However, there would be several key differences. The GPs would no longer be responsible to a Chief Executive but would have their own elected Chairperson (a clinician), alongside new public accountability structures and regulatory bodies (Davies 2013). The Consortia were to be reactive to the demands of their populations and increase the ability of clinicians to alter budgets according to needs in a more effective fashion, thus increasing the power of GPs in the commissioning process, whilst marginalising managers (Davies 2013). The Health and Social Care Act (2012) also replaced the regulatory framework, with oversight of the new CCGs handed over to the newly created NHS England (formerly the NHS Commissioning Board) (The King’s Fund 2013; Timmins 2018). The reforms included clauses which mandated the regulatory framework to ‘promote competition’. The Act enabled commissioners to use procurement, the process with which the commissioners can turn to the market and invite companies, both public and private, to apply to bid for contracts. This policy created opposition to the Act, as some groups feared it allowed for the increased growth of the use of private providers and thereby potentially opened the service to privatisation (Pollock et al. 2012). The considerable opposition to the Act manifested itself through public protest and resistance from professional bodies led to the dilution of some reforms—for example, that the GP Consortia include some allied health professionals, rather than solely being comprised of GPs. Initially, the Act proposed that ‘Any Willing Provider’ would be able to compete for NHS services, which suggested that private providers would provide more NHS care than before. This was replaced with a clause preventing competition on the basis of price and limited the expansion of the private sector (The King’s Fund 2013). The regulatory bodies still had a duty to ‘enforce competition’, introducing competition law into the

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NHS meaning that regulatory bodies could enforce rules to ensure fair competition and consideration of private providers (Davies 2013) leading to concerns that private providers would be utilised in greater quantity than previously in the NHS (Krachler and Greer 2015). In summary, the Act put an emphasis on primary care-led commissioning, in the form of GP-led CCGs as the method by which over two-­ thirds of the NHS budget is delivered. Being responsible for the dispensation of the largest part of the NHS budget, CCGs could decide to commission a large number of private providers. The CCGs were to operate in a framework that included regulators with additional powers in order to promote competition, while simultaneously being obliged to assist CCGs in integrating public, private and third sector providers in one system.

 eveloping a Conceptual Framework: D Exploring New CCG Decision-Making Structures The legislation formally gave commissioners greater levels of autonomy in the selection of providers than their colleagues in previous incarnations of primary care-led commissioning (Miller et  al. 2016). However, this autonomy may be limited by various internal and external pressures, bringing into question their ability to select the most suitable provider. Figure One offers a conceptual framework to explain what might shape the decision-making process. It identifies the external and internal pressures (Checkland et al. 2018) that may have resulted from the new organisational structure of the NHS as stipulated by the Act. The external pressures (also called top-down pressures) relate to the regulatory framework created by the Act, where new bodies were created and some previously existing regulators had expanded responsibilities. For example, the newly formed body, NHS England, was tasked with ensuring that targets on competition and efficiency are met. This was to be accomplished through its control over CCG budgets and its power to place any under-­ performing CCG under special financial measures (NHS England 2016),

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Figure One  Internal/external conceptual framework. Source: Calovski (2018)

thus placing pressure on CCGs to generate savings (which could mean making greater use of public providers). The internal pressures (also called new service pressures) relate to the structure of the CCG and how commissioners operate within them. This includes the preferences of the commissioners, as some may look more favourably on private providers than others. It also identifies how decisions are reached, as there are different decision-making structures in the CCGs, with some placing more emphasis on group decision-making, while others focus on decision-­ making by key actors (McDermott et al. 2017). The framework draws on theories of decision-making in organisations which highlight the influence of different system, organisational and professional interests in the shaping of the implementation of health policy (Pettigrew et al. 1992). Adapted from Pettigrew et al. (1992), the framework informed our ethnographic study exploring possible internal and external contexts, and whether or not top-down or local internal ­influences can assist in explaining the success or failure of structural change (Williams et al. 2018).

The Ethnography Focusing on two different sites, the aim of our ethnographic study was to understand how, in their new role, commissioners reach decisions about the providers they select for the commissioning of services and what

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Table One  Decision-makers interviewed and meetings observed Site one Interviews

12 interviews (Chair, Vice-Chair, Deputy Managing Director, Lead Service Commissioners, GP Commissioners, Assistant Directors of Commissioning) Observations 150 hours (Clinical Board, Governing Body and Finance and Performance Committee)

Site two 8 interviews (Chair, Vice-­Chair, Deputy Managing Director, GP Commissioners and managers) 65 hours (Governing Body, Finance subcommittee and Transformation and Redesign group)

effect internal/external pressures may have on these decisions. The two sites were CCGs with access to a variety of providers and services with some history of use of private provision. The research data comprised approximately 215  hours of observations and 20 interviews with key decision-makers and providers across both CCGs (see Table One). The commissioning of specific services was tracked at both CCGs. Under the new commissioning arrangements, the commissioners at the two CCGs had the ability to choose a public, private or third sector provider to deliver that service. At site one, the first service to be examined was elective procedures where there is a mixture of both public and private providers (NHS Digital 2012), and at site two, physiotherapy services were examined. Both elective procedures and physiotherapy services are commissioned by CCGs, but there has been an increasing involvement of the private sector (Iacobucci 2013). Mental health services were examined at both sites. In this case, there is a mixture of providers, although there may be a slightly greater number of non-state/third sector providers of mental health services than private providers (Peck and Hills 2000). During the data collection phase, there was a particular pressure on commissioners at both sites to secure additional mental health services. The researchers utilised an inductive thematic data analysis (Guest et al. 2013) aided by Nvivo. The data were used to understand how commissioning decisions were reached and whether or not commissioners preferred to use public/private/third sector providers. Once key themes were identified, they were explored in more depth at the sites through further observation and interviews. This process was repeated with the

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data from site two. The differences and similarities between these two sites were then contrasted before addressing the over-arching questions of the study.

 ecision-Making Within CCGs: D What Shapes It? Both CCGs were located in large urban areas covering around 300,000 people each. Both sets of commissioners have access to private providers which tend to be concentrated in such urban areas (King’s Fund 2017a), so commissioners were able to choose providers from what can be characterised as an active ‘market-place’, that is, one in which they have the ability to choose various types of providers for the same service.

The Salience of Financial Pressures One of the key challenges facing commissioners since 2012 is the need to generate additional savings that were to be enforced by the sector regulators, such as NHS Improvement and NHS England (Appleby et al. 2014; Health and Social Care Act 2012). This task is made more complex by the financial pressures on the provider side (i.e., the hospitals) of the NHS, which reported a deficit of £1.85  billion (King’s Fund 2017b). Thus, commissioners have to seek to continue to improve services, whilst under pressure to spend less. The two sites selected for the research reflected these financial pressures. Site one had been able to generate a recurrent surplus and were able to explore how to best select providers, focusing on the clinical needs of their populations in the selection of providers. These commissioners were not forced to select any type of provider. They had the ability to choose how to improve their services and this included developing existing services. At site two, the situation was considerably different. The commissioners faced an annual deficit and this meant that the focus of commissioners was on generating savings to prevent sanction by NHS England.

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These financial pressures had implications for the internal processes of the CCGs. Commissioners value their autonomy (Iacobucci 2016) and believe they are best placed to deliver providers for their local populations (Checkland et  al. 2018). The reasons for commissioners becoming involved in CCGs are numerous, but the predominant one appears to be a desire and belief that they can effect positive change. There is evidence that in previous primary care-led arrangements, commissioners disregarded external pressures and pursued their own commissioning arrangements which favoured local providers (Smith et al. 2004). Often this took the form of working alongside local providers (Flynn et  al. 1997). Commissioners sought to utilise arrangements which they had prior experience of, rather than seeking new providers. These sort of commissioning priorities were enabled by the financial surplus at site one. Commissioners could focus on developing local providers, which were mostly NHS Trusts. They were able to select to utilise procurement in some instances but chose to do so only when existing providers may have been unable to provide a service. They sought to circumvent centrally imposed rules and focus on these existing relationships (Hunter et al. 2015). At site two, the pressures were much more severe and this affected the commissioning priorities of the CCG, which resulted in a greater use of private providers. The financial pressures that the CCGs faced also affected how they approached commissioning. In addition to procurement, tools available to commissioners when exercising choice over the selection of providers were transformation, and decommissioning. Transformation involves the purchasing of additional services from providers with whom the CCG has some existing form of contractual arrangement. There is an obligation that commissioners should do this for contracts in excess of £100,000 (NHS Commissioning Board 2012). Commissioners could also decommission providers if they were deemed to be failing.

The Nature of the Provider Market-Place The most significant issue faced by commissioners with regard to the provider market-place is the behaviour of large NHS hospital Trusts.

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These Trusts are the major providers in the English NHS, representing most hospitals and, by extension, secondary care within the system. The majority of patients in the NHS are treated by such institutions. They dominate this market-place by virtue of their sheer size (i.e., budget, number of patients). There is some competition within the system, where these Trusts compete with smaller private and third sector providers. CCGs struggle with the behaviour of the Trusts as, in their view, Trusts are seeking to maximise the amount of money they can get out of the system: I was leading on the Urgent Care Centre [UCC] … [Local Hospital Trust] had it, they actually came to us and said, we don’t want to do this anymore, as they were having lots of issues with subcontractors … and they thought they weren’t making money on it, so we looked at it, and realised we were paying a lot of money for it compared to other UCCs … [Local Hospital Trust] realised they were making money and wanted to change their mind, but it was too late (Commissioner 3, Site One, Interview).

Commissioners perceived that the Trusts were focusing on their own financial priorities, even if that meant that the CCG would be put under increasing financial strain. This strain was exacerbated by the use of Payment by Results (PbR) contracts, which meant commissioners had to pay hospitals for the number of patients they saw, even if this outstripped available resources as evidenced in a Transformation and Redesign group (TRG) meeting: The discussion in the meeting is about how commissioners can adjust existing resources to address the unexpected increased cost of the PbR contracts with the local Trusts. Had to deploy reserves to meet control totals for the month (Observation, Site Two, March 2017, Field notes).

The commissioners are faced with the challenge of finding a balance between the best possible care for their populations and working alongside existing providers. With the provision of beds considered to be a key descriptor of the overall performance of the NHS (Smith et al. 2014), the commissioners have to dedicate the majority of their budgets to the NHS

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Trusts, which are the only provider of beds. They provide the majority of the care to NHS patients; however, as a result of this, when there are contractions in the NHS budget, they tend to be affected as they are reliant on public funds. Under the new regime, they receive their money from the CCGs. Trusts therefore dominate the landscape, providing the majority of care, but are also very vulnerable to changes to funding. This dominance of the Trusts, due to their size and scope of services, makes them vulnerable to financial pressures which characterise the current environment (Smith et al. 2014). In response to these financial pressures, the Trusts are exploring various solutions and methods. Commissioners, on the other hand, have no alternative providers that they can utilise to replace the Trusts. So, while competition is encouraged by the new reforms, there is a lack of provider diversity (Allen et  al. 2012). Commissioners are also unable to affect the cost of their contracts as the mechanism through which changes are conducted favours the provider (Allen and Petsoulas 2016). Commissioners therefore have limited options that they can utilise to relieve the pressures that they face when it comes to the NHS Trusts. NHS Trusts remain key partners, but there is a general perception amongst commissioners that they do not represent good value for money. These financial pressures are best illustrated by the situation at site two, where the commissioners were facing severe resource constraints. Over the course of the 12-month ethnography, the CCG had focused on attempting to eradicate a deficit in excess of 6 per cent of its annual budget. Commissioners entered voluntary ‘turnaround’, in which they agreed on a plan to reduce the deficit with NHS England and thus managed to remove the threat of sanction. The CCG Chair was elected on a platform of bringing the finances into order: Yes, we had to change direction because we were … in a financial hole, and the only way of getting out of that financial hole was to … bring the clinicians in the practices on board, and say look, you are the solution to this, if we go on doing the same, we will be a problem, so how can we do it? I think the previous Chair, probably [um] hadn’t got the confidence that … of their peers that they were going to do that (Chair, Site Two, Interview).

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The Use of the Market to Control Financial Pressure The commissioners at site two utilised procurement in order to relieve financial pressures. They sought to move care from hospital settings to community providers. As the only mechanism to introduce new providers is procurement, commissioners at site two used this process more frequently than those at site one. For example, the CCG awarded physiotherapy services to a private provider. This private provider undertook the work at a lower price than the previous public provider, alleviating some of the financial pressure faced by the CCG. Not only did the private provider assist in reducing the financial burden on the CCG, they also provided a more effective service, further encouraging the use of private provision. This perception of the provider was shared by the commissioners that were found at site two: Our best provider of the things that we have commissioned is a private organisation, [Name of private provider], physios, is the best provider, they do everything, everyone is happy with them, because they run things with energy, when there is something that is a threat to my practice, we need to be better and provide a better service, provide better care, because of performance reviews and we need to get big, and that’s it, and I think like that, and I think that’s what’s missing, it’s a market out there but you can use it to your advantage but you have to be smart, so the hospitals don’t think like that (Commissioner 3, Site Two, Interview).

In securing the contract with the CCG, this private provider then adapted their own practices to prove more attractive to commissioners. After becoming a provider in the local healthcare economy, they were then able to provide additional services if the commissioners wished them to. In this way, private providers can become dominant in certain elements of care in some areas. The commissioners at site one were able to utilise local providers and focus on the medical aspects of care due to their positive financial situation. Here, the CCG was able to commission new services and demonstrated it could and would utilise the commissioning tools at its disposal. It managed to achieve this through generating an annual surplus, which

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was reinvested into expanding existing services or writing procurements for new contracts. Commissioners at site one emphasised using their surplus to address areas of care which they felt they were under-performing in, most notably Child and Adolescent Mental Health Services (CAMHS). After identifying the need, commissioners discussed their options at board-level meetings and the simplest method of improving provision was to provide additional funds to existing providers: so if you look at CAMHS, so [local Mental Health Trust A] do most of the CAMHS service already, if you want to put another £100k into CAMHS, the most sensible place is to put into that service, or into that existing provider (Commissioner Five, Site One, Interview).

The GP Mental Health lead confirmed an availability of resources and claimed that the contracts could be bought from the existing providers: it just seems that you know what you want, and if it’s just there, why not just get it? If it’s more of what’s already there and you’re happy with the service, why do you need to procure? In this particular … well because the money involved at each different level, for particularly CAMHS, there were lots of them, but they were quite small that it wouldn’t have justified a procurement, so we didn’t get any pressure (GP Mental Health Lead Commissioner, Site One, Interview).

In addition, working alongside the local providers would also help the commissioners: Arguments were made that the new Mental Health Provision being commissioned would help generate savings, and relieve pressure on the local Trust which has a deficit (Clinical Board, Observation, April 2015, Site One, Field Notes).

Commissioners exhibited a preference for utilising existing local arrangements rather than turning to procurement. The process is assessed ‘blindly’, with commissioners rating the applications without knowing which provider submitted which bid. Generally, applications are assessed on the basis of quality but the process includes financial considerations,

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with some providers promising to provide the service at less than the advertised value. Commissioners did not appear to be ideologically opposed to the process, but in some cases were concerned at the length of the process and the amount of staff time required to rate providers: Procurement is lengthy, and it takes another 18 months once you have a service in to get service implementation up and running to what your vision and your dream is, so it’s not easy (Deputy Managing Director, Site One, Interview).

Therefore, the financial situation did affect how commissioners acted. Those who were facing more severe financial situations were more likely to utilise procurement to target private providers in a bid to alleviate the difficult financial situations they faced.

 ontextual Differences: Implications C for Marketisation and Privatisation The adverse financial situation at site two resulted in increased use of decommissioning. The commissioners at site two directly decommissioned and changed services due to the need to generate savings, notably decommissioning a podiatry clinic. The savings generated from the decommissioning of the service were modest—£75,000 annually (TRG Observation, Site Two, February 2017, Field Notes). The challenge in meeting their financial targets was a key factor in the strategies adopted: We are coming to that time when it is really difficult, because we are in a deficit position, fortunately not a recurrent deficit position, we will meet our control total for the year, we will still meet some of our [savings] expectations, and Friday before last, in this very room, we managed to persuade NHSE that we were still likely to be better at doing this than any likely alternative that is available to them, so I think we are in as good a place as can be, I think (Commissioner—Head of Finance, Site Two, Interview).

In persuading the NHS England that they could meet savings expectations, commissioners at site two entered voluntary turnaround, a process

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where they agree to reduce their expenditure with the sector regulator. They agreed to change and potentially eliminate contracts in order to reach financial targets. As a result, the level of marketisation and privatisation increased as commissioners turned to private providers to generate the necessary savings. With commissioners increasingly using procurement, coupled with their negative perception of Trusts and the financial pressures (at site two), there has been a growing acceptance of the presence of private providers in the market-place of NHS providers. The success of the private physiotherapy provider at site two left a positive impression on some commissioners. This could signal a deeper cultural shift in the NHS—that the private sector may have a key role in the delivery of some services in future. The private providers seem to have found a niche in the market in which they are comfortable and are proving to be successful in the delivery of services. The contracting arrangements mean that the commissioners have little ability to limit the demand and activity levels of the Trusts. The Trusts are large providers which usually work with several CCGs and thus, one CCG cannot greatly affect the working of a single Trust. The Trusts also compete with other providers in the market-place, which further disrupts the work of the commissioners, as the Trusts can win contracts that commissioners have previously decommissioned from them in order to attempt to find a cheaper alternative provider via procurement. However, the decommissioning of Trust-provided services remains a rare event, primarily due to a view shared by commissioners that they have duty towards the Trusts, and the fact that the provider market is still underdeveloped and incapable of meeting the demands of providing service for a large hospital.

 iscussion: A Changing Private/Public Balance D in the NHS? The ethnography provided evidence that the new commissioning arrangements have led to an increase in privatisation, although in a limited sphere in the context the NHS as a whole. It also confirms a growing use

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of market mechanisms (e.g., procurements) but a lower level of involvement of the regulatory bodies than was initially expected. It showed that despite the wide powers commissioners are given by the Act, in reality they have very limited choice when commissioning. Depending primarily on the financial circumstances, commissioners are more likely to opt for commissioning tools which result in a private provider being selected when faced with budget deficits (external pressure) as opposed to a situation in which they possess a surplus, which allows them to prioritise quality of care (internal/local demand). The latter is confirmed by the differences in the findings at the two CCGs. The evidence suggests that as a result of the interplay between the external and internal pressures, the commissioner’s autonomy in decision-­ making is limited to the ‘periphery’ of the commissioning process. Commissioners tend to exercise choice when they use procurement or when they choose to work with existing providers. Often the choice of the method is the major determinant of what type of provider is awarded the contract (procurement is the only entrance to the NHS market for a private provider). With regard to privatisation, commissioners are faced with a limited choice of private providers as, on the whole, they do not have the capacity, either financially or in expertise, to provide complex care. There is a lack of a developed private market, with many of the ­private providers in the UK focusing on areas of health where they can generate profit quickly (such as physiotherapy). While historically this has been the case in the UK, it is suggested that it may change in the future (Krachler and Greer 2015).

Explanatory Power of the Conceptual Framework The internal/external framework has proved to have some explanatory power for understanding how commissioners reach decisions. Evidence from this research suggests that a complex network of different elements influences the decisions made by commissioners, particularly their interactions with local hospital trusts and the sector regulators. The framework does not do an adequate job of explaining how and why certain actors may act within the new framework. At both sites, many of the GPs

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had considerable prior commissioning experience and adapting to new commissioning arrangements took less time than was anticipated (most of the commissioners previously worked for PCTs or other commissioning bodies). Hence there was a reservoir of commissioning experience which the CCGs drew upon. These clinicians, in their hybrid roles (Checkland et al. 2009), enhanced their managerial autonomy, discretion and confidence in their decision-making in this setting (Harrison and Ahmad 2000). Thus, given this experience, clinicians were particularly insistent on their independent role and predisposed to maintaining existing relationships to ensure the continuing provision of services. They believed that they are best placed to make the decisions necessary for their population, which helps to explain their willingness to enter agreements such as ‘voluntary turnaround’. While these clinicians do have considerable freedom, this remains very constricted due to the financial situation, but they are able to manage this to some degree. The limited resources, however, have had a particularly constraining impact—which is reflected in the way NHS England involved itself in the affairs of the CCGs. This course of action suggested that NHS England assumed a passive role in regard to most issues, apart from those deemed critical, and is nearly exclusively concerned with financial matters and management, to the detriment of clinical care and best outcomes for patients. The regulator only became involved when it was forced too, providing further evidence of a lack of systematic, central leadership in the NHS (Ham et al. 2015). In summary, the balance between the public and private sectors has changed in the NHS, but to a limited extent and not to the extent that many of the critics of the Act feared. This change occurred through commissioners utilising their tools to expand the range of providers they use. However, the private sector has not supplanted or become a viable alternative to the existing public providers. Privatisation, when it has occurred, has appeared only within the scope of certain services. The most effective characterisation of this process would be ‘passive privatisation’, in which services which have been allocated to the private sector are those in which the treatment of patients is possible outside hospital settings. Commissioners do not appear to have been led or driven by any clear ideological agendas, but have rather used procurement when it assisted them in generating savings, whilst still attempting to support local pro-

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viders. Therefore, it can be concluded that the new regulatory framework has helped to move some smaller contracts from the public to the private sector, but only within certain services.

F uture Implications of the Health and Social Care Act (2012) There has been a continued growth of marketisation in the NHS (Ham et al. 2015). Commissioners feel that the use of procurement is a key tool that can help them achieve their aims. Procurement has become an accepted ‘norm’ within the CCGs, and commissioners have not been ideologically opposed to the introduction of these mechanisms, or even the appointment of private providers, but are more concerned with the length of the process and other issues (i.e., potential legal challenges). Indeed, if the private sector was developed enough to function as a true alternative to the large NHS Trusts, there would likely have been some movement on behalf of commissioners, exercising their autonomy to shift away from existing arrangements, in order to meet their financial goals. The majority of procurements are awarded to public providers, meaning there is little privatisation but an ever-increasing use of market principles, which represents a significant level of marketisation of the system. The Act has also had the effect of further marketisation of the system by the opening of the internal market to outside competition. The role of the private sector was entrenched on the ‘periphery’ of the NHS but, more significantly, has allowed private sector actors to present themselves as direct competitors to public NHS Trusts in certain fields. The private sector could move in the direction of extending its activity to services where they have not traditionally been involved. For example, Virgin Care has purchased 21 primary care services in the UK (Virgin Care 2017). It is possible also, with the recent slowdown in the growth in funding of the NHS (the consequences of which were exemplified in the site two CCG in this study), might mean that a ‘broke’ NHS could encourage further ‘creeping’ privatisation (Klein 2013).

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Describing GP Fundholding, Le Grand stated ‘the constraints were too strong and the incentives too weak’ (Le Grand 2002). This seems to be an accurate description of the current state of the NHS after the Health and Social Care Act (2012). Whilst commissioners have the powers to change the service radically, they are in fact restricted in doing so by the dynamics of the new regulatory framework. In practice, commissioners do not seem to have an incentive to change the status quo, in seeking to ensure the continued provision of services in an increasingly complex and uncertain environment. However, with regard to the global private healthcare market, the UK remains a predominantly public system. There have been little wholesale shifts and compared to many other health systems, hospitals and most secondary care services remain publicly owned and funded bodies and there is a continued absence of private provision in primary care (Mossialos et al. 2015). This is slowly starting to change with a greater emphasis on using private providers in order to deal with increasing financial pressures on the health system, suggesting the high public control of both funding and provision which characterises the English health service may be shifting provision into greater pluralism (Hunter 2016). The neoliberal austerity policies introduced over the last decade, significantly reducing public investment in the NHS and other welfare services, appears to have led to a need to use the market and increase in the use of private providers perhaps indicating either a form of passive or ‘creeping privatisation’.

References Allen, P., Turner, S., Bartlett, W., Perotin, V., Matchaya, G. and Zamora, B. (2012). Provider diversity in the English NHS: a study of recent developments in four local health economies. Journal of Health Services Research and Policy, 17(1_suppl), pp. 23–30. Allen, P. and Petsoulas, C. (2016). Pricing in the English NHS quasi market: a national study of the allocation of financial risk through contracts. Public Money and Management, 36(5), pp. 341–348. Appleby, J., Galea, A. and Murray, R. (2014). The NHS Productivity Challenge. Experience from the Front Line. London: The King’s Fund.

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Calnan, M. (2000). The NHS and private health care. Health Matrix, 10(1), pp. 3–11. Calnan, M., Cant, S. and Gabe, J. (1993). Going Private: Why People Pay for Private Health Care. Open University Press. Calovski, V. (2018). The New NHS in England: Exploring the Implications of Decision Making by Clinical Commissioning Groups and Their Effect on the Selection of Private Providers. Doctoral Dissertation, University of Kent. Checkland, K, Harrison, S. and Coleman, A. (2009) Structural interests in health care: evidence from the contemporary national health service. Journal of Social Policy, 38(4), pp. 607–625. Checkland, K., Dam, R., Hammond, J.O.N., Coleman, A., Segar, J., Mays, N. and Allen, P. (2018). Being autonomous and having space in which to act: commissioning in the ‘New NHS’ in England. Journal of Social Policy, 47(2), pp. 377–395. Davies, A.C. (2013). This time, it’s for real: the Health and Social Care Act 2012. The Modern Law Review, 76(3), pp. 564–588. Dixon, A. and Ham, C. (2010). Liberating the NHS: The Right Prescription in a Cold Climate? London: The King’s Fund. Flynn, R., Williams, G. and Pickard, S. (1997). Markets and Networks. Buckingham: Open University Press. Guest, G., Namey, E. and Mitchell, M. (2013). Collecting Qualitative Data: A Field Manual for Applied Research. Thousand Oaks: Sage. Ham, C., Baird, B., Gregory, S., Jabbel, J. and Alderwick, H. (2015). The NHS Under the Coalition Government. London: The Kings Fund. Ham, C., Dixon, A. and Brooke, B. (2012). Transforming the Delivery of Health and Social Care. London: The King’s Fund. Available at: https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/transforming-thedelivery-of-health-and-social-care-the-kings-fund-sep-2012.pdf [Accessed 7 May 2017]. Harrison, S. and Ahmad, W. (2000). Medical autonomy and the UK state 1975 to 2025. Sociology, 34(1), pp. 129–146. Hunter, D. (2016). The Health Debate, 2nd edition. Policy Press. Hunter, D., Erskine, J., Small, A., McGovern, T., Hicks, C., Whitty, P. and Lugsden, E. (2015). Doing transformational change in the English NHS in the context of “big bang” re-disorganisation. Journal of Health Organization and Management, 29(1), pp. 10–24. Iacobucci, G. (2013). Majority of £1.5 bn NHS contracts go to private providers, study finds. BMJ: British Medical Journal (Online), 34.

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Iacobucci, G. (2016). More doctors are engaged in commissioning under CCGs. BMJ, 354, p. i3875. Klein, R. (2007). The new model NHS: performance, perceptions and expectations. British Medical Bulletin, 81(1), pp. 39–50. Klein, R. (2013). England’s national health service-broke not broken. The Milbank Quarterly, 93(3), p. 455. Klein, R. (2018). The National Health Service (NHS) at 70: Bevan’s double-­ edged legacy. Health Economics, Policy and Law. Cambridge: Cambridge University Press. Krachler, N. and Greer, I. (2015). When does marketisation lead to privatisation? Profit-making in English health services after the 2012 Health and Social Care Act. Social Science and Medicine, 124, pp. 215–223. Le Grand, J. (2002). Further tales from the British national health service. Health Affairs, 21(13), pp. 116–128. Lewis, R., Dixon, J. and Gillam, S. (2003). Future Directions for Primary Care Trusts. The King’s Fund. McDermott, I., Checkland, K., Coleman, A., Osipovič, D., Petsoulas, C. and Perkins, N. (2017). Engaging GPs in commissioning: realist evaluation of the early experiences of Clinical Commissioning Groups in the English NHS. Journal of Health Services Research and Policy, 22(1), pp. 4–11. Miller, R., Peckham, S., Coleman, A., McDermott, I., Harrison, S. and Checkland, K. (2016). What happens when GPs engage in commissioning? Two decades of experience in the English NHS. Journal of Health Services Research and Policy, 21(2), pp. 126–133. Mohan, J. (2009) Visions of privatisation under new labour. In: J. Gabe and M.  Calnan (eds.) The New Sociology of the Health Service. Routledge. pp. 79–99. Mossialos, E., Wenzl, M., Osborn, R. and Sanark, D. (2015). International Profiles of Health Care Systems. Commonwealth Fund. Available at: http:// wwww.issuelab.org/resources/25100/25100.pdf [Accessed 21 Jan. 2019]. Naylor, C. (2009). Briefing: Independent Sector Treatment Centres. London: The King’s Fund. Available at: https://www.kingsfund.org.uk/publications/briefing-independent-sector-treatment-centres [Accessed 5 Mar. 2018]. NHS Commissioning Board. (2012). Procurement of Healthcare (Clinical) Services. London: NHS Commissioning Board. Available at: https://www. england.nhs.uk/wp-content/uploads/2012/09/procure-brief-3.pdf [Accessed 12 Feb. 2018].

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NHS Digital. (2012). NHS Hospitals: New Figures Suggest 11 Per Cent Increase in Procedures Carried Out by Private Sector in a Year - NHS Digital. Available at: http://content.digital.nhs.uk/article/2285/NHS-hospitals-new-figuressuggest-11-per-cent-increase-in-procedures-carried-out-by-private-sector-ina-year [Accessed 3 Aug. 2017]. NHS England. (2016). Mental Health » Valuing Mental Health Equally With Physical Health Or “Parity Of Esteem”. Available at: England.nhs.uk [Accessed 2 Nov. 2016]. Peck, D. and Hills, B. (2000). Provider arrangements for mental health services in ‘The New NHS’. Health and Social Care in the Community, 8(5), pp. 325–335. Peedell, C. (2011). Further privatisation is inevitable under the proposed NHS reforms. British Medical Journal, 342. Pettigrew, A., Ferlie, E. and McKee, L. (1992). Shaping strategic change - The case of the NHS in the 1980s. Public Money and Management, 12(3), pp. 27–31. Pollock, A. and Price, D. (2011a). How the secretary of state for health proposes to abolish the NHS in England. BMJ, 342(mar 22 1), pp. d1695–d1695. Pollock, A. and Price, D. (2011b). The final frontier: the UK’s new coalition government turns the English National Health Service over to the global health care market. Health Sociology Review, 20(3), pp. 294–305. Pollock, A.M., Price, D., Roderick, P., Treuherz, T., McCoy, D., McKee, M. and Reynolds, L. (2012). How the Health and Social Care Bill 2011 would end entitlement to comprehensive health care in England. The Lancet, 379(9814), pp. 387–389. Saltman, R. (2003). Melting public-private boundaries in European health systems. The European Journal of Public Health, 13(1), pp. 24–29. Shaw, E. (2003). Privatisation by stealth? The Blair government and public-­ private partnerships in the National Health Service. Contemporary Politics, 9(3), pp. 277–292. Smith, J., Mays, N., Dixon, J., Goodwin, N., Lewis, R., McClelland, S., McLeod, H. and Wyke, S. (2004). A Review of the Effectiveness of Primary Care-Led Commissioning and Its Place in the NHS. London: The Health Foundation. Smith, P., McKeon, A., Blunt, I. and Edwards, N. (2014). NHS Hospitals Under Pressure: Trends in Acute Activity Up to 2022. London: Nuffield Trust. The King’s Fund. (2013). Changes to the Health and Social Care Bill: Competition. Available at:https://www.kingsfund.org.uk/projects/reforming-the-healthbill-index/competition-reform [Accessed 22 Aug. 2018].

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The King’s Fund. (2015). Commission on the Future of Health and Social Care in England: The UK Private Health Market. London: The King’s Fund. The King’s Fund. (2017a). Public Satisfaction with the NHS. Available at:https:// www.kingsfund.org.uk/projects/public-satisfaction-nhs [Accessed 10 May 2017]. The King’s Fund. (2017b). Trusts in Deficit. Available at: https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/trusts-deficit [Accessed 10 May 2017]. Timmins, N. (2012). Never Again? The Story of the Health and Social Care Act 2012. London: The Institute for Government. Timmins, N. (2018). ‘The World’s Biggest Quango’: First Five Years of NHS England Kings Fund. Institute for Government. Tuohy, C.H. (2018). Remaking Policy: Scale, Pace and Political Strategy. Toronto: University of Toronto. Turner, D. and Powell, T. (2016). NHS Commissioning Before April 2013. London: House of Commons Library. UK Legislation. (2012). Health and Social Care Act2012.Available at: http:// www.legislation.gov.uk/ukpga/2012/7/contents/enacted [Accessed 18 May 2017]. Virgin Care. (2017). Virgin Care - Virgin Care Provides NHS and Local Authority Services Across England with a Difference Virgin Care. Available at: http:// www.virgincare.co.uk [Accessed 21 Apr. 2017]. Williams, I., Brown, H. and Healy, P. (2018). Contextual factors influencing cost and quality decisions in health and care: a structured evidence review and narrative synthesis. International Journal of Health Policy and Management, 7(8), pp. 683–695.

Part IV Healthcare Professionals

Chapter Eight: Safeguarding Through Work Arounds: Socio-Materiality and the Organising of Care in a Private Hospital Trudy Rudge and Luisa Toffoli

Introduction Across small metropolitan or regional settings in Australia, the private hospital sector is where particular forms of care are performed for the broader healthcare system, such as elective surgery, obstetric care and some forms of medical care (e.g., in-patient oncology care). In this setting, private healthcare is perceived to have characteristics qualitatively different from the public health system (Toffoli 2011). In a marketised approach to care, hospitals must ensure their viability both in attracting patients and the allocation of resources to the care provided (Moody 2011). In many small metropolitan settings, a hospital’s reputation comes T. Rudge (*) Susan Wakil School of Nursing and Midwifery, University of Sydney, Sydney, NSW, Australia e-mail: [email protected] L. Toffoli School of Nursing and Midwifery, University of South Australia, Adelaide, SA, Australia © The Author(s) 2020 F. Collyer, K. Willis (eds.), Navigating Private and Public Healthcare, https://doi.org/10.1007/978-981-32-9208-6_8

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from its position and historical relationship with the local community. Integral to community reputation and economic viability for hospitals in these settings is the work of nurses. Many nurses live locally and are well aware of the value of their work in maintaining the hospital’s reputation for care from ‘cradle to grave’ (Toffoli 2011: 160), and must adapt their nursing practices to ensure both economic viability and quality of care in a privately funded environment. Such a context can create an uneasy tension between business strategies and the provision of care. In this chapter, we detail a theoretical approach useful for understanding the social relations of work in this context—that of socio-materiality. We then present a study exploring beliefs about private care and reveal strategies deployed by nurses to meet consumer expectations of private healthcare, while at the same ensuring the business imperatives of the private hospital are met. In navigating these two broad objectives, nurses develop safeguarding practices to maintain the quality of care they believe is intrinsic to private healthcare provision.

 ractices and Objects: Theoretical P Underpinnings Socio-materiality is an ‘attempt to understand how human bodies, spatial arrangements, physical objects, and technologies are entangled with language, interaction, and practices in the doing of activities’ (Jarzabkowski and Pinch 2013: 581). Theories of socio-materiality allow analyses of the social relations of work, technologies and bodies in spatially sensitised ways (Orlikowski 2010). Socio-materiality affords a view of such entanglements and asserts that the social and the material operate as a continuum rather than a set of binary relations. Such a view enables a dynamic, rather than deterministic, approach to the interactions between technology and nurses’ work within the spaces of healthcare. As Thrift et  al. (2014) suggest, certain ways of thinking about place form the objects of the healthcare system and practices of nursing so as to ‘thing-up’ or emphasise things and bodies as they occupy spaces of work. These may include material objects such as bodies, and technologies such as medical

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records or clinical pathways, which provide deterministic schedules of care for each patient that standardise nursing practice. Clinical pathways, for example, are protocols set by reason for admission (diagnosis), allocation of funding category (Diagnostic Related Group or DRG), days in hospital, and day for intended discharge. This categorisation according to the clinical pathway schedule guides nurses’ practices, thus providing a way of governing the care provided (Foucault 1977). However, such standardised care plans, while governing care, come up against both the individual patient and the individual nurse’s way of interpreting that care, when compared with their knowledge and beliefs about private healthcare and the accountabilities of nurses (Toffoli 2011: 142). The tensions between knowledge(s), managerialist practices (such as care plans) and working relations interact with how nurses accomplish their work; here, with a socio-material analysis, we also shift ‘attention to the relational networks that comprise everyday life’ (Ceci et al. 2017: 57). Taking a socio-material approach, we examine the dynamics of nurses’ work in order to understand how such work is governed and implemented. This includes interactions between mundane care practices, technologies of care (care plans, allocation algorithms), bodies of patients and nurses, and the regulation of such work through policies, protocols and registration requirements. As Thrift et al. (2014: 1) write, such: mundane objects and practices are deeply implicated in questions of governance and accountability. These so-called little things are the real material of [nursing practice], the things that count, the things that guide or impose outcomes.

In such a view, objects and their materiality are active in forming the practice of nurses; things are not merely acted upon, but act back. They are statements, events, architecture or beliefs about what that space or place represents in the world. For instance, a brand new hospital might be seen as merely a building within the healthcare system. However, a hospital is also ‘a cultural statement’ (Thrift et  al. 2014: 6) which ‘embod[ies] social and political interests’ (Thrift et  al. 2014: 6) of any government’s work to meet the healthcare needs of its population. A hospital is also a set of networks, each with its ‘own degree of efficacy’ (Thrift

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et  al. 2014: 7), that—even though constituted through protocols, ­pathways and emergency and safety practices—may be imperfect. Such a lack of complete efficacy leads all systems to require some ‘degree’ of improvisation and tinkering to order the system through ‘mundane acts of repair and maintenance which, though unsung, are vital to their operation’ (Thrift et al. 2014: 7). Following Thrift and his colleagues (2014), objects and practices can be viewed as dynamic, where the dynamics of practice through objects are not entirely determined by the object but also by nurses’ improvisations when tending patients. As Ceci et  al. (2017: 56) note, ‘many of the intricacies in nursing practices are … local responses to specific problems’.

The Study This chapter uses observations and interviews from a larger ethnographic study, completed in 2011, of nurses’ work. Ethnographic methods of participant observation, interviews, field notes and document analysis were used to explore how nurses within a private hospital do their work. Documents include the hospital mission statements and daily allocation sheets for managing nursing numbers, annual reports and advertising, or pamphlets used for patient information. These methods allowed us to examine the mentalities that govern the nurses’ work across 24-hour care, including the weekly rhythms of work in medical/surgical wards. The wards observed consisted of single rooms distributed across one floor but not in one unit; therefore, sometimes nurses had to work across spatially separated wards to care for patients allocated to them (for a full description of the study and its methods, see Toffoli et al. 2011). In our analysis, we focus on calculable space—a space both abstract and real—because the organisation of nurses’ work is tied to a hospital’s performance, financial or otherwise. We analyse the various ways in which nurses’ working time, their nursing hour, is organised in the network of staffing policies and practices, with a focus on nurse-to-patient allocations and the organisation of nursing work in the social relations of the ‘skill mix’.

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 he Context of Private Hospital Care T and Nursing The Australian healthcare system is mixed, with a publicly funded system and private hospitals run on either a not-for-profit (such as Catholic Health, or memorial hospitals) or profit-making basis (such as Ramsey Health or Healthscope). Private hospitals get an allocation of funding from the government for each bed in the system. Insurance companies are subsidised through a rebate to individuals purchasing private health insurance (now means-tested) encouraging individuals and families to stay in the private system (Fedoruk and Toffoli 2014; see also Chapter Eleven of this book). At the time of this research, insurance companies negotiated a payment system with the hospital in our study based on a ‘midnight census’. This means each patient is not funded for the morning of discharge— leading to shortfalls in budget if the patients stay beyond the time budgeted for (or as is sometimes the case, due to doctors not discharging patients on time, the last hours of the admission are not funded at all). The funding is calculated using DRG payments  for each case. While obtaining funding from the Australian Commonwealth Government as a subsidy, private health is a system for profit, and at the same time through the object of the ‘case’ and case management, negotiations such as those above mean that health insurance companies have been able to limit funding to some private hospitals (Toffoli 2011). Hence, private hospitals are encouraged to achieve efficiencies through keeping to the clinical pathways set for each DRG that prescribe days in hospital and what is to happen each day to accomplish a timely discharge (Barnes and Rudge 2005). In this case, ‘local tinkering’ to deal with the problem of economic stringencies occurs through the adjustment of nurses’ working time (the nursing hour) and in the skill mixes of ‘the nurse’, to ensure cost-effective private healthcare. Cost-effectiveness is achieved in private healthcare, in this instance, through the mechanism of manipulating the ‘skill mix’ (various combinations of nurses with different skills on shift). There are two levels in nursing qualification registered in Australia. The RN is a registered nurse who

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has undertaken a Bachelor level qualification through a tertiary level university course accredited with the Australian registration body. An RN is considered able to practice independently and is accountable for their practice (ethically and legally) (NMBA 2016a). An Enrolled Nurse (or EN) is registered with the same registration body, with a diploma-level education through a higher education course of at least two-year duration. ENs are equivalent to second-level nurses in places such as the United Kingdom (State Enrolled Nurse), licensed practical nurses in Canada and the United States or technical nurses in countries such as Brazil. Their use is accompanied by a saving in the nursing budget, as their pay scales are less than the RNs. The EN works under a delegated authority who is accountable for their practice (NMBA 2016b). However, in the hospital sector, the matter of skill mix is ‘a matter for concern’ (Ceci et al. 2017: 58) when the two levels of nurses are allocated to patients who may need an RN for some aspects of their care. RNs are able to provide independent and autonomous care to patients according to their registration. ENs are not able to provide all forms of care and are limited in terms of medication and the form of delivery of that medication. ENs are meant to ensure intravenous (IV) and some other forms of medication (such as pain relief medications) are checked with an RN or left for an RN to administer. When both groups of nurses form the skill mix, how to mix their skills becomes part of the calculation of the accountabilities and delegations of work. Notably, the mix at the studied hospital had changed recently from an RN-only workforce, which was common in the acute care private sector, to one with a mix of RNs and ENs as part of the nursing establishment. The change to the mix of staff was a response to the hospital experiencing funding pressures. In the private sector, nursing hours (number of nurses needed to care for each patient) for the patients’ stay are governed by payments received largely from private health insurers; such payments correlate with an occupied bed or occupancy rates. RNs’ position descriptions specific to the hospital state that nurses are employed to ‘achieve the clinical and operational goals for their specific unit’ (Toffoli 2011: 135), and are also expected to have ‘public relations skills’ (Toffoli 2011: 146)— skills that promote positive relations with the doctors, who are the primary customers of the hospital. The importance of viewing doctors in

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this way is highlighted in a recent example of the bankruptcy of a private healthcare operator where, because of changes by the business for efficiency reasons (with regard to technology requests and visiting clinicians’ protocols), physicians withdrew their services, and their patients, from the hospital (Toffoli 2011: 147–148). While nurses in the public sector are expected to achieve clinical and operational outcomes, the need for a certain level of occupancy rate or public relations skills to keep doctors using the hospital are not part of their role. This makes a qualitative difference in nursing work between the public and private sectors that profoundly shapes the ways nurses engage with the requirements of their workplace. Nurses in the private sector, as Barnes (2000) and Toffoli (2011) note, are very aware of budgetary issues, particularly when these involve occupancy rates as evidence of the hospital’s use by its visiting specialists. Occupancy rates have a bearing on how much funding comes from the case mix, and are affected when patients are not discharged efficiently. In addition to tightening of budgetary allocations to DRG, when a bed is not emptied promptly there may be cancellations or delays on the next day’s list, which can result in difficult relations with the surgeons using the hospital (Toffoli 2011: 145–146). The requirement to meet patients’ needs is seen as secondary to meeting the needs of the medical consultants. Additionally, in a context where fiscal stringency is paramount, nurses navigate between the tension between budgetary restrictions on the number of nurses on a shift and the provision of care as set by medical consultants who are less concerned with achieving efficiencies through adherence to discharge timings. In the two scenarios we outline below, the tension between the mentalities of nurses, their values and beliefs about care in the private sector and the need to meet enterprise requirements or efficiencies due to austerity measures show what nurses do to safeguard hospital budgets as well as the reputation of the hospital as a provider of excellent nursing care.

Working Around Staffing: Buddying-Up? Nurse-to-patient allocations are crucial to the way nurses approach their work. How a shift is ‘set up’ by Nurse Unit Managers (NUMs), After-­ Hours Coordinators and/or colleagues determine whether or not nurses

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choose to accept or change their allocated patient load. All RNs are well aware they remain responsible for the nursing care delegated to ENs, regardless of how the organisation chooses to regulate this. While ENs are personally responsible for the care they provide to patients, it is the RN who is accountable for the care that is delegated to ENs. Yet, according to the Code of Conduct for Nurses and ENs, all nurses are personally responsible for the care they provide as long as that care is within their scope of practice (NMBA 2016a, b). This is seen to matter when RNs negotiate how they record their oversight of ENs’ practice by counter-­ signing the records of ENs in the medical record. As this is also a recent change to delegation practice, there are confusions with the RN and EN relations of work. Moreover, legislation does not indicate that counter-­ signing is a practice requirement (Health Practitioner Regulation National Law Act 2009). The dominant change highlighted by staff and managers in our study involved a shift from an RN-only workforce, with a ratio of one RN to six patients as its average, to one with a mix of RNs and ENs. With a reduced number of RNs and a subsequent change in the skill mix, staff talked about ‘buddying-up’. This term meant that an RN and an EN worked together across a shared allocation of 10 to 12 patients, with the RN having direct oversight or close surveillance of the EN’s work. The buddying system means that the RN/EN combination work as ‘one’ rather than the loose RN/EN constellation of team nursing where they work with separate allocations with intertwined moments to deal with the variable levels of scope of practice across patient needs. In this ‘buddying’ system, described by the RNs at this hospital, the RN does not have to come back to do the medications for the EN and they would know what care outcomes were, rather than having to go back to check on separated EN delivered care. Further, the RN does not have to rely on the EN coming to get them (if they had separate patient allocations) to do treatments outside of the EN’s scope of practice, such as IV medications/fluids or administration of RN only level medications. Anita, a NUM, describes how she rosters staff, showing how the model of care altered as a result of changes in skill mix. She highlights how staffing numbers are affected by variations in the number of patients, the closure of wards and reductions in nursing to patient ratios:

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So what I tried to do when I did the roster is ensure that there was only … one EN on per shift on an early and a late. And certainly the way then I rostered the RNs was to make sure that in terms of personality and skill mix was that there was somebody whom I could buddy that EN with, and that’s how I had to do the roster (Anita NUM, emphasis added).

The rostering of nursing staff required the NUM to ensure there would be an RN on shift who was amenable to working with an EN, and also taking into account numbers and spaces, so that ‘Sunday night you could go down to ten [patients], you know, [Ward B] could shut by Friday afternoon, Saturday afternoon. So I really had to be mindful of my numbers’ (Anita NUM). As Ward A had high-dependency patients, that ward also had to have a nurse with critical care qualifications. The problem of skill mix is framed as a change in the models of care to a model with fewer RNs on shifts, taking into account prevailing assumptions about differences between RNs’ (and ENs’) knowledge levels. The nurse manager has to make allowances for ‘somebody I could buddy that EN with’. As discussed below, not all RNs have adjusted to these changes. Moreover, prior to the changes in skill mix, most nurses were used to being accountable for their care as well as for the delegated ENs, and management had recently changed these expectations. The NUM below viewed RNs failure to separate allocations as a problem related to how RNs thought about RN/EN coupling: we went to changing the model of nursing or care, to then get … RNs to think that there is now two of you for ten patients, the mind-set of the RN was still that they had ten patients to care for (Anita, NUM).

Despite the planning that goes into rostering, what determines whether nurses will or will not continue to ‘buddy’ with a colleague is more often dependent on the grade and skill of the individual working with them; those seen as more problematic identified as either EN or agency nurses. Agency nurses are not part of the permanent staff of the hospital but are brought in from an agency that provides casual staff under contract to the hospital. The agency ensures staff are registered, thus guaranteeing their level of practice. Agency nurses are paid at higher rates to include allow-

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ances for leave. Agency nurses move about the healthcare system, most taking shifts when and where they choose—nursing’s form of ‘flexible’ worker. RNs employed by a hospital then have to make calculations based not only on level of qualification, but familiarity with hospital, procedures, and with the type of patients in the hospital. Mary explains below when a buddying system is necessary for her to believe she meets the hospital’s claimed excellence of care: if I wasn’t happy with how they [nurse managers] set it up I’d probably change it and … if it was an agency enrolled nurse and me I would probably buddy up with that agency EN and work as a directive, find out what her capabilities are, where she’s happy at what she’s done and then just go through and work through them [the patients] together … whilst we don’t tend to do that as much, I think there are some times you just have to do that and that would be for my own peace of mind as well. I’d prefer to have 12 patients under my wing and direct someone than I would have my own six [patients] and put my head in the ground and not know what those other six [patients were doing] … and then find out retrospectively that those other six [patients] were compromised or weren’t happy with their care (Mary, RN).

In both the situations above and below, nurses prefer to work with, and have direct oversight of, the EN’s work so they can feel sure of the quality of care provided. This means that the RN will not have to rely on the EN or agency nurse coming to her if there are treatments they cannot do (i.e., beyond the scope of practice of the EN). The RNs believe ­buddying-­up in a close RN/EN coupling results in greater control over care delivery: if I had an EN to work with, I used to try and find out what I needed to do for them, and what they needed to do. I found it actually better if we worked as buddy/buddy (Lily, RN).

However, in Doris’ opinion, some of the problems with agency ENs stem from the agency provider:

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because they [Agency ENs] are an unknown quantity … that’s more of an agency point of view of not knowing the staff member rather than being an EN (Doris, RN).

Like Doris, many participants identified working with EN and agency nurses as an issue, suggesting their capacity to manage their workloads lay with these nurses’ levels of experience and skill. Whether an EN was medication competent or not, and/or whether they were employed by the hospital or an agency, determined the nurses’ control over the organisation of their work: I actually will go through their [patient case] notes and their charts at the beginning and at the end [of the shift] and countersign them … if we do get enrolled nurses here, [and] they have not a lot of experience, then I’m set for a rotten shift (Laura, RN).

A perceived lack of EN experience and skill is further compounded by the sense of not being able to adequately supervise these nurses due to the geography of the single bedrooms that spread out far from the nurses’ station. Moreover, past practices, where an RN counter-signed ENs’ entries in the patient medical record, continue as nurses fail to adapt to the changed organisational delegation policies and practices which leads to confusion regarding when RNs need to counter-sign an EN’s medical notes. Doris suggests: There are still staff that are resistant towards being responsible for the work that the ENs do. I’ve only become aware of this because on my last shift I asked my EN to put out her [patient case] notes so that I can sign them and she was surprised that I would do that (Doris, RN).

Other RNs did not sign because they believed signing for unobserved care was illegal, with a lack of clear policy: It’s all up in the air, you can never get a straight answer, you get one thing from somebody, and one thing from another, and I just decided, if I wasn’t buddied up with them, I wasn’t signing their notes. I didn’t. So [CN] …

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did and she wasn’t even on duty. How stupid’s that? In a court of law, you would be responsible (Lily, RN).

Although Anita (NUM) believes buddying-up is ‘mind-set’, many of the RNs above are cognisant of their professional and legal obligations. Nurses’ issues are structural; they involve nursing the skill mix allocated to the wards in light of patient numbers, patient acuity, turnover and business expectations—in short, their increased workloads. Nurses want to avoid compromising their standards of provision of care according to the traditions of their private hospital, which they believe are core to the hospital’s mission statement. Many RNs perceived the shifting from RN-only care provision would inevitably lead to a lowering of standards. This belief was compounded by a perceived lack of consultation with nurses about staffing numbers and/or issues with managing numerical and functional flexibility, which is a source of irresolvable tension for them—and an example of what Cooke (2006) terms ‘seagull management’: No one says anything and it’s almost like the hospital coordinator scuttles in and sort of writes something down, then scuttles back out the door again … it’s gone from a consultative sort of, ‘What do you think?’ … to ‘This is it’. And not even ‘this is it’, it’s just nothing said and you just sort of look and discover for yourself what’s going to happen … and then chase [the nurse managers] if you’re not happy (Linda, RN).

While many nurses used buddying-up as way of organising their work, not all nurses do. Sandra, like many of the participants, has worked on and off at the hospital over the course of 20 or more years and for varying lengths of time. Sandra is aware of this practice of buddying-up but is resistant, although she concedes it may be a useful strategy when working with agency staff, particularly ENs: Maybe if it’s an agency enrolled nurse and you buddy up and you’ve got a total of 12 patients, that’s just impossible to care for, and that’s what I’m overseeing, is 12. I can’t do that. Some girls like it, I don’t (Sandra, RN).

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What Sandra recognises is that working with agency staff, and in particular EN agency staff, is problematic, because of expectations that they orientate nurses to the ward and find time to teach what she considers basic nursing and organisational skills. She does not believe that working with an EN halves her workload; instead, she believes she carries the entire workload. The RN/EN buddy system leads to impossible workloads or work intensification.

Working Around Staffing: ‘Holding the Baby’ One way managers manage the nursing hours is through varying shift lengths to accommodate shortfalls in staffing numbers, increasing productive hours, and/or reducing the nursing hours when the wards are quiet. Changes to nurses’ working time are not limited to nurses employed on casual contracts; they extend to those employed on full-time and part-­ time contracts. Analysis of the documents termed Daily Allocation Sheets highlights that whereas the organisation’s work is made up of a series of financial flows at an administrative level—budgets, cost centres, nursing hours—nurses’ work is not a ‘flow’ but a set of disjunctures or disconnections made into a ‘flow’ (Lake et al. 2015). Disruption occurs through shortened shifts or variations in the numbers of nurses at different times of the shift as a way to reduce labour costs, often leaving nurses to take care of patients they consider are their specific patients as well as those of the nurse who has flexible hours who will come on later. This is termed ‘babysitting’, as it is sold to nurses that the care they provide for patients allocated to staff not yet present does not have to be more than a distant surveillance. Once the allocated nurse comes on to the ward, that nurse will provide the care for the shift. This kind of workload sharing occurs because nurses have ‘flexible hours’. Previously, nurses had standard-hour contracts where they worked set hours of a shift and for the entire shift for four to five days a week. If they were contracted part-time, ahead of time they knew the hours, shifts and the days they were contracted to work. In conversations with nurses,

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the use of this strategy to manage ‘the nursing hour’ is met with a mixture of responses: Half night duty shifts … that was a real bummer (Joan, RN). I thought that was a very bad way to do things, bring people in at 6.00 [pm] … On the other hand it’s better having someone come on at 6.00 [pm], than no-one (Lily, RN).

While accommodating personal preferences for staff so they can ‘come on at 6 [pm] because they have children’, the hospital’s flexible working time practices have implications for others, whose work is both interrupted and intensified. There were many reasons this could occur, but predominantly it is because staff are sick or agency staff are unavailable to replace numbers: There are some shifts that aren’t staffed very well and that could be for a whole lot of reasons due to late sick leave, you can’t get any agency staff (Angela, RN).

Nevertheless, despite managers rationalising why some shifts are staffed in particular ways, nurses begrudge the way ‘babysitting’ patients adds to their workload: I just used to get angry when we’d get left holding the baby for four hours until somebody came on at 6.00 [pm] (Lily, RN). Probably till 6.00 [pm] has been the latest I’ve had to babysit, so we’re looking at three hours [since commencement of shift], and that can impact terribly on your workload, and then particularly if they’re [nurse] coming in at 6.00 [pm], you will have most likely have done their pre-tea observations, because we do them about that time, and their drugs … I really hate, if there’s no-one to cover, and sometimes … I just think, stuff it, I’m not going to do it, because time-wise, you can’t … I think there is an unwritten expectation [to do others’ work] because we’re nurses (Angela, RN).

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Managing nursing working time by demanding that nurses ‘babysit’ patients for a period of time diminishes the value of their caring work for the hospital. Using this term to describe nurses’ work reduces that work to merely ‘minding’ patients as one would a child; an assumption being that nurses only check on these patients quickly and that care is limited to just answering bells. However, the practice reality is that nurses carry an increased, and at times significant, workload: We often babysit patients until staff can get on later in the shift … and handover [to] them as well … you can come on to a shift and be allocated your workload and possibly up to three or four [patients] of somebody else’s (Yvonne, RN).

Nurses themselves make assumptions about what constitutes their work and just what has to be done before the next person comes on duty—irrespective of time assigned—such as observations and medications. A management discourse of ‘flexibility’ in the workplace, associated with changes in skill mix and an expectation of delivery of the ‘sustainable excellence in-patient care and associated services’, a central point of the hospital’s mission, makes for acrimonious feelings in nurses left ‘holding the baby’. Lily describes her frustrations: I worked a lot of lates [evening shifts], and [nurse] used to come on at 6.00 [pm] because she had children. Somebody else used to come on at 4.00 [pm] that’s no problem, really, you know, by the time the morning staff leave, that’s an hour, that’s answering bells, that’s nothing. But till 6.00 [pm] is a different thing. They need care. You’ve got tea break to cover, you’ve got patients going to and from theatre. One day, there was only two of us actually on the ward, until she came on at 6.00 [pm]. Q: A:

How many patients? … it must have been about 18 or more … that’s hairy, when one of you is in Recovery and when you take someone to theatre and they take 15 minutes to come and take over from you, and you’ve left someone back at the ward on their own, with the Ward Clerk … I don’t see why we should have to look after nine patients and go through nine lots of [case] notes, and

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sometimes, by the time that person came on, you hadn’t even caught up with what you were doing for your own patients. Yet by the time, if you took over from three morning girls, depending on who they were, quite often they’d leave all the 3.00 [pm] things for you. Quite often they’d say, ‘Oh, I hadn’t had the time to take the tray out, can you do it?’ They seem to have this conception that you know, that you had more time than they did … So by the time you’ve checked up whether the antibiotic and Clexane [anticoagulant medication] were given at 2.00 [pm], and they weren’t and you gave that, and took a couple of people to theatre, you haven’t even gone through your [patient case] notes at 5.00 [pm]. You haven’t got time to go through her [patient case notes] as well … I hated it. And then she gets on at 6.00 [pm], and she’s got to get handover, and she’s got to get her head together, and no-one’s been to tea (Lily, RN).

In response, some nurses discuss choosing not to finish tasks that are allocated. One of the Night Duty After-Hours Coordinators comments: There are a number of them [nurses] who I think are just being very proactive in their management of their [work]load and just saying well now I will just have to say to the morning staff I have not been able to perform this task. I have not been able to physically do this, my workload has been such that I could not achieve that but I know that they do that with a sense of, I would have much rather have completed my work … nurses don’t traditionally like leaving unfinished work (Rosemary, After-Hours Coordinator).

Whether or not the term ‘babysitting’ is used, interviews show the many instances where nurses manage patients for short amounts of time across, and at either end of shifts with an intensified workload. The flexing of the nursing hour up, down, and across shifts as an organising strategy for the hospital’s efficiency and productivity demands leads to work intensification for nurses; intensification due to increases in nurse to

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patient ratios, constant interruption to their care of allocated patients, fluctuating patient occupancy and/or nursing hours. Nurses provide detailed descriptions of how they go about sorting things out (Bowker and Star 2000). Allocating patients is a ‘matter of concern’, taking into account not only the skill and experience of individual nurses but also the geography of the ward as well as the acuity or dependency of the patients. While patient intensity or acuity is undoubtedly taken into consideration when allocating nurses to patients, it is not the ultimate arbiter of how they order their work. It is the hospital’s flexibility practices that nurses have to work around and that increase the work intensity for nurses. Yet, nurses remain committed to the caring ethos of the profession as well as to the hospital’s mission of providing sustainable excellence in care when working around shortages, care planning technologies and spatial difficulties.

Discussion Following Ceci et al.’s (2017: 59) observation that nursing ‘is not actually a matter of fact, nursing is a “matter of concern”’, we consider how nurses in their accounts of working in a private acute care hospital voice matters of ‘concern’ for them. We have focussed on practices we have termed ‘safeguarding’: work they do to maintain the qualitative differences with public healthcare. Such differences include the spatial arrangements of care in dispersed single rooms and the spread of oversight of patients in two units geographically separated. These allocations are not only about who does the care but about who is responsible. Such responsibilities are recorded against a nurse’s name for a group of patients and are part of the hospital records—that is, the allocation sheets. Moreover, nurses operate with a sense of ‘theirs’ and ‘mine’ with respect to allocations of patients according to this sheet, even when not present. Due to reductions to the nursing establishment, nursing management has chosen to shorten some shifts of some nurses, when they believe there is reduced demand from patients, for instance, during early afternoon or in the early morning of night shifts. This change has been sold to RNs as a way of bringing flexibility to working hours, with some RNs coming on

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for a half shift of four hours, or leaving after half a night shift when demands from patients are reduced. However, what this does is spread responsibilities from the 1:5 patients (on the allocation sheet) to 1:10 for half of the eight-hour shift. In such practices, managers play with times of lessened activity, yet as Angela (above) points out, sometimes such a spread is waiting for a temporary or casual worker to reduce the workload. The amount of work that falls to the nurse who is present is ‘minimised’ by management and nurses themselves by calling such a spread of responsibility ‘babysitting’—a metaphor that suggests the responsibility will be given back to the real parent or responsible nurse whose name is on the allocation sheet. Manipulation of shift times is uncommon in public hospitals, where nurses are more likely be moved around the shift establishment within the hospital instead using movement of nurses from units with over-supply to areas of shortages (Rudge 1997; Heartfield 2002), and the use of a hospital nursing bank of casual nurses/agency nurses. The aim in all of these instances is to manage the nursing budget. As Ceci et al. (2017: 58) suggest: ‘in [such practices], nursing is an object to be manipulated like any other—limited, determinant and bound tightly to a narrow conception of “good practice”’. However, as the nurses in private care indicate in their attempts to maintain appearances of active care, they find themselves having to do obvious care such as medications, much more than ‘answering a few bells’ that management suggest. This is in contrast to the values of these nurses in private care who appreciate the gaps and missed care (Harvey et al. 2017). In the safeguarding practices engendered by the use of two levels of nurse to provide care for an allocated group of patients (skill mix of RN/ EN), there are several effects manifested that maintain what nurses believe maintain the ‘safety and quality’ of care (Rudge 2011). As we highlighted in the context of the hospital where the study was located, it was a time of economic austerity. The ‘concerns’ spoken of in nurses’ conversations were about how to manage ‘scope of practice’ limits. Scope of practice is a regulatory phrase and the term masks a gathering of beliefs and practices, which are not always determinate, but instead are contested and partial (Ceci et  al. 2017). Nurses have defined limits on their practice according to their level of registration, that is, RN or EN. RNs have the capability of being able to meet all requirements of patients as set by their

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clinical pathway and/or doctors’ treatment protocols. ENs cannot do this in the acute care surgical units where this study was located. Due to recent changes to an RN/EN skill mix, with conflict between management and staff understandings of the results of this move, skill mix is an area of contestation. Moreover, RNs in private hospitals have dual mentalities (guided by both hospital clinical pathways and also doctors’ protocols), and this informs the RNs’ concerns about the use of lower-skilled (and lower-pay scale) nurses to control the nursing budget. RNs employed by the hospital discussed the tension between maintenance of what they believe was excellent care in private acute care nursing to what is possible with nurses they judged to cost less but also were limited. In their manoeuvring around the social relations of skill mix, hospital-employed RNs displayed confusion about responsibilities, delegation and their position as RN. This was not, as one nurse manager stated, a matter of ‘mind-set’; rather it played out in how the RNs worked with an agency RN or EN. The term they used—buddying-up—speaks of close association, but the relation is not friendly. To safeguard what the employee RN considered the values and mission of the hospital, the relation was one of close surveillance and vigilance where the RN/EN team worked in the same room, working their way through the shared allocated patients. Such a relation of work overcame what the RNs saw as shortcomings of working in a loosely coupled team where the RN and EN worked separately on their own patients. What buddying-up did was to reduce the amount of time an RN would have to leave their work to provide care for the EN’s patient, check on the EN’s work or wait for the EN to ask for assistance. All of these practices are matters of concern: workload, regulation and ‘quality and safety’ of patient care. The safeguarding practices, underpinned by beliefs about quality of care, are a ‘local response to a specific problem’ (Ceci et al. 2017: 56). As highlighted in the context of the study, this stand-alone private hospital was experiencing budgetary constraint due to its contractual arrangements with private health insurers (Toffoli 2011), hence RNs worked to safeguard qualities they saw as intrinsic to private acute care work. Both Barnes (2000) and Toffoli (2011) undertook studies in not-­ for-­profit stand-alone acute care private hospitals during times of change in how nurses’ work was managed. Barnes (2000) noted that the use of

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technologies such as clinical pathways led nurses to focus on their ethical beliefs about ‘private care’ to maintain standards of care. Similarly, Toffoli (2011) noted how changes to the calculations of ‘the nursing hour per patient day’ meant nurses used ‘safeguards’ to maintain what they saw as the qualities of private care. In both cases, nurses’ understanding of austerity in a private hospital is about the need to have a financially viable business or enterprise (Barnes 2000). The argument from management and the NUMs was that previous levels of staffing were unsustainable, hence the move in the mission statement to ‘sustainable excellence of care’ as a matter of fact. Such instrumentalisation of care is a common response to austerity in healthcare (Molina-Mula et al. 2018). Nurses are constrained by these managerialist techniques (Ceci et al. 2017; Cooke 2009) and forced by external governmental structures to work within those constraints (Heartfield 2005). In the public sector, Heartfield (2002) asserts that surgical patients are organised out of the hospital before admission so as to bring about efficiencies of care, when their discharge is planned for in pre-admission clinics. In the private hospital, such a form of financial management is not possible because the doctor dictates a patient’s pre-admission care. Moreover, management of care according to DRGs may be emphasised by the private health insurer so as to ensure efficiencies, but such situations are not front of mind for the visiting surgeons. In the public sphere, failure to discharge has a political as well as a budgetary effect—the spectres of bed-blockers and waiting lists are used to ensure nurses’ compliance with bed managers managing the flow of patients out of the hospital. Failure to manage budgetary constraints in private care, as nurses understand, may lead to closure of hospitals. In exploring what nurses do in private hospitals to safeguard the quality of care, we note how networks gathering around technology and the relations of work are things that are contingent and contextual—and specific to local situations. While nurses in the public sector are governed at a distance, nurses in private hospitals do not have such a luxury. Rather, their practices for maintenance of reputation of the hospital drive them to work across tensions between austerity and the perceived superiority of private acute care nursing. This is done in the intimacy of a small hospital where the things that matter are seen as residing in the politics of the

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hospital rather than in the wider healthcare system. Nurses acknowledge they are safeguarding the quality of the nursing hour as a matter of concern. Nurses’ practices of ‘working around’ management’s policies safeguard the hospital’s seamless organisation where reputation remains the main arbiter of private healthcare (Toffoli and Rudge 2006; Toffoli et al. 2011). Safeguarding beliefs about such care result in nursing practices ‘through which [private healthcare] values emerge’ (Ceci et al. 2017: 65). Safeguarding is nurses’ specific solution to a local problem, but it is not idiosyncratic. It resides in nurses’ generalised belief in the need to maintain appearances of seamlessness, while attending to changes that nurses view as matters of concern about the way an organisation works (Rudge 2011).

Conclusion In this study’s focus on a specific location—a private hospital in metropolitan Australia—we reveal that nursing practices in private healthcare are ‘an unfolding activity situated in a collective social and material world’ (Ceci et al. 2017: 53). In the nursing practice, as represented in the calculable space (Miller 1992) of the ‘nursing hour’, nurses’ practices evolved to meet the instrumental, deterministic procedures designed to manage financial viability. As management moved to ‘sustainable excellence in care’, nurses attempted to maintain the values of private healthcare through changes to sharing workload through attempts to appear as usual (Rudge 2013). The effects, however, were intensification of their work and observations that appearances were difficult to sustain. Invariably the RNs were aware of the gaps, risks and stretching of limits to care. There were tensions in the private health system that played out in patterns of staffing (or models of care) used to navigate budgetary restraints. There was an uneasy tension between the hospital’s business strategies and nurses’ beliefs about care, and the hospital resolution of labour costs by drawing upon nurses’ care ethos to re-distribute nursing hours per patient day—the algorithm that governs nurse staffing. Such tension is absorbed in the nurses’ practice through buddying-up or forming teams (usually pairs of RNs with ENs) to care for allocated patients when the skill levels

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are mixed on a shift. Nurses share patients allocated to them with others who have shorter shifts where shifts are ‘flexibilised’ to cover workload rhythms of the 24 hours of care. Nurses ‘tinker with’ (Graham and Thrift 2007) standardised care to change, adapt or resist management policies so their practices remain aligned with their understandings of what constitutes private healthcare. This form of analysis also shows how metaphors used by nurses, such as ‘babysitting’, incorporate and describe practices that hide how nurse allocations are ‘tinkered with’ to overcome perceived systemic shortcomings. The RNs develop safeguards to keep with their values associated with working in a not-for-profit, stand-alone private hospital, contracted to private health insurers and satisfying visiting surgeons and physicians who are understood to be the primary customers of the hospital. While public hospitals are funded by a similar mechanism of DRGs, the viability of the hospital is not reliant on bed occupancy rates and private insurers’ rates of payment to meet the nursing budget. Government funding and the numbers of beds such funding allows are the ways nursing budgets are managed in public hospital acute care. In a context of low rates of casualisation, rather than a reduction in pay scales and hours on shift, public hospitals move nurses around the hospital within the nursing establishment. In the private hospital, nurses are left holding to the hospital’s ‘primary goal of achieving sustainable excellence in-patient care and associated services’. Exploring the social relations of care thus indicates how nurses perceive their workspace, and how they use various forms of technologies and interconnections between their knowledge, power and ability to resist the worst effects of economic stringencies.

References Barnes, L. (2000). The social production of an enterprise clinic: nurses, clinical pathways guidelines and contemporary healthcare practices. Nursing Inquiry, 7(3), pp. 200–208. Barnes, L. and Rudge, T. (2005). Virtual reality or real virtuality: the space of flows and nursing practice. Nursing Inquiry, 12(4), pp. 306–315.

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Bowker, G. and Star, L. (2000). Sorting things out: classification and its consequences. Cambridge: The Massachusetts Institute of Technology Press. Ceci, C., Pols, J. and Purkis, M.E. (2017). Privileging practices: manifesto for “new nursing studies”. In: T.  Froth, D.  Holmes, M.  Hülsken-Giesler, S. Kreutzer and H. Remmers (eds.) Critical Approaches in Nursing Theory and Nursing Research: Implications for Nursing Practice. Göttingen: V and R Unipress. pp. 51–68. Cooke, H. (2009). Theories of risk and safety: what is their relevance to nursing? Journal of Nursing Management, 17, pp. 256–264. Cooke, H. (2006). Seagull management and the control of nursing work. Work, Employment and Society, 20(2), pp. 223–243. Fedoruk, M. and Toffoli, L.P. (2014). Australia’s healthcare system. In: M. Fedoruk and A. Hofmeyer (eds.) Becoming a Nurse: An Evidence-Based Approach. Australia: Oxford University Press. pp. 95–110 Foucault, M. (1977). Discipline and Punish (translated by A.  Sheridan). Harmondsworth: Penguin. Graham, S. and Thrift, N. (2007). Out of order: understanding repair and maintenance. Theory, Culture and Society, 23(4), pp. 1–25. Harvey, C., Thompson, S., Pearson, M., Willis, E. and Toffoli, L. (2017). Missed nursing care as an ‘art form: the contradictions of nurses as carers. Nursing Inquiry, 24(3), p. e12180. Health Practitioner Regulation National Law Act (Queensland). (2009). Available at: https://www.ahpra.gov.au/About-AHPRA/What-We-Do/ Legislation.aspx [Accessed 3 Mar. 2018]. Heartfield, M. (2005). Regulating hospital use: length of stay, beds and whiteboards. Nursing Inquiry, 12(1), pp. 21–26. Heartfield, M. (2002). Governing Recovery: Hospital Length of Stay and Episodes of Acute Care. Unpublished PhD thesis, School of Post-graduate Nursing, University of Melbourne, VIC. Jarzabkowski, P. and Pinch, T. (2013). Socio-materiality is the new black: accomplishing repurposing, reinscripting and repairing in context. M@n@ gement, 16(5), pp. 579–592. Lake, S., Rudge, T. and West, S. (2015). Making meaning of nursing practices in acute care. Journal of Organizational Ethnography, 4(1), pp. 64–79. Miller, P. (1992). Accounting and objectivity: the invention of calculating selves and calculating spaces. Annals of Scholarship, 9, pp. 61–86.

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Molina-Mula, J., Peter, E., Galow-Estrada, J. and Perelló-Campaner, C. (2018). Instrumentalisation of the health system: an examination of the impact on nursing practice and patient autonomy. Nursing Inquiry, 25(1), p. e12201. Moody, K. (2011). Capitalist care: will the Coalition’s ‘reforms’ move the NHS further toward a US-style healthcare market. Capital and Class, 35(3), pp. 415–434. Nursing and Midwifery Board of Australia. (2016a). Registered Nurse Standards for Practice. Available online: http://www.nursingmidwiferyboard.gov.au/ Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx [Accessed Mar. 2018]. Nursing and Midwifery Board of Australia. (2016b). Standards for Practice: Enrolled Nurses. Available online: http://www.nursingmidwiferyboard.gov. au/Codes-Guidelines-Statements/Professional-standards/enrolled-nursestandards-for-practice.aspx [Accessed 3 Mar. 2018]. Orlikowski, W.J. (2010). The socio-materiality of organisational life: considering technology in management research. Cambridge Journal of Economics, 34, pp. 124–141. Rudge, T. (2013). Desiring productivity: nary a wasted moment, never a missed step. Nursing Philosophy, 14(3), pp. 201–211. Rudge, T. (2011). The “well-run” system and its antinomies. Nursing Philosophy, 12(3), pp. 167–176. Rudge, T. (1997). Nursing wounds: A discourse analysis of nurse and patient interactions during wound care procedures in a burns unit. Unpublished PhD thesis, School of Nursing, La Trobe University, Bundoora, VIC. Thrift, N., Tickell, A. and Woolgar, S. (2014). Introduction: respecifying globalization. An editorial essay for globalization in practice. In: N.  Thrift, A.  Tickell, S.  Woolgar and W.H.  Rupp (eds.) Globalization in Practice. Oxford: Oxford University Press. pp. 1–16. Toffoli, L. (2011). ‘Nursing Hours’ or ‘Nursing’ Hours - A Discourse Analysis. PhD Thesis. University of Sydney, Sydney, NSW. Toffoli, L., Rudge, T. and Barnes, L. (2011). The work of nurses in private health: accounting for the intangibles in care. Health Sociology Review, 20(3), pp. 338–351. Toffoli, L. and Rudge, T. (2006). Organizational predicaments: ethical conditions for nursing research. Journal of Advanced Nursing, 56(6), pp. 600–606.

Chapter Nine: Reducing Healthcare Costs in Portugal: Outcomes and Implications for Public and Private Medicine Tiago Correia

Introduction Portugal is among those Western countries where the 2008 economic and financial crisis was intensely felt. In 2011, an assistance programme was established by the International Monetary Fund, the European Central Bank, and the European Commission to achieve a mass reduction of public expenditure—including in the health sector. Although the risks linked to the abrupt reduction of investment in health are well identified (Bezruchka 2009), the Portuguese authorities and their international counterparts considered the implementation of the programme to be feasible and one that would not undermine the regular functioning of the health system. This assumption was confirmed in the ex-post assessment of the programme in 2014 (European Commission 2014). However, evaluations of such policy reform are limited. On the one hand, analyses that use T. Correia (*) Associate Professor, International Public Health and Biostatistics Unit, Researcher at Global Health and Tropical Medicine (GHTM), Instituto de Higiene e Medicina Tropical - Universidade Nova de Lisboa, Lisbon, Portugal e-mail: [email protected] © The Author(s) 2020 F. Collyer, K. Willis (eds.), Navigating Private and Public Healthcare, https://doi.org/10.1007/978-981-32-9208-6_9

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macro-level indicators from secondary data are less able to capture the nuances regarding the functioning of health organisations and patients’ experiences. On the other hand, analyses that build on primary data tend not to give detailed attention to different medical settings, including between and within the public and private sectors. The aim of this chapter is to explore whether the policy responses to the 2008 crisis adopted in Portugal affected the functioning of the health system, notably in terms of the public-private relationship. This study focuses on how physicians experienced the policy responses to the crisis in their practice, and their perceptions of patients’ use of healthcare. Using primary data on access to, and perceived quality of, healthcare, the focus here is on specific organisational situations and experiences, generating in-depth knowledge on the conditions of healthcare provision. This approach is advantageous as some impacts of the policy change may not have been evident at the time of the previous evaluation, nor apparent at the macro level or in institutional data. With both institutional and macrolevel data less sensitive to the unexpected events of the functioning of health systems, a more nuanced approach to understanding the effects of policy change is provided. This approach avoids the methodological challenges associated with large-scale surveys of the population, in particular when specific situations and realities are not yet known. Large-scale surveys combine various groups under categories such as gender, age, ethnicity, social class, geography, and religion and in the process render outlier distributions invisible. In the absence of a clear understanding of which groups may face problems accessing healthcare, and in which circumstances, sectors of activity and medical services; the knowledge of those who are directly in contact with patients are a valuable source of information. Although focusing on the view of those working inside the system is insufficient in itself, it provides a greater diversity in the sources of information from which health systems are usually analysed. This issue is raised because policymakers often use the term ‘resilience’ when referring to the Portuguese health system’s capacity to resist the negative effects of the crisis. For this to be said, complementary methodological approaches need first to be tested. This work therefore focuses attention on the public and private sectors and the various medical services. Such attention has been to a large extent disregarded in debates about the policy responses to the crisis in the European context. Although public-private relationships are present in all

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universal health systems, specific configurations across countries make context-sensitive analyses necessary (Greer et  al. 2013) to gain better knowledge of the differences that are relevant to the analysis (Figueras et al. 2002). One difference in context is between private for-profit (e.g., voluntary, market-driven insurance schemes) and not-for-profit insurance (e.g., social insurance schemes). While the first builds on individual conditions of risk management and healthcare access, and funding is subject to market rules, the second builds on shared conditions of risk management and healthcare access, and funding is somewhat regulated (e.g., based on occupation, age, or region). This difference is even more important to acknowledge given that for-profit funding and provision is generally growing in countries with health systems built on either a publicly provided and financed system (such as the British National Health Service) or social insurance schemes (such as those in France, Germany, or the Netherlands). Another contextual difference concerns the form these public-private relationships can take. Such forms can be duplication (when public and private funding are in competition and cover the same basket of services), complementary (when private funding complements the public provision), or supplementary (when private funding and provision covers services not included in the publicly funded basket of services). Most health systems articulate two or even three of these configurations across their medical services (e.g., in-patient care; out-­ patient care; oral care; complementary diagnostic and therapeutic services). This chapter commences with a theoretical background underpinning the analytical approach, followed by an overview of the Portuguese health system. The goals of the study, methods, and main empirical findings are then presented and discussed in light of the public-private relationships of the healthcare system. The final section summarises the main conclusions.

 Theoretical Approach to Healthcare Policy A Analysis When signs of the 2008 crisis became visible in the European context, the WHO Regional Office for Europe (2009) recommended that member states monitor the effects of their policies on the performance of

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health systems with regard to efficiency, quality, and access. Few countries did so on an extensive basis, and evaluations focused more on efficiency than on quality or access (Thomson et al. 2014). Importantly, efficiency, quality, and access can be analysed differently depending on whether the focus is placed on service planning, purchasing, or delivery. In this context, performance evaluation focused mainly on service planning and purchasing, and to a lesser extent on service delivery (Mladovsky et al. 2012). As a result, evidence is still scarce about whether or not the crisis has affected access to, and quality of, care delivery in Europe. While the analysis of service planning and purchasing is unproblematically linked to institutional and macro-level data, the analysis of care delivery is more complex due to organisational functioning. The key to understanding organisational functioning is acknowledging that individuals play an active role within institutional contexts (DiMaggio 1997; Leca and Naccache 2006). This is the core premise of neo-­institutionalism, which echoes the theoretical assumptions of symbolic interactionism, phenomenology, and critical realism. Briefly, neo-institutionalism assumes that the behaviour of individuals is responsible for recreating institutional settings and functioning even where they are subjected to, and share, institutional roles. Organisational life therefore goes beyond its formal aspects (Mutch et  al. 2006; Hallett 2010; Delbridge and Edwards 2013). Neo-institutionalism, applied to the analysis of care delivery, links with several sociological arguments. One argument is the need to take into account non-linearity between expected and achieved outcomes of policies. Although this argument has a long tradition in micro-level approaches to organisations (Kirkpatrick and Ackroyd 2003; Lawrence et al. 2009), including in the health sector (Correia 2017), the fact that the analysis of health system performance pays more attention to service planning and purchasing than it does to delivery reveals a weakness in debates about the functioning of health systems. A study of institutional design and formal decision-making can reveal only one aspect of a healthcare system. What occurs in the everyday activities of organisations also requires attention. A second argument is that health professionals are a valuable source of information about patients’ experiences. Professional-patient relation-

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ships involve mutual trust and affection (Rowe and Calnan 2006); hence professionals should be included as key informants. Although there is controversy about whether trust in health professionals, and physicians in particular, is decreasing due to better informed patients, an increase in lay knowledge and improved patients’ rights; the overall conclusion remains that alternative sources of information have not replaced the clinical encounter and that health professionals’ empathy is the cornerstone of patients’ compliance with treatment regimens (Charon 2012). A third sociological argument links with the absence of systematic research into how the private sector has adapted to the crisis, despite previous evidence that public regulation of for-profit private providers can be less effective during economic and financial crises (Nishtar 2010). One way to capture specific labour conditions is to look at the internal differences of professions (Evetts 2006). Specifically concerning the medical profession, specialties have long been described as a pivotal form of internal stratification (Freidson 1970; Chauvenet 1973; Bodolica and Spraggon 2014), a form which translates across different work contexts (hospital or non-hospital care), medical procedures (more or less technological), relationships with the patients (direct or mediated by other specialists), clientele choice (indiscriminate or selected), and the sector of activity (public, private for-profit and not-for-profit). Therefore, making analysis sensitive to medical specialties is likely to reveal meaningful differences between and within the public and private sectors.

The Portuguese Health System: An Overview Healthcare services in Portugal are tax-funded and accessed mainly through State-owned organisations. Enrolment in the full basket of services is open to all residents and includes primary, hospital, and long-­ term care. Co-payments for publicly provided medical appointments, emergency attendances, complementary diagnostic and therapeutic services, and medications only exempt certain groups, totally or in part, depending on age, medical condition, and profession (Simões et al. 2017). One important feature of the Portuguese health system is the late establishment of the National Health Service (NHS). This took place in

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the early 1990s (Carapinheiro and Page 2001), a time when most countries were already debating the need to reform the public sector (e.g., see Gruening 2001 on the New Public Management [NPM]). The late establishment of the Portuguese National Health Service (NHS, Portugal) is explained by the opposition of conservative parties and the Portuguese Medical Council (Carapinheiro 2006), despite concerns about the epidemiological patterns in the population and an immediate need for massive investment in infrastructure, technology, and human resources (Carapinheiro and Pinto 1987). Not surprisingly, giving this timing, the NHS in Portugal emerged in combination with a well-established private sector with both for-profit and not-for-profit providers. The former includes hospitals, small-scale offices, and clinics with specialist care and complementary diagnostic and therapeutic services. The latter includes charity organisations that complement public coverage, mainly in-home and long-term care, and profession-based social insurance (Carapinheiro and Page 2001; Carapinheiro 2006). Access to private providers occurs through either the market (e.g., voluntary health insurance) or the NHS (e.g., public-private partnerships to reduce waiting times for surgical, diagnostic, or therapeutic services). Over the years, national and international private investors began to expand into innovative medical areas (e.g., cancer research) and competitive hospital and long-term care (Simões et al. 2017). In the 2000s, the health system clearly reflected a liberal conception of the NPM. This can be seen in three key areas (see Correia 2011; Correia and Denis 2016 for detailed descriptions). First, there was deregulation of the labour market (e.g., a rise in individual contracts, short-term contracts, and service provision; the freezing of professional careers; and increases in wage variation). Second, there was increased managerial control of professional practice (e.g., evidence-based procedures; clinical guidelines for monitoring and assessing incentives and sanctions; administrative approval of medical decisions; opening of management positions in departments; and the hiring of general managers). Third, there were changes in financing control (e.g., performance-based funding; penalties for non-compliance with a contracted activity; budget control tools at the organisational and ward levels; and evaluations in accordance with quantitative criteria).

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The purchaser-provider split is the underlying model of the NPM-­ driven reforms in Portugal. Initially, the purchaser-provider split was conceived only to introduce accountability and efficiency among NHS providers. More recently, it has also included the management of public hospitals by private third parties. While the effects on the public-private relationship remain unclear, it has shown two consistent patterns over time: one is the presence of for-profit and not-for-profit private players; the other is that the public and private funding and provision of medical services is either complementary or in duplication. Complementarity is found in co-payments (including for publicly provided care). Duplication is when public and private funding provide the same basket of services and compete for patients and resources. As a result of the 2008 crisis, Portugal underwent a financial assistance programme in 2011. This was agreed in consultation with the European Central Bank, the European Commission, and the International Monetary Fund. The three-year programme comprised clear policy targets and timelines to achieve a mass reduction in the budget deficit from 9.8 to 3.0 per cent of gross domestic product (GDP) in 2013 (Government of Portugal 2011). Health-related policies were aimed at various targets: increased co-payments; better drug-market regulation; tighter control over physicians’ prescribing and of the management of public provider organisations; more transparent public-private partnerships; the expansion of primary healthcare services; and savings on workforce costs (Correia et al. 2017b). The ex-post assessment of the programme shows that not all targets were achieved equally, despite the reduction in public expenditure. This reduction was more severe than initially estimated: from €550 million to €742 million in 2013 (Ministry of Finance 2014), which represents a total cut of around 7.0 per cent in public spending. The areas that were hit by these particularly severe cuts included co-­ payments, drug-market regulation, control over prescribing, and the management of provider organisations. The areas that were reduced to a lesser extent included transparency in public-private partnerships, access to primary healthcare, and workforce changes (European Commission 2014; Correia et al. 2017b). Perhaps not surprisingly, the unfulfilled reforms reflect some of the key issues of the Portuguese NHS: geographical imbalances in healthcare

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access and population health; the need to improve performance-based management models; lack of prospective planning for healthcare workers; and lack of consistency in the public-private relationship—particularly given that health professionals are allowed to work in both sectors and consequently public expenditure partially funds private provision (Correia et al. 2015). The outcome has been a growth of private health spending in voluntary health insurance and out-of-pocket payments. Overall, public expenditure in health reduced from 5.4 to 5.0 per cent of GDP and from 68.7 to 64.7 per cent of total health-related spending in 2010–2013 (World Bank 2015). Private spending consistently increased from 3.1 per cent of GDP in 2002 and reached a peak of 3.6 per cent in 2012. Out-of-pocket costs increased from 27.2 to 31.7 per cent between 2007 and 2012. Out-of-pocket costs reflect the growth in both the private market (voluntary private insurance premiums increased from 2.5 per cent in 2007 to 3.2 per cent in 2012) and users’ co-payments in the NHS (Statistics Portugal 2013). Nevertheless, both the Portuguese and various international authorities assessed the reforms as good practice (OECD 2015), based on the fact that, according to institutional data and large-scale surveys, population health indicators and patient satisfaction with healthcare services have not declined (Direção-Geral da Saúde 2015a, b).

Survey of Physicians: Methods This study sought to ascertain physicians’ perceptions of patients’ use of healthcare services, notably concerning requests to prescribe cheaper medications; requests not to prescribe medication; requests to pay for consultations and complementary diagnostic and therapeutic services (CDTS) in instalments; and patients’ abandonment of therapies explicitly for financial reasons. Physicians were also surveyed about their experience in several aspects of their practice. First, whether they experienced administrative interference in decision-making. This would tell us about perceptions of a loss of autonomy in such things as a rejection of innovative treatments, pressure to choose cheaper treatments, or not to prescribe certain medications. Second, whether their practice was affected by a lack

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of material resources, such as regular supplies (gloves, masks, needles, etc.) or medications. Third, whether there had been any deterioration in medical residency, that is, a lessening of opportunities for advanced learning and training, poorer working conditions or reductions in the availability of tutors. All registered physicians in the Portuguese Medical Council were surveyed via a structured, self-administered postal questionnaire (n  =  43,974), of which 3442 were validated for consistency, readability and in practice in Portugal at the time of data collection. Medical settings in the public sector included primary healthcare and hospitals, and small-scale offices, clinics and hospitals in the private sector (see Correia et  al. 2017a, b for detailed information on the study design, participants, measures, data analysis, and descriptive results).

Outcomes of Reducing Healthcare Costs Healthcare Access Physicians’ overall perceptions were that patients changed their use of healthcare services during the policy responses to the crisis: 82.2 per cent indicated that patients’ requests for the prescription of cheaper medications increased; 62.9 per cent reported that patients refused medical treatments for financial reasons; 27.6 per cent stated that patients more frequently asked them not to prescribe medications; and 18.8 per cent suggested that more patients requested the opportunity to pay for consultations and CDTS in instalments. A statistical difference was found between physicians working exclusively in the NHS and those who work exclusively in the private sector. Those in the NHS tend to report all these perceptions more often. Within the NHS, the comparison between primary and hospital healthcare is statistically significant for patient requests for cheaper medications and the suspension of treatments. The frequency is higher in the primary healthcare sector. Within the private sector, the statistical relationship is only found for patients’ abandonment of treatments, which takes place more often in private hospitals.

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Results varied by medical speciality: patient requests to prescribe cheaper medications was particularly high (response rate above 90 per cent) among neurologists, general practitioners, pulmonologists, internists and gastroenterologists; abandonment of treatments was highest for anaesthesiologists and psychiatrists (response rate above 80 per cent); requests not to prescribe medications was reported mostly by psychiatrists, ophthalmologists, and pulmonologists (response rate above 35 per cent); and patient requests to pay in instalments was most evident in responses by dentists and radiologists (response rate above 40 per cent).

Quality of Care The physicians’ overall experience shows that the quality of care was somewhat undermined during the policy responses to the crisis: 64.9 per cent reported regular shortage of supplies; 48.9 per cent less favourable conditions for medical post-graduate training; 30.6 per cent regular shortage of medications; 23.8 per cent greater pressure by the administration to opt for cheaper treatments; 17.3 per cent more refusals by the administration of innovative treatments; and 15.6 per cent administrative limits to the prescription of certain medications. These experiences tend to occur more often in the NHS. Differences are statistically significant for regular shortage of supplies and m ­ edications, pressure to choose less expensive treatments and not to prescribe specific medications. Specifically referring to the NHS providers, a statistical difference is found for all variables. Physicians in hospitals mention more administrative refusals of innovative treatments, shortage of medications, and lesser conditions for medical residency. Physicians in primary healthcare are more likely to mention a shortage of supplies, administrative pressure to choose cheaper treatments and not to prescribe certain medications. Regarding private providers, a statistical difference is found for the refusal of innovative treatments and less favourable conditions for medical residencies, which are more often reported in clinics. Complementary analyses by specialty provide evidence of the differences between working in the public or private sector. The refusal of innovative treatments in the NHS’ occurs mainly in radiology, while

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shortage of medications in physical medicine and rehabilitation, internal medicine, general surgery, ophthalmology, and psychiatry. In the private sector, the refusal of innovative treatments occurs mainly in oral care, while shortage of medications occurs mainly among general practitioners.

 ecessive Policies and the Implications R for the Public-Private Relationship Although the peak of the crisis has passed in the European region, a full assessment of the reform paths remains incomplete. The likelihood of economic and financial crises to take place in the future makes this analysis both timely and necessary. One major conclusion from the data collected is that the abrupt reduction of public health expenditure has negative effects on the functioning of health systems. It should be highlighted that this pathway was not followed in all European countries. For instance, cuts in health budgets were made more intensively in Portugal and Greece, while in countries such as Belgium and Denmark budgets remained at a similar level before and after the crisis (see Thomson et al. 2015; Karanikolos et al. 2013; and Albreht 2011 with regard to the various policy directions taken in Europe). According to the surveyed physicians, access to, and quality of, care delivery has been undermined, particularly with regard to the purchase of medications and treatments. This finding is relevant because the retail price of medications was reduced (Barros 2012), and the number of users exempted from co-payments in the NHS for medical appointments, emergency attendances, complementary diagnostic and therapeutic services and medications increased (Health Regulatory Authority 2013; Rodrigues and Schulmann 2014). We raise the issue of whether these policies sufficiently protected patients’ access. The undermining of the quality of healthcare is the result of the regular shortage of supplies and less favourable conditions for post-graduate medical training. One matter of particular consensus among academics and politicians is that the quality of care plays a crucial role in the sustainable functioning of health systems (Patel 2016). Therefore, this evidence draws attention to the

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extent to which the policy responses linked to sudden cuts in public spending may not only have immediate but also long-term effects in health systems. A second major conclusion of the study focuses on comparisons between the public and private sectors. The evidence shows that the NHS has been the main target of health-related austerity measures, even though these were expected to apply to all types of providers without exception. Accordingly, increased difficulty in healthcare access and the lower quality of care delivery is felt mainly in the NHS, while in the private sector the main outcome of reforms was the negative impact on medical residency due to over-worked residents and less time for tutors to provide training. Lower quality of care delivery in the NHS refers to insufficient resources and greater constraints on physicians’ individual decision-­ making (e.g., equipment shortages and administrative interference in clinical decisions). Greater difficulty in users’ access in the NHS may link to two different situations. One is the extent to which the NHS has placed limits on its universalistic vocation, as users cannot afford the increasing level of co-payment in publicly funded providers. Previous studies have already reported that some patients may have been unable to visit a physician or obtain medications (Sakellarides et al. 2014; Portuguese Observatory of Health Systems 2014). Another outcome is that users are likely to make choices between basic needs. This situation highlights not a problem of access to the NHS per se, but that lower levels of household income which occur during economic and financial crises eventually limit healthcare access, even if there are policies aimed at protecting the most vulnerable groups. It should be noted that household health expenses include illegal payments to ensure prompt access or receive good quality care (e.g., under-the-table payments, gifts, and favours) (Dubois and McKee 2004). The point here, which these authors also observe, is that apparently even small payments can have a large impact on patients’ access to care, particularly among those with low incomes and frequent healthcare needs. Further research on these matters will considerably assist in the design of effective policy responses to crises. A third major conclusion is that policy responses produced different effects also within the public and private sectors. In public services, physi-

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cians working in primary healthcare reported greater difficulty in patients’ access to healthcare, particularly evidenced by the higher number of requests for cheaper medications and the abandonment of treatments because of a shortage of money. As to lower quality of care, those working in primary healthcare more often reported equipment shortages and administrative interference in medical decisions, while those working in the hospitals reported more denials of innovative treatments, medication shortages and less favourable conditions for medical residencies. In private services, many patients in hospital care halted their treatments for financial reasons, which is a sign that voluntary private health insurance and other private subsystems (e.g., for civil servants, employees at banks and insurance companies) are not adequate options compared with publicly funded healthcare. However, in contrast to the NHS, there is little sign that the quality of care has been undermined in private hospital care; instead, effects were felt mainly in the small-scale offices and clinics. This evidence suggests the public-private relationship in the Portuguese health system is likely undergoing a reconfiguration towards marketisation. The concept of marketisation is employed here to take into account two slow but steady trends of the for-profit sector. One trend is the duplication of private services already provided by the NHS, which has been expanding for specialised care and fundamental research in high-­ technology, innovative fields such as cancer and transplantation. The other trend links with the retraction of small-scale providers and the growth of large investors and better-equipped healthcare facilities. The issue is how effective public regulation of private funding and providers can be in ensuring complementary public-private relationships (e.g., in oral care, CDTS, and in-patient care). The reconfiguration of the public-private relationship thus stems from professionals’ and users’ individual choices that affect the health system structurally, in the sense that they change their preferences about where they are willing to work and receive treatments. Professionals feeling that they are not being given the conditions they need, and patients not receiving care in the NHS, undermine the grounding principles of the NHS: universal access and comprehensive healthcare.

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It should be noted that physicians in the private sector in Portugal are already more motivated and satisfied, and less exhausted than those in the NHS, and these trends are more pronounced as seniority increases (Correia et al. 2015). This is likely to mean that the private sector will increasingly attract the more skilled professionals. This evidence is worth noting within the purchaser-provider split model between the State and private third parties. If the for-profit private sector is able to attract patients and professionals to higher-quality services, and the State is willing to contract the provision of publicly health services to any third party, hypothetically the State is likely to shift part of public expense and investment to the more attractive and high-quality providers regardless of whether they are privately or publicly funded. This scenario points to growing competition between not-for-profit and for-profit providers, and to the use of public budgets to fund market-driven investment in healthcare, which ignores the fact that for-profit and not-for-profit sectors operate for different purposes. Given these transformations, two key findings on health financing options should be recalled: the NHS-model is generally cheaper and performs as well as other funding systems (van der Zee and Kroneman 2007; Wagstaff 2009), and public health expenditure has multiplier effects on the economy (Beraldo et al. 2009) and also contributes to social cohesion and lower-social inequalities (Chuang et al. 2013). Accordingly, although the public-private relationship is found in most healthcare systems, further research is needed to take more account of whether for-profit and not-for-profit public and private funding should be in competition, and to what extent it unnecessarily exposures healthcare delivery to the rules of the market.

Conclusion The effects of financial crises on the functioning of healthcare systems have been a matter of great controversy in the European context. The lack of agreement reflects the way individual countries have pursued different reforms, but also suggests a need for alternative methodologies to assess patients’ choices and needs, and how health organisations perform.

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Building on the Portuguese case, this chapter has brought evidence of relevance to other countries. In Portugal, there is an institutional discourse about the way the health system has effectively adapted to cost containment measures. However, this discourse draws on analyses of institutional data on health services planning and purchasing, with little regard for care delivery. The intention of this study has in contrast been to focus on the experience of those working inside the system to learn more about how possible changes in access to and quality of care are perceived. The underlying assumption has been that the outcomes of policy responses may not have been the same throughout the health system, therefore, requiring more context-sensitive analyses. Physicians’ concrete experiences highlight the way that policy setting and outcomes do not always match. Findings showing a reduction in the quality of care and limitations to the access of patients to services indicate that the aim of mitigating the crisis in the health sector was not fully achieved, or that the health system did not adequately cope with the substantial ‘savings’ imposed on it. Furthermore, it should be noted that despite the fact that the financial programme for Portugal was generally accomplished, the reforms linked to some of the structural problems of the Portuguese health system were either partially implemented or withdrawn, thus the window of opportunity to overcome structural problems was to a large extent wasted (e.g., lack of transparency in public-private relationships, geographical imbalances in population health and access to the NHS, need to increase public expenditure in health, notably in ­public health, investment in technologies, infrastructure, and human resources). Finally, this study design is not free of biases and some limitations need to be acknowledged. While the sample is not fully representative of the physicians working in Portugal, it should be noted that this national database of physicians is one of the largest on this topic. Second, the instrument does not make it possible to fully ascertain the main causes underlying changes in patients’ behaviour or locate barriers to the use of healthcare. Third, the measurements reflect physicians’ personal experiences and are therefore not comparable to institutional data or to other health workers. Despite these limitations, this study provides evidence that focusing on the physicians’ concrete experiences provides new

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insights into the internal functioning of health systems, showing that the crisis did not impact public and private services similarly. Overall, it indicates that further research is required on the effects of marketisation on patient choices and on public health programmes.

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Gruening, G. (2001). Origin and theoretical basis of new public management. International Public Management Journal, 4(1), pp. 1–25. Hallett, T. (2010). The myth incarnate: recoupling processes, turmoil, and inhabited institutions in an urban elementary school. American Sociological Review, 75(1), pp. 52–74. Health Regulatory Authority. (2013). The New Legal Regime of User Fees. Lisbon: Health Regulatory Authority. Karanikolos, M., Mladovsky, P. and Cylus, J. (2013). Financial crisis, austerity, and health in Europe. The Lancet, 381, pp. 1323–1331. Kirkpatrick, I. and Ackroyd, S. (2003). Archetype theory and the changing professional organization: a critique and alternative. Organization, 10(4), pp. 731–750. Lawrence, T., Suddaby, R. and Leca, B. (2009). Actors and Agency in Institutional Studies of Organizations. Cambridge: Cambridge University Press. Leca, B. and Naccache, P. (2006). A critical realist approach to institutional entrepreneurship. Organization, 13(5), pp. 627–651. Mladovsky, P., Srivastava, D., Cylus, J., Karanikolos, M., Evetovits, T., Thomson, S. and McKee, M. (2012). Health Policy Responses to the Financial Crisis in Europe - Policy Summary 5. Copenhagen: WHO Regional Office for Europe. Ministry of Finance. (2014).Budget Outturn Summary Report 2013. Portugal: Ministry of Finance. Mutch, A., Delbridge, R. and Ventresca, M. (2006). Situating organizational action: the relational sociology of organizations. Organization, 13(5), pp. 607–626. Nishtar, S. (2010). The mixed health systems syndrome. Bulletin of the World Health Organization, 88(1), pp. 66–73. OECD. (2015). OECD Reviews of Health Care Quality: Portugal 2015. Paris: OECD. Patel, M. (2016). Changes to post-graduate medical education in the 21st century. Clinical Medicine, 16(4), pp. 311–314. Portuguese Observatory of Health Systems. (2014). 2014 Spring Report. Lisbon: Portuguese Observatory of Health Systems. Rodrigues, R. and Schulmann, K. (2014). Impacts of the Crisis on Access to Healthcare Services: Country Report on Portugal. Vienna: European Centre for Social Welfare Policy and Research. Rowe, R. and Calnan, M. (2006). Trust relations in health care  – the new agenda. European Journal of Public Health, 16(1), pp. 4–6.

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Chapter Ten: Promoting Health as a Form of Capital: The Transformation of the Danish Healthcare Field as Experienced By Private Healthcare Professionals Kristian Larsen and Ivan Harsløf

Introduction The predominantly public Danish healthcare system offers free or heavily subsidised access to healthcare services financed by progressive taxation. Yet, in recent decades, private sector medicine has gained some foothold. This development has been part of a general reorienta-

K. Larsen (*) Oslo Metropolitan University, Oslo, Norway University Hospitals Centre for Health Research (UCSF), Copenhagen, Denmark Department of Public Health, Copenhagen University, Copenhagen, Denmark e-mail: [email protected]; [email protected] I. Harsløf Oslo Metropolitan University, Oslo, Norway e-mail: [email protected] © The Author(s) 2020 F. Collyer, K. Willis (eds.), Navigating Private and Public Healthcare, https://doi.org/10.1007/978-981-32-9208-6_10

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tion of Danish society towards marketisation. Within healthcare, one has seen the ­privatisation of certain services, including the emergence of for-profit hospitals from the 1990s (although these remain relatively small and specialised). The expansion of private healthcare services has been stimulated by a dramatic increase in private health insurance. Moreover, through a full-­fledged adoption of new public management strategies, a market logic has been introduced into the public healthcare system. In this chapter, we examine how the marketisation of healthcare services, and transformations in the field of employment, has brought about a more general commodification of health, nurturing health as an object of individual investment. We investigate how this development manifests in a general transformation of the Danish healthcare field, paying special attention to professionals employed at private health service providers. We present an analysis of four cases revolving around the professionals’ experiences with their working environments, peer pressure for engaging in health activities, their reflections regarding the patients’ motives for seeking private health services, as well as their strategies for maintaining and improving their own health status. This chapter is organised as follows. First, we account for changes in the Danish healthcare system, demonstrating how elements of private sector medicine have grown in importance. We locate this account within larger developments in the Danish labour market and welfare system. Second, we outline a Bourdieusian perspective for analysing these interrelated fields. Third, we present the methodology of the study. Fourth, we present analysis of four individual cases. We conclude that health and healthy lifestyle are promoted in private healthcare institutions. This promotion occurs within healthcare institutions among different groups of patients (in their capacities as clients and customers) and the service staff themselves on different levels. The healthcare professionals display a high level of awareness on how to play the ‘health game’, navigating a field increasingly dominated by processes of commercialisation and individualisation.

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Recent Changes in the Danish Healthcare Field With 85 per cent of health expenditures covered by the state, the Danish system has one of the lowest levels of user payments in the world (Nomesco 2017). Even among the Nordic countries, Denmark stands out as having no user fees for visits to general or specialised practitioners. Thus, Denmark maintains strong universal characteristics, with principally free and equal access to high-quality healthcare services. Yet, recent decades have seen a restructuring of the relationship between the public and private sectors in Danish healthcare, with an increased emphasis on healthcare financing and the healthcare market. In 2001, the Liberal-Conservative government passed legislation that boosted this development. It issued a treatment guarantee allowing patients on waiting lists to opt for private treatment that would then be paid for by the state (Andreasen et al. 2009), as well as exempting private health insurance from taxation. Such insurance is purchased by employers to cover employees’ immediate treatment at private healthcare providers. In the subsequent decade, the number of people holding private health insurance covering immediate private treatment multiplied by 20. Currently, of a population of 5.7 million, 3.3 million have private health insurance. Throughout the 2000s, the number of private hospitals and clinics grew from five, in 2002, to 178, in 2008, although each of these was much smaller than the 49 remaining public hospitals (Danish Ministry of Health and Domestic Affairs 2007: 27). During the same decade, private hospitals attracted international venture capital and became consolidated businesses (Møller Pedersen 2010). The public hospitals have recently adjusted to this form of competition and, supported by regulation, ‘taken back’ treatments related to skeleton/ bones, muscles, and circulation. Yet, following new agreements between the regions and the private hospitals, the private sector has moved from functioning as a buffer to becoming more of an integral part of the healthcare system, with an increasing number of patients receiving medical examinations and treatments by private providers (Danish Regions 2016).

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The stimulus towards private health insurance has privileged the private employment sector, since providing such insurance to employees was much more advantageous for private employers (see also Chapter Three). Indeed, as of 2008, 58 per cent of private employees had private health insurance compared to only 6 per cent of public employees (Ugebrevet A4 2008). An abolition of the tax exemption in 2011 by the incoming Social Democrat-led government did not curb the popularity of private health insurance. To stay attractive, coverage was subsequently extended to new areas such as physiotherapy and dental treatment. Since the early 2000s, Denmark has followed many other countries in moving from the block grant funding of hospitals to activity-based funding, facilitated by the adoption of the Diagnosis Related Group (DRG) system. This system turns treatments into ‘products’ with a fixed price. By stimulating competition between healthcare providers, the DRG pricing system invigorated a system where patients could choose their treating hospital or clinic—a free choice that had existed since 1993, but until the early 2000s had seldom been used (Andreasen et al. 2009). In 2007, a healthcare restructuring entailed downward rescaling towards new, larger, municipal units, and furthered a process of contracting-­out (Green-Pedersen and Baggesen 2009). The reform set up a new financing structure that entailed municipal co-funding of their residents’ general hospital admissions, and additional fees for patients staying at hospital when ‘discharge ready’. The new system was meant to encourage preventive measures and post-acute treatment and care (Andersen and Jensen 2010). However, research indicates that because municipalities can hardly act on these economic incentives by substituting hospital healthcare services, the reform penalises municipalities with a socio-demographic structure characterised by a high number of low educated, unemployed or disabled persons (Møller Pedersen 2005). A strong focus on efficiency, budget control and new public management practices— including the economic incentive for municipalities to take over ‘discharge ready’ patients—has resulted in an intensified patient turnover. The average length of stay in hospital has been reduced dramatically and is currently estimated at 5.5  days, compared to an OECD average of 7.8  days (OECD 2017a). Hospital social workers, whose services are often provided in the late stages of hospitalisation, have expressed concern

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that vulnerable patient groups will be left on their own too early. Indeed, during the past three decades, the number of hospital social workers has been dramatically reduced in Denmark (Harsløf et al. 2016). The private market has also expanded in the periphery of the healthcare field. The purchase of alternative therapy services more than doubled between 1987 and 2010 (The Danish Patient Safety Authority 2018). During the same period, other commercial institutions appeared in the field, offering a wide range of possibilities for investing in the body (e.g., fitness, aerobics, yoga, spinning, cross training) (Kirkegaard 2011).

A Changing Field of Employment These changes in the healthcare sector should be seen against the background of a general reorientation towards the market in Denmark over the same period. This reorientation has included deregulation of the financial sector, a comprehensive privatisation of societal infrastructure (airports, telecommunication companies), corporate tax cuts and substantial retrenchments in social security (Hornemann Møller 2013; Pedersen 2011). The restructuring of welfare provisions to encourage active labour market participation of groups with poor health is particularly of note. As an advanced and transnational post-industrial economy, almost four out of five employees work in the service sector in Denmark. From the mid-1990s and throughout the 2000s, Denmark’s rise in foreign value-added share of gross exports was among the highest in Europe, indicating a strong integration into global value chains (OECD 2017b: 90–91). These features have stimulated demand for workers with not only strong formal credentials but also informal skills, such as the ability to adapt to new work tasks and processes, and a host of socio-emotional skills, including creativity and inter-cultural competencies. Purchasing employment services, or contracting them out to private actors, increased strongly between 1995 and 2006 (Kvist and Harsløf 2014). This trend later stagnated somewhat, and public-private collaboration and partnerships became a more frequent model of private sector involvement (Breidahl and Larsen 2015). Danish state authorities have also encouraged local authorities to adopt employment-oriented measures towards out-of-work citizens by setting up a financing system that rewards

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‘activation’ and, at the same time, offers municipalities little reimbursement for keeping citizens on ‘passive’ programmes (e.g., sickness benefits or a disability pension). Related policies include those seeking to promote marginalised clients’ ‘employability’ by health-oriented measures (including counselling and lifestyle interventions), or even supporting aesthetic treatments to remove barriers towards employment (e.g., obesity operations, removal of tattoos, treatment of poor teeth). However, research has found no employment effect of health-oriented employability measures for marginalised groups (Rosholm et al. 2018). Vocational rehabilitation programmes, a cornerstone of the social contract between the state and its citizens during the golden age of the welfare state, have been scaled down. The embracement of the virtues of the private sector also appears in a reorientation of what remains of these programmes towards ‘place-thentrain’ models (organising work training in real enterprises without preliminary training in vocational rehabilitation institutions) (Harsløf 2004). Perhaps most pertinently, an ‘asset model’, focusing on opportunities rather than hindrances and deficits, has come to dominate social and labour market policies towards people with health problems (Håvold et al. 2017). The strong return-to-work orientation of such policies is reflected in a 2009 large-scale government-initiated experiment, where randomly sampled sickness benefit recipients were required to participate in mandatory activation ten hours a week, even if they had to sacrifice regular treatment. While the experiment had to be called off, lacking sufficient legal basis, the asset model is encapsulated in the explanatory memorandum from the 2012 Danish law proposal that significantly restricted access to the disability pension, which claimed that for many people with somatic or psychological illnesses ‘working is a part of the way to recovery’ (Danish Ministry of Employment 2012: 25; translation by authors).

 Bourdieusian Perspective on the State A and the Healthcare Field Bourdieu argues that an important function of the state is to produce and canonize social classifications. For certain individual attributes to be of value, they need to be appreciated by the states’ institutions: the school

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system, the healthcare system and so on. Promoting value systems related to certain attributes and artefacts through the state’s institutional apparatus serves an important function of social stratification. As Vandenberghe (1999: 53n) states, the ‘dominant classes are only dominant if they successfully impose their sort of capital as the dominant principle of hierarchisation’. The healthcare field intersects with the state, and the state is not a monolith. Rather, pointing to its inherently ambiguous nature, Bourdieu and Wacquant define the state as an ensemble of administrative or bureaucratic fields … within which agents and categories of agents, governmental and nongovernmental, struggle over this peculiar form of authority consisting of the power to rule via legislation, regulations, administrative measures … in short, everything that we normally put under the rubric of state policy as a particular sphere of practices (Bourdieu and Wacquant 1992: 111).

Struggles within the state are fought between positions in and between political parties, organisations and departments, involving politicians, bureaucrats, activists and professional lobbyists. In pointing to the main antagonist positions, Bourdieu (1999: 183–184) speaks about the ‘right hand’ and the ‘left hand’ of the state, representing economics/finance and social concerns, respectively. Building on Weber’s notion of the state’s monopoly on legitimate (physical) violence, Bourdieu argues that what is at stake in these internal struggles is the monopolisation of legitimate symbolic violence. This monopoly regards ‘the power to constitute and to impose as universal and universally applicable’ (Bourdieu and Wacquant 1992: 112). Bourdieu argues that the state is a meta-capital; that is, the culmination of a process of concentrating different species of capital, which involves physical force or instruments of coercion (army, police), economic capital, cultural or informational capital and symbolic capital. This meta-capital involves the possibility of controlling and regulating other species of capital, including their ‘exchange rate’ (Bourdieu and Farage 1994: 4). The healthcare field has some autonomy but is dominated by the meta-­ field, especially as the latter can control the ‘exchange rates’ of capitals;

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however, it should be added that it is only partially national. Many transnational institutions and organisations shape the field. Supranational institutions such as the European Union and the World Health Organization produce critical legislation, regulation and frameworks (Vollaard et al. 2013). Moreover, both for-profit (e.g., the pharmaceutical industry) and non-profit (humanitarian) organisations operate internationally, setting important premises and forming discourses, terms and concepts that affect structures and practices at the national level. A healthcare field involves struggles between key actors (e.g., medical doctors, government ministers), groups (e.g., activists, lobbyists), organisations (e.g., specialist colleges, pharmaceutical companies, professional associations) and institutions (e.g., universities, medical schools) (Collyer et al. 2017: 98). These transformations of meta-fields and the intersection between fields of labour and health change institutional practices. New possible social strategies appear as the rules of the game slowly change. Below, we examine how transformations change practices among patients and professions and form new rules for inclusion and exclusion. Inspired by the work of Bourdieu, our concept of health capital (Larsen et  al. 2013) highlights new forms of distinctive practices among social groups and individuals pertaining to their work with, and on, the body or specific body parts. While grounded in distinctions between social class, the practices encapsulated by health capital also relate to age, gender and ethnicity. These are specified in a typology comprising five types of investment styles (Larsen et al. 2018) and articulated as continuous investment in the physical body, the mental body, the surgical body, the chemical body and the nutritional body. These investments take place in spatial, temporal and institutional contexts (e.g., training in fitness centres or treatment in clinics), with the purpose of stabilising or optimising social position in specific social fields. Expanding on previous work (Larsen et al.2013), we argue that health assets acquired by investments in the body become an extra asset enabling leverage in the social game, both in the field of healthcare and the field of employment. Health capital is promoted and traded both in practice and in symbolic representations. Practice constitutes actually ‘doing’ the investment (taking the right medication or training of the body) and symbolic representations ‘express’

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investment (e.g., through conspicuous health consumption, updating sports achievements on social media or even job applications) (Larsen et al. 2018). We argue the changes that have taken place in the Danish healthcare field have allowed for the emergence of a new type of capital concerning the physical and mental body.

This Study Our research focuses on individuals working in private healthcare settings and examines how institutional contexts advance the accumulation and conversion of health capital. We anticipate that such processes can be observed in terms of practices and representations among the staff working in such settings. This chapter reports from a specific and selected part of a wide-ranging study involving a survey with 540 respondents and in-depth interviews of 30 participants from the Danish healthcare field (clinicians, teachers and students). The in-depth interview participants had previously responded to the survey and were sampled strategically to represent a broad spectrum of educational backgrounds, job functions and public/private sector affiliation. The four interviews presented in this chapter were conducted in 2017 and lasted 30–40  minutes. Interviews were conducted face to face, recorded and transcribed verbatim. Interviews at the interviewees’ workplace provided insight and observations of the physical space, design and artefacts of the context. The semi-structured interviews focused on the five investment styles: the physical body, the mental body, the surgical body, the chemical body and the nutritional body (Larsen et al. 2018). We asked questions such as: ‘Are you doing physical training?’ and ‘Is this practice an advantage or the opposite in your job position?’ We also asked about health practices and preferences among patients/clients and ­leaders/ administrators in relation to their jobs. Overall, we were interested in participants’ ‘taste of health’ related to their own bodily investments and also their perception of how patients/clients and organisations value bodies. The cases comprise two physiotherapists (one of them, the owner of a clinic), an occupational therapist and a dental nurse. With an interest in the larger processes of change in the healthcare field (genesis and struc-

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ture), we sought to analyse deductively with sensitivity to Bourdieu’s theory, with special attention to health capital. In this respect, inspired by Glaser’s (1978) analytical codes, we systematically searched for passages in the interviews related to processes indicating changes over time. This might, for example, occur in situations where interview participants with long tenure reflect on changes they have witnessed during their career.

Four Empirical Cases Four illustrative cases of health professionals working in private health services are presented.

 nne, Physiotherapist: Witnessing a Transition A from Helping Others to Training the Individual Anne is a physiotherapist with approximately 30 years of experience. She works in a relatively large private clinic in a prosperous neighbourhood. In addition to private clients, the clinic collaborates with the local authorities to provide various courses for municipal employees on sick leave, focusing on back pain, coping and stress. Anne refers to the place as dynamic and busy, and as ‘a fast clinic’, meaning that they have a strong focus on patient turnover, enlisting new clients and producing an economic profit. She reports that, in her experience, the profit-driven culture is a general trend across the various private physiotherapy clinics and states: ‘When I was young, we had a quite different approach’. Anne senses a new culture among her young colleagues. Many are especially interested in the training of patients. This ‘fixation on training’, she believes, is supplanting the traditional physiotherapist role of ‘helping other people with problems’, in favour of a new role as ‘personal trainer’. Anne tells us that even when explicitly looking for new physiotherapists with more traditional forms of specialism, such as neurology, they are swamped with applicants with ‘personal trainer’ profiles. Her colleagues are preoccupied with the numerous physical activities in which they are

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engaged in their leisure time, emphasising their strong physical condition and performance, bragging about the records they have broken and competing with each other: The vast majority of the young people [employed here] have very well-­ trained bodies, they are absorbed in sport. I am sitting with job applications right now … and the [young] candidates use a lot of space in their applications on presenting their leisure interests, which are sport (Anne, physiotherapist).

According to Anne, the older colleagues at the workplace are less involved in such competition. However, many of the social gatherings in which they partake, and invite each other, revolve around physical activities, like arranging tennis tournaments, kayaking, cross training and running. She estimates that 95–98 per cent of the staff, including the receptionists, are involved in some kind of sport in their leisure time. When recruiting new physiotherapists, informal competencies and appearances play a strong role for Anne: I look at whether the person in question is well groomed. That’s important—that you look presentable, because this is a service profession. We need to go out and sell ourselves in a sense. We have to do that, because this [i.e., the physiotherapy services] costs money (Anne, physiotherapist).

Anne qualifies this by stating that, to her, a good appearance, having an ‘open gaze’ and being an ‘open person’ counts more than ‘weight and muscles’. Later, however, she states that it is important that you look ‘healthy’. She explains that the clinic is a place where one ‘sets the stage for’ fitness, as they have a fitness centre, halls for sport and a spa. She goes on: ‘today this is very much built on that you should look good and look well-trained’. In a few instances, temporary staff have not been offered permanent contracts due to problems of cleanliness or overweight. Pursuing health capital, and especially focusing on the physical body (and to a lesser degree on the nutritional and mental body), is a core activity for the clients, employees, management and the leaders of the organisation. This clinic attracts clients with the necessary economic cap-

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ital, but also with the time and energy for such an investment in the physical body.

 arie, Occupational Therapist: Improving M Unemployable Bodies Marie works as an occupational therapist in a section of a private health institute concerned with health and employment. The institute is sub-­ contracted by the public employment services to provide health services for certain groups of unemployed people. While working part-time, Marie is taking a master’s degree in pedagogics, focusing on the facilitation of learning and processes of change. Marie and her colleagues work with clients sent from the employment services, assisting them with mastering everyday life tasks. Among other things, Marie and her colleagues use mental training, such as acceptance and commitment therapy—a psychological method to help patients cope with pain. Exercise and physical activities are an important part of the clients’ therapy. A keyword for Marie and her colleagues is ‘progress’. Preparing ‘progress reports’ for the individual clients is an important task. The reports log the clients’ incremental development during their enrolment in the programme—‘where are you now, and where are you going next?’ She refers to the philosophy as ‘the small steps’, meaning that they aim to obtain small improvements one step at a time. Healthy living is cultivated among the staff. Marie makes reference to the ‘physical body’, the ‘nutritional body’ and the ‘mental body’: We really talk a lot about keeping fit, and you can also see that among the staff. This is the prevailing conception. So, the physical body is important, but also nutrition … We eat lunch together, nutritionally correct food. And actually also the mental; we have relaxation of tension, we talk a lot about mindfulness (Marie, occupational therapist).

Norms about nutrition are cultivated among colleagues in a humorous way:

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We can be sitting laughing … like commenting if a colleague is eating a salami sandwich without any vegetables, you can say: ‘That’s delicious food you’ve got today, would you like to borrow some cucumber?’ Then we can sit and laugh about that, and the person may say: ‘Oh you know I refuse to eat vegetables’, but then of course she has broccoli cooking in the microwave (Marie, occupational therapist).

Yet, beneath the collegial humour, there is a grain of seriousness: ‘When I think about it, one should rather demonstrate that one eats healthy one way or another’ (Marie, occupational therapist). Despite the importance of demonstrating an awareness of healthy living, Marie explains that the staff are not ‘fanatical’ about this. Often during the afternoons, sweet foods are passed around. She tells us that some of her colleagues are overweight themselves, and this may not be a big problem. In fact, it may even have a pedagogic effect—it signals to their clients that ‘it’s possible to exercise even if you’re obese’. However, she holds that it is important that they, despite being overweight, appear healthy. When asked about hiring practices, Marie says that besides formal qualifications, she looks for a good level of personal energy. Resilience, youthfulness and a sparkling personality are important qualities. She tells us that job applicants always write in the applications what type of sport they do in their leisure time: ‘I run, I do this, I do that …’. In this private health institution, the recruitment of both the clients and the professionals is dependent on the amount and composition of economic, cultural and health capital. The out-of-work clients sent by the public employment services are offered programmes related to physical training (the physical body), personal energy and mindfulness (the mental body), as well as information about eating habits (the nutritional body). The products are sold to clients who strive to optimise their position in relation to the labour market.

 irgitte, Dental Nurse: High-Class Clients and Low-­ B Class Professions Birgitte has held several different jobs within private healthcare. At the moment, she works part-time while recovering from an accident. The

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interview revolved around her experiences working as a dental nurse in several private clinics. Her longest period of work experience involved an upmarket clinic in a metropolitan city area. The clientele of that clinic consisted of affluent people, primarily women, who, according to Birgitte, were highly preoccupied with their appearance. Birgitte believes that almost all of the patients had undergone plastic surgery. Conversations with patients, Birgitte recalls, revolved to a high degree around health issues. Expectations were that the personnel at the clinic were kind of selling the idea that this [the dental service] is healthy—not only for your teeth, but also for your body, seen in the larger context (Birgitte, dental nurse).

Birgitte tells us that there was a strong focus on appearance among the staff of the clinic. They talked a lot about healthiness and nutrition, with subjects ranging from the type of leisure activities to engage in to the effects of probiotics in yoghurt: You were very conscious that this is being preached, it is what you’re living for, like if you didn’t have any leisure interests, then you were outside … There was a community revolving around healthiness and what the norms are (Birgitte, dental nurse).

Discussions on healthiness among Birgitte’s colleagues primarily concerned family life, and particularly the forms of active leisure activities in which their children were involved. She says it was also common among the staff to have eyebrow lifts or a contouring of their lips: ‘It was the standard to have gotten such jobs’. The focus on appearance originated not only from the staff and the clientele but appears to have been encouraged through organisational priorities. For example, staff were supposed to wear a uniform that, according to Birgitte, only fitted a slim body and thereby quite clearly imposed a specific body ideal upon them. ‘It made me feel like a fat cow’, she recounts. Birgitte refers to processes of staff recruitment as ‘casting’; candidates were sought who signalled to the patients that ‘here we devote ourselves to healthiness’. Also, the internal staff care revolved around the commu-

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nication of health ideals. When choosing a restaurant for a staff night out, for example, more exclusive places were chosen that overtly cultivate nutritious cooking—‘it had to look right, you know’. While demonstrating a strong awareness of such systems of classification (the type of restaurant appropriate for the type of clinic), one also sensed a tension between her habitual dispositions and the position she later got in this ‘posh’ clinic. Over time, Birgitte internalised the health culture of the clinic: ‘In the beginning, it was a pressure, but eventually it became a lifestyle’. When referring to her work experiences with other dental clinics, Birgitte mentions easily fitting into their more relaxed cultures, where the ordering of pizzas for staff events was not considered ‘sinful’. Nevertheless, Birgitte believes that keeping certain standards is important when working in private health services. As she expresses it, ‘Health is also a competence; [you ought] to look presentable, the best version of yourself ’. In the clinic from which this case derives, certain distinctive attitudes are necessary, both in relation to ‘dental performance’ but also in general towards eating, drinking, clothing and body habits. The wealthy clients have distinctive preferences and can invest economic and cultural capital in improving their dental appearance but also in plastic surgery: eyebrow lifts, contouring the lips (the surgical body), diet and eating habits (the nutritional body), as well as fitness and bodily appearance (the physical body). Similar ideals are distributed among and are, more or less, adopted by the employees. But often there is a discrepancy between what is needed in the job (similar to the high-positioned clients) and the dispositions of the employees. In this case, a relatively low-positioned dental nurse with a two- to three-year education can experience a mismatch between her objective job position and her own dispositions, given that she needed some time to adapt to the position.

Jonas, Physiotherapist: Knowing the Business Jonas is a physiotherapist and owner of a private physiotherapy clinic. Part of a franchise, it is relatively large and has numerous areas of specialisation. Yet, the business only has a small staff of employed physiotherapists, since the majority are affiliated as independent practitioners. The

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clinic receives patients with national health insurance, most of them coming through referrals from their GP. An increasing proportion of the patients come with private insurance, attending, says Jonas, ‘because they have a choice’. Even if privately insured, the insurance companies may require that some of the treatment is covered by national health insurance. When accounting for this complex situation of different types of insurance schemes and levels of coverage, Jonas adds, ‘I know the business, you know’. His own employed staff are also covered by private health insurance through the clinic. When recruiting, Jonas is reluctant to look at the ‘bodily expression’, preferring, he says, to look at what he terms the ‘human expression’ or personal qualities. He seeks ‘team players’ and avoids people with ‘big egos’, for example, those who are overly particular about the clientele they want to work with. However, Jonas adds that people can weigh too much to be suitable staff members for his clinic: It is just not convincing in my world, to work with patients, if you are to treat their knees and hips, if you are overweight yourself (Jonas, physiotherapist).

Jonas admits that there was one occasion when he terminated an employment position because the staff member was overweight. He estimates that about 90 per cent of the staff have a ‘normal BMI’. The people working in the clinic like sport, competing in running, cycling and other activity-based events; for example, most staff are very preoccupied with exercising in fitness studios. Nevertheless, Jonas tells us that those not engaged in such activities, or those who do not look like they exercise (even if they do), are not necessarily excluded. Jonas personally goes to the gym twice a week. He has a personal trainer ‘so that I know for certain that I’ll be there … another person is expecting you—it’s his time and your time’. Furthermore, he plays golf. ‘Investing’ in his body, a term Jonas uses, is something he considers ‘ordinary common sense’. On an annual basis, he visits his GP to monitor blood values, and he is screened for diabetes as well as prostate and kidney diseases: ‘The numbers are super great, blood pressure is ok’. He partly attributes his ability to maintain a healthy lifestyle to his ‘young

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wife’, who is very much into organic and healthy food. Mentally, he has been seeing a psychologist to improve his ability to cope. There are regular meetings between the owners within the franchise organisation. In Jonas’ experience, there has been an increasing focus on sport and health activities among this group. When they are organising meetings, questions arise about whether there is a fitness centre at the venue and whether they should arrange for running in the morning. Their recent meeting was located in an all-sports-inclusive resort in the Mediterranean, with the meeting programme interspersed with training sessions. In this private clinic, physiotherapy and a broad range of physical activities are offered to clients supported by national health insurance, and to an increasing degree clients with an employment-based private insurance. Most clients pay little or no fees at this private clinic, though a few pay too much—although this group are primarily on the job market and relatively privileged in economic and cultural capital. As the fields transform the clinic experience to a larger degree, clients, but also the employees, ask for different, individualised and varied forms of physical training, and the owner changes the clinic in order to meet this demand from the market, which also includes his own staff. The individualised training and the physical body are central in every aspect of the institution, involving the training artefacts, the supply of treatment to the clients, as well as the stories and narratives told between the employees. The owner has quite distinctive attitudes in relation to body and bodily practices, indicated by his overt dislike towards smokers, but we also note a somewhat laid-back attitude (attributing his healthy nutrition regime to his young wife), a nonchalance that is perhaps afforded by having a management/owner position in the organisation.

Discussion This empirical material about bodily health capital offers a window into the substantial transformation of the healthcare field of Denmark, which is reflective of social change.

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Across the cases, we identify a number of analytical oppositions and distinctions, such as the oppositions between clinic owner and employed staff (including professionals affiliated with a clinic on an independent basis). Likewise, we have accounts of a young generation of professionals who are absorbed in sport, competition and the role of ‘personal trainer’, contrasted with an older generation who have cultivated a professional ethos around ‘helping people with problems’. We have people working with well-off clients ‘who come because they have a choice’, contrasted with people working with various marginalised clients who are sent by the public employment services to improve ‘employability’. Yet, at a certain level, there is also a structural homology across the contexts in which these different groups of patients are embedded. The former group often comes with private health insurance, paid by their employers, accelerating the return-to-work process. The latter group receives treatment supported by the authorities to prepare themselves for the world of work. These distinctions and relations of dominance between young/old therapists, well-off/marginalised clients and employed/non-employable clients are in line with studies showing high/low positioned institutions, professions, diseases and so on (Hindhede and Larsen 2018). Hence, in both cases, we observe how a post-industrial labour market, increasingly preoccupied with health and the healthy body as a marker of competence, is structuring the field. While research, as cited previously, finds the employment-oriented health measures adopted towards the marginalised groups ineffective, we may consider these measures a means for the dominant classes to impose their health ideal as a principle of hierarchisation. The health professionals display a highly reflective stance on health behaviour and motivational factors. They know how to counter their own temptations (e.g., the temptation to skip training) and are also aware of how to motivate various client groups. They excel in observing the culture at their workplaces, recognising the serious undertone behind seemingly humorous exchanges on eating habits. We hear explicit reflections on systems of classification concerning the way a certain clinic might indicate an appropriate place for dining out as part of staff events. The commercialised setting of the private clinic and its relation to its surroundings has become habituated into taxonomies of practice. We have insider accounts of processes of change. There are testimonies of a field shifting towards a more individualised and profit-seeking

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approach to services. Moreover, there are accounts of processes of internalisation of the new culture, as encapsulated in Birgitte’s statement on the way the workplace health culture eventually became a lifestyle. We observe private organisations that set the stage for health performance, that is, how traditional treatment facilities are now combined with spa and training studios and how personnel are provided with uniforms that ‘require’ certain body shapes. The terminology of ‘casting’ (when recruiting) and taking roles that are ‘convincing’ (when working with clientele) bears witness to how employees in private sector health services see themselves as actors who are supposed to embody and practice health—and especially the physical body—in support of the organisation’s profit. In this setting, the professionals find themselves urged to ‘sell’ services as healthy, ‘invest’ in their own bodies, selling themselves (in the sense that their body/appearance merges with the product), and lead patients to buy into the health and lifestyle ideals. Reflecting on these inferences, we see how health as a capital stands out as ‘relational’. The effect cannot be attributed to the individual agents but is constituted in an interplay between private organisations, public authorities, professional communities and customers/clients. Further transformation of the field related to other fields involves the presence of health capital—more deeply rooted and not only embodied as habitus and orientations among professions and clients, but also institutionalised in regulations of the field and materialised as new health-supporting artefacts.

Conclusion Bourdieu (1981) pronounced, from a theoretical position, how a range of health professionals—doctors, psychologists, psychoanalysts, sexologists, life coaches and body therapists—had supplanted religious leaders as the new priesthood in the social space. During the almost four decades that have passed since he made this observation, this change in the social order appears as fully completed—with ramifications across a range of fields. In this chapter, we have discussed the transformation of the Danish healthcare field and how it intersects with the field of employment. Based on the empirical analysis of four selected cases, we trace changed conditions of social reproduction, which prompt agents to engage in personal health investments.

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While the ‘left hand’ has featured relatively strongly in the Danish welfare state, the ‘right hand’ has gained increasing power. Hence, during the recent 30 years, though relatively modestly in terms of production volume, private sector medicine has been allowed and even encouraged to reach a consolidated position. The private and the public sectors have also become increasingly intertwined. The mechanisms of health insurance and the inroad of employment issues into areas such as the physiotherapy space seem to bring the market and state together in a new way. One may ask whether the state’s ‘monopoly’ on the production of social classifications concerning the healthy body has been broken. We observe a reconfiguration of the healthcare field to serve the employment field with an orientation towards patients’ fast return-to-­ work. The employment field is even lauded for its healing effects, in stark contrast to the rationale of the industrial era that emphasised necessary rest and restitution when physically or mentally ill. In other words, the domination of the right hand state involves a growing supremacy of the field of employment, as its concepts, classifications and logics are promulgated to adjacent fields. With a closer look at the private sector as part of the healthcare field, we observe a correspondence between interests and practices among managements and organisational styles, professional ideals and claims amongst clients. However, we have also seen types of mismatches between clients and professions, for example, when there is a discrepancy between the requirements of high-positioned clients and the habitual dispositions of low-positioned therapists. The therapist either has to adapt to the dominant healthy game or leave and find another job. Processes of exclusion are also playing out within the profession between ‘old-school’ therapists and those oriented towards coaching and encouraging clients to be active. In addition, weaker patient groups in need of traditional, ‘passive’ treatment and care, and not capable of adjusting to the new social order, may lose out. Hence, the reinforced health focus provides some agents with advantages and others with disadvantages. Faced with the growing pressure on institutions, professions and clients to improve bodies, making them fit for working life, not only are clients struggling with overweight or similar conditions but professionals themselves may also feel their own bodies are not meeting ‘acceptable’

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standards. As health is increasingly perceived as ‘a competence’, this not only makes the unhealthy body appear as disgusting and abnormal but also highlights its owner as an incompetent subject unsuitable for a high-­ status position in the post-industrial knowledge society.

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Green-Pedersen, C. and Baggesen, K.M. (2009). Between economic constraints and popular entrenchment: The development of the Danish welfare state 1982–2005. In: K. Schubert, S. Hegelich and U. Bazant (eds.) The Handbook of European Welfare Systems. London: Routledge. Harsløf, I. (2004). Enterprise Rehabilitation: Involving Enterprises in the Vocational Rehabilitation Efforts in Denmark. Paper presented at the 20th World Congress of Rehabilitation International, June. Lillestrøm. Harsløf, I., Søbjerg Nielsen, U. and Feiring, M. (2016). Danish and Norwegian hospital social workers’ cross-institutional work amidst inter-sectoral restructuring of health and social welfare. European Journal of Social Work, 20(4), pp. 1–12. Hindhede, A.L. and Larsen, K. (2018). Prestige hierarchies of diseases and specialities in a field perspective. Social Theory and Health, 17(2), pp. 1–18. Hornemann Møller, I. (2013). A liberalistic handling of new social risks  – Danish experiences from three decades of social policy reform. In: I. Harsløf and R. Ulmestig (eds.) Changing Social Risks and Social Policy Responses in the Nordic Welfare States. Basingstoke: Palgrave Macmillan. pp. 25–49. Håvold, O.K., Harsløf, I. and Andreassen, T.A. (2017). Externalizing an ‘asset model’ of activation: Creative institutional work by frontline workers in the Norwegian Labour and Welfare Service. Social Policy and Administration, 52(1), pp. 178–196. Kirkegaard, K.L. (2011). Fitnesskultur.dk Fitness sektorens historie, de aktive udøvere og breddeidrættens kommercialisering. Ph.d. University of Southern Denmark, Odense (The history of Fitness culture, active practitioners and the commercialization of mainstream sports). Kvist, J. and Harsløf, I. (2014). Workfare with welfare revisited: instigating dual tracks of insiders and outsiders. In: I.  Lødemel and A.  Moreira (eds.) Activation or Workfare? Governance and the Neo-Liberal Convergence. New York: Oxford University Press. pp. 47–72. Larsen, K., Cutchin, M. and Harsløf, I. (2013). Health capital: new health risks and personal investments in the body in the context of changing Nordic welfare states. In: I. Harsløf and R. Ulmestig (eds.) Changing Social Risks and Social Policy Responses in the Nordic Welfare States. New  York: Palgrave Macmillan. pp. 165–188. Larsen, K., Harsløf, I., Højbjerg, K. and Hindhede, A.L. (2018). Health Capital: An Empirical Study of Danish Healthcare Professionals’ Bodily Investments. Paper XIX ISA World Congress of Sociology, Toronto, Canada. pp. 548–549.

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Part V Patients, Consumers and Citizens

Chapter Eleven: The Imperative of Choice in Australian Healthcare Karen Willis and Sophie Lewis

Introduction Despite a universal, health insurance programme in Australia (Medicare), which provides financial support to access to medical care and public hospitals, the private sector plays a significant role in healthcare provision. The growth of private medical services has been encouraged by the Australian government, particularly through incentives for people to purchase private health insurance (PHI) and penalties for those who do not. Integral to such policy measures is the notion of choice—that purchasing PHI will enable patients to choose their healthcare providers (perceived as a positive development) rather than being reliant on public providers K. Willis (*) School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, VIC, Australia e-mail: [email protected] S. Lewis Centre for Social Research in Health, Faculty of Arts and Social Sciences, UNSW Australia, Sydney, Australia e-mail: [email protected] © The Author(s) 2020 F. Collyer, K. Willis (eds.), Navigating Private and Public Healthcare, https://doi.org/10.1007/978-981-32-9208-6_11

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(perceived as negative). The uncritical acceptance of choice as a benefit in healthcare provision is a major factor in Australians’ purchase of PHI. In this chapter we examine how the imperative of choice shapes values and beliefs about private healthcare provision, with particular reference to PHI. We commence by outlining the Australian healthcare system and the policy initiatives aimed at encouraging consumers to purchase PHI. We describe the conceptualisation of choice and the emergence of choice as an imperative in the contemporary healthcare field. Drawing on data from interviews with 78 individuals and Bourdieu’s concepts of field, capital and habitus we explain why choice is valued and how the valuing of the idea of choice contributes to maintaining and increasing inequity in healthcare.

 he Coexistence of Public and Private T Healthcare in Australia The healthcare system in Australia is a complex mix of government and private services, funded and delivered in a federal government structure. From the time of British settlement in Australia, governments have provided medical care. From the mid-nineteenth century, some healthcare was financed through insurance schemes provided by Friendly Societies, and provided through a combination of private and public facilities. Since that period, medical care in Australia has been based on a fee for service approach, with the right to private practice for doctors and dentists subsequently enshrined in the Australian Constitution. The idea of healthcare as a marketised product is thus well entrenched. In 1975 a universal tax-based health insurance scheme (Medibank) was implemented by the then Labor government, aimed at providing universal access to public hospitals and subsidised medical care. This scheme was subsequently scaled back by the incoming conservative government, with the current universal scheme, Medicare, reinstated by the next Labor government in 1983 (Collyer et al. 2019). This history reveals that the field of healthcare has, for some time, comprised a mix of public and private financing, laying the groundwork for positive dispositions towards ­private healthcare to coexist with a very popular universal health insurance

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scheme. We have reported previously on the discourses of choice and individual responsibility in the marketing of PHI (Harley et al. 2011), and the purchase of PHI as a demonstration of responsible citizenship (Natalier and Willis 2008). What is also interesting from our perspective is how these ideas come together to create contemporary doxa privileging private healthcare, and the contribution of active government intervention in shaping the healthcare field. Since 1999, there has been a concerted set of policies to increase participation in PHI, through what have been termed ‘carrots and sticks’ policy measures. These measures were introduced in response to the progressive decline in people purchasing PHI after the introduction of Medicare. PHI policies cover some or all of the cost of treatment in private hospitals, and items not included in the universal scheme (e.g., optometry and dental). Policy ‘carrots’ include a government subsidy of the cost of PHI (initially set at 30 per cent but now means tested and a maximum of 27 per cent); and community rating, which prohibits insurers from charging different amounts based on age or risk factors. Policy ‘sticks’ include a tax penalty (the Medicare surcharge) for high-income earners without PHI, and ‘lifetime loading’—increased PHI premiums for people who delay purchasing PHI until after the age of 31 (Boxall 2015). Most recently, the government has added amendments aimed towards increasing membership of the funds by subsidising premiums for people who purchase PHI before the age of 31. Such policy approaches are controversial—for example, there is considerable debate about whether governments should provide a subsidy to people choosing to purchase PHI—the cost of which is now over 6 billion AUD per year (Cheng 2018). Though not based on supporting economic evidence, it is publicly promoted that higher participation in PHI will take the pressure off the public system (Cheng 2018). Purchasing PHI is viewed as a form of ‘responsible citizenship’ by those who can afford it, leaving the public system to provide care for those who cannot. In encouraging citizens to purchase PHI, the Australian government has become inextricably linked with the health insurance industry, in a way not seen in other industries in Australia. Integral to the success of this encouragement is promotion

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of the idea that purchasing PHI provides individuals with ‘choice’ in healthcare.

Our Study—Australians and Healthcare Choice Our study of people’s choices about healthcare is part of a broader study investigating navigation of the healthcare system (see also Chapter Six of this book). We interviewed 78 Australians to explore the healthcare choices people make with particular reference to whether they have chosen to purchase PHI, and their experiences of using the healthcare system, including both public and private services. Participants ranged in age from 19 to 90 years; 48 had PHI and 30 did not have PHI. They had a diversity of illness experiences, with 45 participants describing living with a chronic or life-limiting illness; some participants (mostly younger in age) with very limited contact with healthcare providers, and some with on-going and extensive contact with healthcare providers, either for themselves or other family members. In presenting findings below, we indicate the participant’s pseudonym, age, and PHI status.

Field and the Promotion of Choice Bourdieu’s concepts of habitus, capital and field assist in explaining the durability of positive dispositions towards PHI that coexist with positive perceptions of universal healthcare. As Scambler and Newton (2011: 138) claim, ‘Field, habitus and capital serve to condition the individual and maintain structures through repeated social practices’. The habitus and its dispositions structure individual practice through the interplay and interaction of the various forms of capital, but the habitus is in turn structured by the dynamics of the social arena of the healthcare field (Bourdieu 1977). Thus, the conditioning of individuals through social practices, their capacity to leverage capital (Bourdieu 1984) to make choices, and the structuring of the field (Bourdieu 1993) to facilitate preferred social practices, are all important in examining why private healthcare becomes privileged in the public mind.

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Understanding the value of choice promoted in the healthcare field enables us to explain why individuals in Australia have been persuaded, or some would say ‘nudged’ (Thaler and Sunstein 2008), to purchase PHI, even though they also contribute through taxation to the universal health insurance scheme, Medicare. The idea of choice has gained legitimacy globally in societies where there is a shift towards emphasising individual responsibility rather than collective rights, and where the market and free competition determine the provision of services, both public and private. In a globalised world, uncertainty and an increased focus on the risks of modern society has led writers such as Giddens (1991) and Beck (1992) to emphasise the plurality of choices available to individuals as they navigate their way through the necessity of ‘strategic life planning’ (Giddens 1991: 85). Individuals must become active choosers in their own lives, as, according to these writers, structural factors such as social class and other habituated ways of being in the world lose their potency. The notion of agentic, choice-making individuals is claimed to be so dominant that it ‘matches the worldview of most people living in advanced capitalist democracies, which includes the ultimate importance of agency (whatever structural constraints may exist)’ (Pescosolido 1992: 1100). The notion of ‘choice’ has been particularly resonant in health and healthcare. Set against the backdrop of a doctor-dominated, paternalistic approach to care, the social movements of the 1970s were about reclaiming autonomy over our bodies. According to Greener (2009), the emphasis on choice was initially related to healthcare organisations being responsive to patients’ needs, and the right to information on which to base healthcare choices was integral to such responsiveness. However, since that time, the notion of choice has been closely linked with individual responsibility and the expectation that people will make ‘the right’ choices about their health, health behaviours and healthcare. It is therefore not surprising that policy approaches, seemingly predicated on the notion of choice, resonate with a population exposed to ideas about information, rights and responsibility. Rational choice theory and, more recently, the behavioural economic approach of nudge (Thaler and Sunstein 2008) provide the basis for such policy approaches. This view posits an individualistic view of actions, where actors make

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choices to maximise outcomes for themselves; and it is the idea of choice as an individual capacity that has become an imperative both within the public arena and in policy rhetoric. The dominant assumption underpinning current logics is that with the presentation of information, individuals will make ‘rational choices’ (Collyer et  al. 2015). This individualistic model takes little account of the fact that individuals exist in social and relational arenas. Healthcare choices are often made in the context of uncertainty and anxiety about health, may be dictated by affective rather than ‘rational’ knowledge, and may draw on imperfect or incomplete information (Petersen et  al. 2017). However, assumptions about the value of choice persist. Linked to the valuing of choice is the idea of control. In an era dominated by uncertainty, health remains a ‘certain uncertainty’, despite technological advances in diagnosis and prediction. Thus, making choices becomes an active strategy directed at bringing the uncontrollable back within personal control, through lifestyle choices and, importantly, financially ensuring that future healthcare needs can be met. Power dynamics in the field are vital to the reproduction of dominant cultural norms and values. Policy encouragement to purchase PHI is one active way of shaping the field; others include the circulation of ideas through PHI industry marketing, the internet and mass media coverage. For example, media reporting about ‘problems’ with public hospitals and services and the benefits of private healthcare assist in constructing the knowledges available to individuals, and shape the choices they make about their healthcare (Lewis et al. 2018a). For example, in our interview study, Kylie discussed media coverage of healthcare and how it influenced her choices to purchase PHI: I guess to some degree it probably does, particularly news media. I suppose that’s where the perception comes in, the perception of public hospitals, that’s pretty much based on what you hear in the news. So I guess that has a negative effect (laughs). Because you only ever hear the bad stories, you don’t really hear the good stories (Kylie, 41, has PHI).

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Habitus and the Valuing of Choice Participants’ accounts about the value of choice and why they choose to purchase PHI make evident that the conditions in the field interact with the possibilities available in the habitus, and generate preferred choices. Previous research has found that choices about public and private healthcare reflect habituated understandings stemming from family dynamics and practices (Natalier and Willis 2008) and this is supported by participants’ accounts  in our study. Dispositions towards PHI travel through time via family experiences, particularly in a healthcare field where, at varying times, both private health and universal healthcare have dominated policy approaches. Although participants currently aged in their forties or younger have little personal awareness of the policy context prior to universal healthcare, it is through their family history that PHI is privileged. Consider the influence of family discussed by Kylie and Nicki (both aged in their early forties): My parents had it when I was growing up, so you know I suppose the fact that the family always had it … My mother always saw benefit in having it. So again her strategy was risk management. You know trying to have something in place in case something goes wrong (Kylie, 41, has PHI). Growing up, my parents always had top cover. And my parents being risk averse, my dad being an engineer, not leaving anything to risk. Which was probably quite influential on my decision making (Nick, 42, has PHI).

For many participants, family influenced the positive disposition towards PHI, but it was government policy initiatives that solidified their decisions to purchase PHI—particularly strategies directed towards purchase of PHI at the age of 30, suggesting that the dynamics of the field must align with habitus for maximum effect. Older participants, particularly those aged in their fifties and sixties, discussed the influence of both family predispositions towards PHI and the active marketing strategies of PHI in workplaces:

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I’ve had it ever since I started working full-time as a teacher probably because that’s how I was, like we’ve always had it in the family and … I also know that [name of health insurance fund], well in the past, is very good (Michelle, 61, PHI). I think when I joined the public service they gave me a flyer about the [name] Fund and so I thought I could afford it, so I went for it (Annabelle, 70, PHI).

For some participants, like Paul, where PHI was not part of family practice, it became so: My wife having had private health insurance all of her life, it was an issue to not have private health cover (Paul, 34, PHI).

The positive valuing of choice in healthcare is now a fundamental tenet of habituated thinking—particularly for people who have purchased PHI: ‘The more choice I can have the better’ (Paul, 34, has PHI). The choices that matter to participants are the choice of doctor (whether general practitioner [GP] or specialist), the choice of hospital, and control over the timing of healthcare, particularly for non-clinically essential (elective) surgery. As Coulter says, ‘the offer of choice seems to have intrinsic value to patients’ (2010: 974), and this is illustrated by one participant, Rochelle, who, like many participants, gives choice as the reason for purchasing PHI: Probably just that I’ve got choices. For $25 a week if it really came down to it I’d have some choices. If it was an elective surgery thing I’ve got a choice whereas I’ve seen others who have had to wait for an indefinite period and I’m thinking you know I think I’d really rather just have that little bit of a guarantee (Rochelle, 61, has PHI).

The ‘freedom to choose’ is integral to participants’ constructions of choice, even when choice is not exercised. We found that this ‘freedom to choose’ is linked to perceptions of increased control. With health and illness seemingly not within individuals’ control, and inherently uncertain, participants purchase PHI in an attempt to ‘feel’ or exercise some control.

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Choice and control are associated positively with private healthcare, as indicated by participants such as Rhonda: Well I suppose if they’ve got the private insurance that’s one where you feel you’ve got more control (Rhonda, 63, has PHI).

Choice in healthcare comes with increased expectations and responsibility for the individual to make the right choices about their health and healthcare. Yet, there is a general view among participants that taking responsibility for healthcare—demonstrated through purchasing and using PHI—is positive and/or necessary, reflecting neoliberal ideals and logics of care about patient freedom and rationality (Mol 2008). The pressure to purchase PHI and private healthcare extends to people in financially disadvantaged positions. These perspectives reveal how dominant values of patient choice and responsibility are interlinked and embraced, and yet what is concealed is the way this shifts responsibility from professionals and systems onto patients, and may contribute to decreasing quality in healthcare—especially for those who are least able to successfully navigate the healthcare system (Mol 2008).

Capital and the Enactment of Choice While field and habitus shape positive dispositions towards PHI, it is the leveraging of capital that enables the enactment of choice. Although choice is presented in public discourse as an individual attribute available to all, Bourdieu points to the importance of capital in the differential, and structured, ability to exercise choice. Capacity to enact healthcare choice is structured in complex ways by participants’ differential access, and ability, to mobilise economic, social and cultural forms of capital. Economic capital is important. Even with the provision of financial assistance from government, PHI policies are expensive, and the cost of PHI was discussed by those participants in our study who either aspired to purchase it, or who could no longer afford it. For these participants, it was what PHI represented that was lost to them. The most significant loss was choice, because this was perceived as reducing the quality of care

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available. This view was encapsulated by Flo and Estela, both of whom did not have PHI: Oh I do think that the more money you’ve got the easier it is to make choices (Flo, 56, no PHI). If you’ve got money, you’ve got choices, if you haven’t got money, well you just have to shut up and take what you’re given (Estela, 46, no PHI).

Participants who were advantaged in terms of financial position, education, and social networks also discussed the importance of economic capital in choice making. However, most of the more advantaged participants saw that other resources, in addition to financial ones, are necessary to exercise choice. They discussed social and cultural forms of capital, such as personal networks, professional capacities and higher education, as increasing their capacity to exercise choice: But, ultimately I think it’s a combination of financial position and education. And by education I mean it’s your own education, it doesn’t necessarily have to be in formal education, it’s just in what you know and where to go and where to find out about your options (Kylie, 41, has PHI).

These participants undertook extensive internet research to ensure that their choices were well informed. They tended to privilege private healthcare because they viewed this as providing greater choice and control over their healthcare and, as illustrated by Michelle, linked education to choice and better outcomes: I think better educated people probably are able to make better choices … if they’ve got private healthcare that gives them more choice if they choose to use it. Q:

And what benefits do you think it brings them to have the better choice? A: Ah, a more positive outcome (Michelle, 61, has PHI).

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At the same time, participants with ease of access to the capitals required for choice distinguish themselves from others who structurally cannot do so, often in the guise of a critique of the choices not made. Judgements are made about people without these forms of capital, who are perceived as unable to ‘prioritise’ their limited resources appropriately so they can purchase private healthcare, or lack the knowledge to ‘understand’ the benefits of PHI. Thus an individualistic ethos prevails: Your more affluent are more likely to say I’ve got the income to spend on private health insurance. At the same time, people who are probably better educated are more likely to understand the benefits or the use of private health insurance. So the contraindicative of that would be your low socio-­ economics, low education, probably more your older people are more likely to rely on the public health system … And your lower socio-­ economic group of people prioritise their money very differently or may not have the money to put out for private health cover and are a lot less likely to understand the benefits of, or the use of, private health cover (Paul, 34, has PHI).

Cultural capital is not only about the educational resources required to make sense of the choices available. Shim’s notion of cultural health capital (2010) emphasises the interactions between patients and health professionals, and provides evidence of the structural and relational recognition and exchange of capital. The structuring of opportunity was evident in participants’ accounts of opportunities to make choices. Consider Annabelle’s response to a question about whether there are some people in society who can make better choices: Q:

Do you think being well educated has meant that you’re in a better position to make choices? A: Oh, yes. Yes because I think you’re able to be articulate to your practitioners and you are able to read up on things. Also, you probably exude more confidence than somebody who is less well educated, so you probably get more attention from your treating specialists and general practitioner … They know that you’re a well-informed middle class person and that if they fob

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you off you’re likely to cause a fuss. So I think my sort of person does demand better attention (Annabelle, 70, has PHI).

The application of cultural health capital is also evident in Connor’s account. Not only does he have economic resources and university qualifications, his presentation of self assists in effective leverage of capital. He discusses how his senior managerial position prepares him for consultations with health professionals: I don’t go into a meeting unprepared, I wouldn’t go to a doctor’s visit unprepared. That comes with the territory of my job. I want to optimise the time (Connor, 45, has PHI).

Significantly, participants refer to how these resources come together as ‘system knowledge’. In Bourdieusian terms, system knowledge is a particularly nuanced way of applying the often unspoken and sometimes invisible ‘rules of the game’ of healthcare (Willis et al. 2016). Individuals use system knowledge in two ways: (1) through relying on economic resources and social networks (usually both) for leverage into the complex healthcare system; or (2), through the accumulation of knowledge, often drawing on personal experiences to successfully navigate the system. In this context, PHI is not the only resource participants draw on to enable choice. Some participants without PHI have a clear advantage in navigating the healthcare system and exercising choice, across both the public and private sectors, because of their ability to leverage different kinds of cultural and social capital, including their system knowledge, education, and personal networks of people in positions of power in the healthcare field.

PHI and the Quality of Care In a context where choice is positively viewed, PHI is perceived by most participants favourably as an ‘enabler of healthcare choice’. It is the idea of choice that draws people towards private healthcare and this is why choice is the focus of both policy and marketing discourses. This rhetoric

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becomes all the more powerful as individuals discuss planning for eventualities they have not experienced and the uncertainties they fear. In addition to being an enabler of choice, PHI (and private healthcare) is perceived as providing reassurance in the face of uncertainty: I think it [private health insurance] brings me a pretty comprehensive level of choice. I haven’t had to go deeply into using private health insurance because I, unlike many people in my age group, I haven’t gone to maternity services or whatever or had major operations where I’ve had to be hospitalised for them. But I think it’s a peace of mind thing. It’s knowing that if you need to make those choices you can (Audrey, 40, has PHI).

While the public system boasts world-class facilities, large tertiary hospitals and training centres, there is an assumption of greater availability of services and superior care in the private system, even though there is no evidence to support this (Collyer et al. 2017). As Chelsea indicates: ‘in private health insurance, you get more of a choice of services you need’. This idea of better services extends to the health professionals and managers working in the private sector, despite the fact that most clinicians in Australia work in both the private and public sectors (Collyer et al. 2017). The view that choice is inherently positive, and only provided within the private sector, has emerged as healthcare has become increasingly marketised and is juxtaposed alongside discourses emphasising the negative attributes of the public healthcare system. Being given a choice is associated positively with the capacity to choose ‘the best’ (or choose to avoid the worst), and, for many participants, choice is a proxy measure for quality. The relationship between choice and the quality of healthcare is evident in Kylie’s discussion about the choices she wishes to make. Kylie illustrates the perspective of those with both the economic and cultural capital resources that enable one to make healthcare choices: For me cost isn’t an issue, it’s just a case of, case of who do I want to put me under the knife so to speak. For me it’s all about having an option to choose who I want to treat me.

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Q: So that is a really important consideration for you? A: Yeah and you don’t get that kind of choice with the public you just get whoever they’ve got. Q: So what does that mean to you to be able to have that choice, in terms of? A: I guess it’s my perception of safety and skill, skill level. I want somebody who is experienced and is well renowned I guess in his or her field in whatever they are doing (Kylie, 41, has PHI).

The ability to choose specialists and hospitals is seen as a key benefit of PHI. This perception coexists with the (mistaken) idea that without PHI, you cannot choose which hospital you attend or the specialist you will see. These ideas are most expressed by participants who struggle to navigate the healthcare system: But I think it should be a lot better, like you should be able to look up where there’s a gynaecologist for instance and say can you recommend this one. But it has to be someone that the GP knows I think. So no I don’t really think there is enough choice (Flo, 45, no PHI). With private health cover, you’ve got a choice of who you go to. Whereas if you haven’t got that health cover, you really don’t have a choice who you’ve got to see. You go there, and that’s it, that’s all you can do. I suppose there may be an option that you can go to another doctor and say, ‘Well, I’m not happy with that so I’d like to go to another one’ (Helena, 58, has PHI).

While most Australian patients recognise that they are able to choose their GP, there is uncertainty about the processes of referral to hospitals or specialists, and thus the perception that they have little or no choice without PHI is an example of where perceptions of (the lack of ) choice in the public healthcare system do not accord with reality. Thus, in the public system, being assigned a ‘good’ specialist is viewed as ‘getting lucky’ (i.e., an unlikely outcome), while the greater likelihood is that you ‘risk’ a bad outcome because you are not able to exercise any choice. This

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is evident when participants talk about maintaining their private health insurance, which is becoming more expensive, in the face of price rises each year: I know I have to do a knee replacement at some point, but obviously in that case I would much rather do that through the private system with the surgeon that I trust, the hospital where I know I’ll get good after post op care. I will maintain my private health insurance, even though I know it’s getting more expensive, I will be maintaining that to give me those options (Michael, 50, has PHI). So it would be the quality of the service. I wouldn’t mind having to pay more as long as I trusted and knew that the service I was going to get was the right sort of service (Alice, 34, has PHI).

While choice of doctor and hospital are both important, the speed at which healthcare can be accessed is a key feature of the preference for private care for many participants. Waiting lists for treatment, particularly elective surgery, receive substantial negative media and public attention (Lewis et al. 2018a). Again the idea of control is important: waiting implies lack of control and participants value the possibility of choice and control over timing of procedures, and the perception that every healthcare need is urgent. In contrast to perceptions of public care, participants see a key positive feature of the private system as providing immediate access to care. Participants also draw on the idea of convenience as important, as the following quotes illustrate: But had anything come up we could get to the top of the waitlist, we could pick our specialist, pick our hospital, basically pick from a choice of treatment dates. Which is always preferable to going on the waitlist which I think is around about 18 months (Paul, 34, has PHI). You know it was just a case of when was it convenient for me and for work, to actually do it. So I had to go in and do it. Yes, it did cost me $4–5000 dollars but in the end I put that as the price of convenience and actually having the better quality care (Michael, 50, has PHI).

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If something happens I know that I can get in quickly as opposed to being a public patient … And if you’re in the public system you can wait for months and months (Caroline, 65, has PHI).

 oexisting Doxa? Public and Private C Healthcare As previously discussed, the Australian healthcare system comprises both universal tax-based healthcare available to all citizens and the option to purchase PHI. For most participants, the valuing of PHI coexists with a high regard for the principle of universal care and this was particularly the case for older participants, who can recall when universal healthcare was introduced. The introduction of universal healthcare centred the healthcare field around the principle of equity, particularly in terms of access, and as Collyer (Chapter Six) points out, universal healthcare remains a popular public policy. Many participants argued that universal and public services should be available to all and adequately funded. Their valuing of universal healthcare coexists with their personal choice to choose to purchase PHI. Kathleen, who purchased a PHI policy because of the tax penalties associated with not doing so, stated: I don’t work in the system, I don’t socialise with people in the system, but I would like to think that it was fair and equitable (Kathleen, 51, PHI).

But, as indicated by Rochelle, choices are made in the context of the system as it currently exists, and thus, the imperative of choice promoted by government, media and industry means that at the individual level, people believe they should purchase PHI: So I don’t think we were born with any rights but I think as citizens of Australia we’re born to expect good healthcare and an education … It should be a level playing field amongst all, I realise that, but that’s the way it is and if that’s the system then that’s what I’ll go with for now (Rochelle, 61, has PHI).

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The notion of ‘taking pressure off the public system’ is one way that individuals reconcile support for both universal healthcare and the private system. This idea has been successfully linked with the notion of responsible citizenship—that is, those who can afford PHI should purchase it, and leave the public system for those who cannot. In effect, this shifts the healthcare system towards a ‘de facto’ selective system, rather than a strong universal one. As Audrey indicates: I pay my Medicare levy every year and I know that it isn’t necessarily for me to use it, it’s for the whole system (Audrey, 40, has PHI).

This view was also held by Julian (67, no PHI), an extremely disadvantaged participant, who argued that everyone with PHI should use the private health system, in order to ‘take the pressure off the public system’ so it could better meet the needs of people like him. The broader debate about whether healthcare should be an individual or a social responsibility in the current healthcare field therefore sits somewhat uneasily in the current context. Despite a rhetoric of equity and ‘a fair go for all’ as publicly espoused values in Australia, the shift towards individual responsibility is exclusionary. When younger participants such as Lauren (30, has PHI) argue in addition to people taking responsibility for their individual needs, ‘there needs to be a strong public health option for people as well’, she is viewing universal healthcare as an add-on for those who have failed to realise the mantra of individual responsibility. While purchasing PHI because it gives him ‘choice’ in healthcare, Graeme is one of very few participants in our study who is also critical of the increased marketisation of healthcare: ‘They’re all there to make sure that the returns to shareholders are maximised. My concern is that the privatisation of the health system to that degree and to health funds is a very, very bad downside’ (Graeme, 63, has PHI).

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Conclusions Consumer choice is now the dominant discourse in Australian healthcare, underpinned by beliefs about individual control and personal responsibility. Just as the discourse of choice is highly valued, the private sector is viewed as an enabler of choice—and the public system as a system in which there is no choice. One effect of a discourse of choice is that navigational struggles are presented as an individual rather than social capacity. A consequence of the imperative of choice, and the greater integration of private healthcare services into healthcare systems, is that the dominant idea of ‘patient choice’, upon which much of the growth in private care is predicated, ‘shifts responsibility from healthcare systems onto individual patients’ (Van Natta et al. 2018). This development conceals the differential capacity to exercise choice, and the complex ways in which the field of healthcare is structured to advantage some social groups over others. The popular assumption is that, based on the information provided, individuals can assess where they will receive the best outcome and where the outcomes will be worst, and make their choices accordingly. Thus, the valuing of choice as an individual attribute overrides the well-documented issue of information asymmetry in healthcare, which exists where there is an imbalance between the knowledge bases of health professionals and their patients. This is difficult, if not impossible, for patients to reconcile, because it is not merely about information provision—rather it concerns the capacity to become fully informed, understand, and act on the evidence available, and this knowledge is hierarchical and unevenly distributed (Collyer et al. 2017). The systematic lack of information about both public and private healthcare was evident throughout our research. There has been ­substantial public concern about the lack of information supplied by PHI companies, and the complexity of information provided (Willis and Lewis 2015). PHI is perceived as being a consumer product and thus inadequate information is viewed as ‘market failure’ (ACCC 2015), in need of rectification to ensure consumers can maximise their choices about product selection. There has, however, been much less focus on ensuring there is adequate information about choices and services available in the public

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and private systems more broadly. We have previously concluded system knowledge is in short supply (Willis et  al. 2016). Given the lack of emphasis on making choices in public healthcare and the difficulty in interpreting information, it is therefore unsurprising that, where such information is available, there is little evidence that individuals draw on published performance data in making healthcare choices (Coulter 2010; Lewis et al. 2018b). Participants rely primarily on their general practitioner to assist with navigating the healthcare system (often describing this as their GP ‘giving them a choice’); or draw on (often limited) experiential knowledge—either their own, or their family or friends (Willis et al. 2016). However, the assumption that health professionals can guide patients must be interrogated, as our research has also found many health professionals do not themselves have sufficient knowledge about the system (Collyer et al. 2017). While choices do exist in the public system, they are likely to be unevenly distributed, due to the maldistribution of resources (particularly geographically). As private healthcare has become so strongly linked with the ideal of increased choice, private healthcare is privileged. Participants’ narratives reflect dominant cultural ideas that the private healthcare sector gives those who can access it an advantage in the field. This is because it is assumed that the private sector, by appearing to offer more choice, provides a better quality of care compared to what is provided in the public system. Despite these dominant cultural narratives that private health insurance is an enabler of choice, our participants’ accounts show that enacting choice in healthcare is much more complex. Some groups with, for example, higher levels of education, system knowledge, or personal networks are more able to exercise choice and select healthcare options across both public and private healthcare settings to their advantage to ensure their healthcare needs are met. This includes participants with and without private health insurance. In contrast, some participants with PHI are not able to increase their choices or overcome navigational struggles in the healthcare field. Even from a research perspective, the focus on choice and private healthcare in Australia is somewhat problematic. Writing about choice, and the capacity to make choices, while an important part of the healthcare landscape requiring scrutiny, means there is little discussion of what

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some would say is the crux of the issue—and that is the structure of the healthcare system, the extent to which healthcare is increasingly marketised, and the broader debate about universal versus selective healthcare. Price increases for PHI are government regulated, and each year insurers make submissions to the government on the percentage increase they require. For several years, the focus of discussion has been on PHI price increases and whether they represent value for money, rather than whether the health system should be marketised or whether there should be an increase in the tax base to support the public system. At the time of writing, during a federal election campaign, there is little to distinguish between conservative and social democratic parties in their support for PHI. The conservative Liberal party is clearly in support of PHI, and the social democratic party (Labor) promises to investigate the rebate (McCauley 2019), suggesting a reluctance to markedly shift the dynamics of the healthcare field. Bourdieu’s concepts of field, habitus and capital illuminate the importance of connecting ideas in the public space to the durable perceptions and practises in private spaces, and to the resources required to enact choice. In the Australian healthcare system, the privileging of private healthcare over public healthcare structures the field, ensuring the increasing dominance and power of the private sector in the healthcare system. The valuing of private health insurance and private care more generally also conceals the complexity of navigational struggles, challenges, benefits, advantages and disadvantages. The imperative of choice hides a stronger hidden message, not the promised suite of options and alternatives across public and private healthcare sectors, but a command to ‘go private’. Acknowledgements  We acknowledge and thank the participants in this study for their time and thoughtful contribution to this project; the Australian Research Council, who funded the research (DP130103876); our colleague Fran Collyer, who provided supportive critique throughout the project; and research assistants Marika Franklin and Ian Flaherty, who provided research assistance support. Approval for this study was obtained from the Human Ethics Committee (HEC) at the University of Sydney.

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Lewis, S., Collyer, F.M., Willis, K., Harley, K., Gabe, J., Calnan, M. and Marcus, K. (2018a). Healthcare in the news media: the privileging of private over public. Journal of Sociology, 54(4), pp. 574–590. Lewis, S., Willis, K., Collyer, F. (2018b). Navigating and making choices about healthcare: the role of place. Health and Place, 52, pp. 215–220. McCauley, D. (2019). Labor will not rule out scrapping the $6billion health insurance rebate. The Sydney Morning Herald, 2nd May. Available at: https:// www.smh.com.au/federal-election-2019/labor-will-not-rule-out-scrapping6-billion-health-insurance-rebate-20190502-p51jgp.html [Accessed 6 May 2019]. Mol, A. (2008). The Logic of Care: Health and the Problem of Patient Choice. London: Routledge. Natalier, K. and Willis, K. (2008). Taking responsibility or avoiding risk? A socio-cultural approach to risk and trust in private health insurance decisions. Health, Risk and Society, 10(4), pp. 399–411. Petersen, A., Munsie, M., Tanner, C., Macgregor, C. and Brophy, J. (2017). Stem Cell Tourism and the Political Economy of Hope. Palgrave Macmillan. Pescosolido, B. (1992). Beyond rational choice: the social dynamics of how people seek help. American Journal of Sociology, 97(4), pp. 1096–1138. Scambler, S. and Newton, P. (2011). Capital transactions, disruptions and the emergence of personal capital in a lifeworld under attack. Social Theory & Health, 9(2), 130–146. Shim, J.K. (2010). Cultural health capital: a theoretical approach to understanding healthcare interactions and the dynamics of unequal treatment. Journal of Health and Social Behavior, 51(1), pp. 1–15. Thaler, R.H. and Sunstein, C.R. (2008). Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven, Conn.: Yale University Press. Van Natta, M., Burke, N.J., Yen, I.H., Rubin, S., Fleming, M.D., Thompson-­ Lastad, A. and Shim, J.K. (2018). Complex care and contradictions of choice in the safety net. Sociology of Health and Illness, 40(3), pp. 538–551. Willis, K., Collyer, F., Lewis, S., Gabe, J., Flaherty, I. and Calnan, M. (2016). Knowledge matters: producing and using knowledge to navigate healthcare systems. Health Sociology Review, 25(2), pp. 202–216. Willis, K. and Lewis, S. (2015). Confused about your private health i­nsurance? You’re not alone. The Conversation, 23October. Available at: https:// theconversation.com/confused-about-your-private-health-insurancecoverage-youre-not-alone-49493.

Chapter Twelve: The Marketisation of Aged Care: The Impact of Aged Care Reform in Australia Julie Henderson and Eileen Willis

Introduction Many Western countries are experiencing increasing demand for aged care services due to the ageing of the population which, in turn, is associated with concerns with increased expenditure on health and social care. In Australia, the ageing of the baby boom population in conjunction with post-war migration is projected to lead to an increase in people over 65 from 14 per cent in 2012 to around 19 per cent by 2031. This increase is accompanied by a doubling of the population of people aged 85 and over, who are the main consumers of residential aged care facilities (Willis et al. 2016). The opening of the provision of aged care to market forces has been identified as one means of reducing the fiscal demand on governments

J. Henderson (*) • E. Willis Flinders University, Adelaide, Australia e-mail: [email protected]; [email protected] © The Author(s) 2020 F. Collyer, K. Willis (eds.), Navigating Private and Public Healthcare, https://doi.org/10.1007/978-981-32-9208-6_12

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arising from an ageing population (Barron and West 2017; Brennan et al. 2012). The marketisation of aged care is part of a wider neoliberal agenda in which cost savings are achieved through the replacement of public service providers of social services with private providers (Meagher and Wilson 2015). Gordon (1991: 42) argues that neoliberalism redefines the problem of government from the anti-social effects of the market to the anti-competitive effects of society. The role of government becomes that of creating the optimum conditions for the operation of the market. Economics becomes the defining discipline of effective governance, with human behaviour viewed as capable of being judged and understood within the context of economic theory. This has implications for the construction of the individual. Although not opposed to welfare, neoliberalism as a political ideology does not favour state intervention in either the economy or in the provision of social services, believing these to be best handled by family, friends, and charities or for-profit organisations. Society is no longer understood as individually distributed and collectively borne needs but as a source ‘of energies contained within individuals’ exercise of freedom and self-responsibility’ (Dean 1999: 152). The target of government becomes the responsiblised individual. Rose (1996) argues that the essence of neoliberal government is self-governance; that is, governance through making socially responsible choices. The individual is increasingly asked to take financial responsibility for their own welfare but also for making informed choices between competing services. Marketisation involves the use of market mechanisms to allocate care (Brennan et  al. 2012). It is an approach to neoliberalism favoured by conservative governments. Carey et al. (2012) identify two approaches to governance of social services within Australia employed within the last ten years. Both fall within the remit of neoliberalism. The first approach, social inclusion, addresses social inequities through creating the conditions for disadvantaged groups to participate in economic, political and social life. This approach is associated with third-way politics in the United Kingdom, and was adopted by the Australian Federal Labor government from 2008. In this case, Labor sought to improve service delivery to marginalised groups while achieving cost efficiencies through service collaboration and the use of non-government service providers (Carey et  al. 2012). The second approach, marketisation, is associated

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with the Australian Coalition government, and involves a resurgence of the neoliberal values of privatisation, de-regulation, reliance on the market and mutual obligation. Marketisation has been accompanied by programs focusing upon individual consumers and consumer choice. Marketisation has impacted on aged care through the increased presence of private for-profit service providers and the introduction of market mechanisms into service delivery in the not-for-profit and public sectors in many Western countries (Antonnen and Haikio 2011). Changes in ownership are particularly evident in countries with traditionally strong welfare systems. In the United Kingdom, for example, provision of aged care services has shifted to the private sector, with the for-profit sector currently providing 74 per cent of available aged care spaces, resulting in a quasi-market in which the state primarily acts as a purchaser of aged care services for older people (Barron and West 2017). The Swedish government has also moved away from the public provision of aged care services. Stolt and Winblad (2009) associate the privatisation of aged care services with the devolution of responsibility for service delivery to municipalities, often with limited budgets, which have responsibility for providing home care services to prevent the hospitalisation of older people. As a result, many municipalities have outsourced care services previously provided by the state to private for-profit and not-for-profit service providers. Finland has also offset public service provision with the private not-for-profit and for-profit sector, but has also increased subsidies for the provision of informal care by relatives and other lay persons (Antonnen and Haikio 2011). Accompanying the marketisation of aged care has been the discursive construction of services as a commodity for purchase (as opposed to a service to be provided) (Brennan et al. 2012). The marketisation of aged care has also been associated with mechanisms enabling the consumer to purchase the services they require from private service providers. These may include vouchers, care packages, insurance against long-term care and allowances for carers (Brennan et al. 2012). While some resources to purchase services are provided by the state, care recipients are expected to use their own resources to top up public funds, leading to greater personal financial responsibility for care. Marketisation is premised on the construction of the user of health services as a consumer who can make

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informed choice between competing services provided by the market (Fournier 2000). Proponents of marketisation argue that the creation of markets will ensure quality care through consumer choice between competing services (Bergman et al. 2016). Older people are viewed as being able to choose between services to obtain the care they require (Yeandle et al. 2012), and to choose on the basis of the perceived quality of services. For proponents of marketisation, competition between services results in market pressures to maintain service quality, thus ensuring the quality of care is maintained (Mojberg et al. 2016). In this chapter we focus upon recent changes to residential aged care service delivery in Australia through examining recent aged care policy, legislation and changes in ownership of residential aged care facilities, and seek evidence of the marketisation of aged care. We identify a trend towards the achievement of cost efficiencies and targeting of services in aged care which has culminated in the changes recommended by the 2011 Productivity Commission report Caring for Older Australians and instituted by the Federal Coalition government (2013 to the present). These changes endorse the marketisation of residential aged care through facilitating the purchase and provision of aged care beds by private-for-­ profit service providers, the emergence of consumer-directed care (CDC), and the promotion of greater individual financial contributions to care. Our subsequent discussion challenges some of the assumptions underpinning marketisation by examining evidence for the capacity of older people to act as informed consumers of services—and analyses their psychological well-being and psycho-social health, and whether privatisation has improved care service quality. Service quality is discussed within the context of current mechanisms for regulating aged care services.

Aged Care in Australia Australia has a federal government structure with powers divided between the central (Federal) government and states. The Australian Constitution determines the distribution of government responsibilities between the levels of government. The provision of health services largely falls to State governments, while the provision of pensions and funding for welfare

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services is a Federal government responsibility. As such, aged care policy and legislation, funding and regulation are the responsibility of the Federal government in Australia (Brennan et  al. 2012). In contrast to Scandinavia and the United Kingdom, the not-for-profit sector has traditionally been the major provider of residential aged care in Australia. Funding was provided by the Federal government from the 1960s to subsidise aged care, initially under the Aged Care Homes Act (1954) and later through an amendment to the National Health Act in 1963. The latter provided benefits to nursing homes to reduce the burden on private health insurers of the long-term hospitalisation of the frail elderly (Baldwin et al. 2015a; Kendig and Duckett 2001). Kendig and Duckett (2001) argue that this amendment meant that residential care became the main focus of aged care provision, and community care received little attention as a result. Aged care was largely unregulated within Australia until the mid-­ 1970s. In 1975, the Australian Government Social Welfare Commission reported on aged care, concluding that the residential aged care system was financially inefficient and that the care provided was often of poor quality (Venturato et  al. 2007). This report precipitated a period of reform in which emphasis shifted from residential to community services, and the number of residential aged care beds was rationed and targeted towards those with greatest need (Gibson 1998). Reform culminated in the development of Home and Community Care (HACC) in 1985, a joint initiative of Federal and state governments to consolidate community services for older people. At the same time, costs for residential aged care were escalating. To reduce the financial burden of residential aged care, hostel and nursing home accommodation was consolidated and funded on the basis of resident dependency levels (Kendig and Duckett 2001). Dependency funding creates incentives for residential aged care facilities to admit residents with higher care needs as they attract greater funding (see Chan et al. 2014). Furthermore, assessment teams were created to determine need for residential aged care, creating gatekeepers to residential services and further restricting services to residents with higher care needs (Kendig and Duckett 2001). Rights-based outcome standards for residential aged care were also implemented during this period (Gibson 1998).

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The election of a conservative Federal Coalition government in 1996 was accompanied by concerns with population ageing and the escalating costs of aged care. To address these concerns the government proposed a greater role for user payment for services, and a reduction in the regulatory burden through self-regulation of residential aged care. These changes are reflected in the Aged Care Act 1997. Howe (2000) argues that this Act was based on the deregulation of services, cost containment and a greater contribution by those who could afford to pay. It also separated care and accommodation costs (Howe 2000), whereby care cost were to be covered by the resident through a means-tested daily care fee, while accommodation costs were to be covered by an asset-tested refundable accommodation bond (Aged Care Act 1997). The move towards an accommodation bond was politically unpopular and was later abandoned in favour of the daily fee (Kendig and Duckett 2001). The Aged Care Act 1997 reconstructed residential aged care as a welfare rather than a health service. This had two implications. It enabled means-testing as a way of determining resident contribution, but also enabled cost savings through replacement of nursing staff with care workers (Angus and Nay 2003; Kendig and Duckett 2001). Data from 2012 found that care workers comprised 68.2 per cent of the workforce providing direct care to residents in aged care, compared with 14.9 per cent Registered Nurses (Willis et al. 2016). Many of the changes legislated for under the Aged Care Act 1997 have been implemented by the current Federal Coalition government. Since 2014, residential aged care in Australia has undergone significant reform, precipitated by the 2011 enquiry into aged care by the Productivity Commission. The enquiry was framed around ensuring an adequate aged care workforce while identifying means of reducing the fiscal burden of aged care on government. The recommendations of the enquiry included: the removal of restrictions around the licensing of aged care beds; the re-establishment of an accommodation bond, allowing service users to contribute to the cost of care; a greater focus upon re-ablement of residents; removal of the distinction between high- and low-care services; and a reduction in reporting requirements (Hughes 2011; Productivity Commission 2011). The discussion that follows centres on three aspects of reform: de-regulation

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of ownership and the increasing private for-profit ownership of residential aged care facilities; increased financial contributions by users for services; and the development of consumer-directed care and the impact of consumer choice on service quality.

 eregulation of Ownership of Residential Aged Care D and Privatisation The enquiry into aged care promoted changes in the funding and ownership of residential aged care facilities in Australia through the de-­ regulation of ownership and an increase in service provision by private for-profit service providers (Meagher and Szebehely 2013). Recent legislative changes have loosened regulation around ownership of residential aged care services through facilitating the allocation and transfer of licences to provide services. Legislation requires the Federal government to identify levels of need for aged care beds in each region and allocate funding accordingly. Approved aged care providers can then bid for these places (Baldwin et al. 2013). To gain approval, an organisation must be incorporated, be able to demonstrate suitability to provide aged care, and not have any disqualified individuals as key personnel (Department of Health 2017). A second means of obtaining aged care places is through transfer of beds between owners, a process approved by the Federal government (Baldwin et al. 2015a). The recent Aged Care Amendment (Red Tape Reduction in Places Management) Act 2016 has weakened the regulation of ownership through expediting the process of transfer of ownership of residential aged care facilities.

User Payments for Services Recent legislative changes have also enabled a greater user contribution to residential aged care. The 2011 Productivity Commission report recommended that ‘accommodation and everyday living expenses should be the responsibility of the individual, regardless of whether they live in their own home or a residential facility, with a safety net for those who are

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financially disadvantaged’ (cited in Hughes 2011: 530). As a consequence, from July 2014, accommodation payments, now called ‘refundable accommodation deposits’, were re-introduced into residential aged care, requiring high-care residents to contribute to accommodation costs. These changes allowed for the introduction of a means-tested accommodation payment to be paid as a lump sum, a daily payment, or both, with additional fees charged for optional extras (Department of Social Services 2015). Facilities can also charge a fee for the provision of extra services beyond basic care. The Quality of Care Principles 2014 [Commonwealth] outline minimum standards of care, while the Extra Service Principles 2014 [Commonwealth] introduced the capacity for providers to charge for additional services for beds that were not licensed as extra service beds. These changes have resulted in a shift in the funding of residential aged care. Under the current arrangements the Federal government continues to fund aged care (hence the burdens and risks remain with the taxpayers), but has shifted some of the costs across to the consumer (the frail elderly) under a co-payment arrangement. The government currently provides 67 per cent of operating funds for residential aged care facilities, with a further 27 per cent coming through user contributions (Japara Healthcare 2016). Growing demand and the guaranteed government contribution makes residential aged care attractive to private investors who can amass the profits (arising from the funds provided by government and the consumer as well as access to the interest-bearing return on the refundable accommodation deposit—which range from around $300,000 to $800,000), with little risk. Competition is constrained by the fact that the Federal government determines the number of funded beds and their geographical location, further reducing the risk for private companies in this protected market (Macnicol 2015). These changes have promoted the private ownership of aged care services by for-profit service providers. Between 2003 and 2012 there was a growth in the numbers of residential beds in not-for-profit organisations and for-profit organisations, and a decline in beds in government owned facilities (Baldwin et al. 2015a). This was accompanied by a decline in the proportion of residential aged care beds provided by not-for profit and public service providers due to the rapid expansion of the for-profit sector

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(36 per cent in 2012). Not-for-profit companies remain the most common providers of residential aged care services (57 per cent in 2012); however, 92 per cent of aged care beds purchased in 2010–2015 were purchased by for-profit service providers (Thornton 2015).

The Elderly and Consumer Choice The increased privatisation of aged care services in Australia has been accompanied by an endeavour to provide the frail and vulnerable elderly with the same human rights enjoyed by other citizens. These aspirations are often conflated with consumer rights. This slippage in language needs to be unpacked to understand the direction of policy changes. The rhetoric of current reforms within aged care is that frail elderly citizens should be able to choose the care they wish to receive, either through community packages tailored to meet their desire to stay in their home, or by entering a residential aged care home that best meets their requirements and preferences. Underpinning this choice is the notion that the older person has the money to choose the optimum outcomes for themselves as a rational consumer, and that they understand fully what these choices entail and have the capacity to change their mind should the ‘product’ prove unsatisfactory. The ideology of neoliberalism sits neatly behind these assumptions, as it brings together both the concept of a free, unfettered and de-regulated market, the private provision of services and goods as the ideal, as well as the sanctity of individual liberty (Macnicol 2015). These principles are encompassed in consumer-directed care (CDC). CDC is viewed as a means of extending citizen rights to the elderly, despite the fact that they may no longer be able to fend or provide for themselves (Ryan 2014). CDC is now mandated in Australia for community aged care services and is proposed for residential aged care— although it is recognised that considerable training and resource development will be required (Australian Institute of Health and Welfare 2017). CDC was formally endorsed as policy following a Federal government review of community aged care services in 2010, with pilot programs rolled out over the following two years and formally mandated in 2015 (KPMG 2015). Bulamu and colleagues suggest the ‘distinguishing

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feature of CDC is that the recipient, or their representative, has choice and control over the funds allocated to meet their care needs’ (Bulamu et al. 2016). For elderly consumers, accessing one of the four level care packages available for home-based care for example, their provider must prepare an individualised care plan and budget in consultation with them. The provider administers and holds the budget, with the government subsidy paid directly to the provider, and the consumer topping up the payments (Baldwin et al. 2013). The assumptions underpinning consumer-directed care have been widely critiqued. For example, Yeatman (2009a) makes a distinction between two understandings of subjective individual rights, which may account for the slippage in understanding consumer rights. As a first premise, she argues that individual rights arise from the fact that contemporary Western societies view the individual as the site of all social action, rather than some collective, such as family, or national state. Such societies take the concept of individualisation of the self to mean that independently of class, gender or other forms of status, each person is considered human in and of themselves and should be accorded the respect and resources this calls for. This ethical position extends subjective rights to persons independent of their will or decision-making capacity (Yeatman 2009a). The alternate position on subjective rights assumes that human freedom requires cognition, the capacity to understand decisions, to self-­ govern, and make choices for ones-self and others, including the right to work, to own property and exchange this property for goods. According to Yeatman, this second definition is deeply embedded in Western forms of ethics and philosophy and openly discriminates against those who are unable, for one reason or another, to exercise choice and self-­preservation. This is problematic for people who are vulnerable. There is an emerging literature which challenges the assumption that all older people have the capacity to choose between aged care services. Meinow et al. (2011) argue that to be actively involved in decision-making for market-driven systems, the service user must be aware of their needs and able to access relevant information. Capacity to make an informed choice depends not only on access to information but also upon capacity to interpret that information and identify qualitative differences between services

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(Mojberg et al. 2016). Vamstad (2016), in telephone interviews with 324 older Swedes receiving home care services, found that 12.7 per cent of respondents were unaware they had a choice, that chance was a major factor in service choice, and that many respondents were unaware of alternative services. Service users must also have the capacity to manage multiple contracts and leave unsatisfactory services (Meinow et al. 2011). Only 6 per cent of Vamstad’s respondents had changed a service provider due to dissatisfaction with service provision. Meinow et al. (2011) argue that the capacity to access and assess information is dependent upon cognitive ability and communication skills as well as physical disabilities such as visual and hearing loss, with service need increasing with impairment. Hence, older people are at risk of being denied subjective rights. For Yeatman, there are immediate practical implications for our understanding of the welfare state arising from either position. Where subjective rights are reduced to the capacity to make an informed decision, there is a necessity to take considerable care with services for those with limited or no decision-making capacity (Yeatman 2009a). Welfare services that are premised on the capacity for decision-making, deny the ‘self ’ for those who are unable to engage in cognition. For these people, welfare services construct them as objects of charity, rather than subjective persons. Further to this, the relationship between those who provide welfare services and those who receive them requires an understanding on the part of the provider that the ‘service’ is not a charity, but necessary for the recipients’ preservation of self. Consumer-directed care, as a welfare service, discriminates against those who are unable to engage in decision-making. Even if we were to accept that welfare services require the recipient to be able to make decisions to either select the best available service, or to enter into mutual obligation agreements, there are obvious deficits. The failure of consumer choice to improve care quality is evident in low staffing and inadequate skills-mix in residential aged care in both for-profit and not-for-profit services. Inadequate staffing places both the client and worker in a relationship where informed consumer decisions about care may not be honoured as the provider cannot meet these expectations (Willis et al. 2016).

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Secondly, CDC has been critiqued on the grounds of equity of service access. In the United States, where it is referred to as ‘cash and counselling’, the policy provides consumers with means-tested cash to provide their own services, while in the Netherlands and Germany the concept is presented as ‘personal budgets’, and in the United Kingdom as ‘individual budgets’. While all espouse the idea of consumer choice, with few restrictions, most have a component of means-tested user-pays built into the services, with choice in effect limited by the resources allocated to an array of private providers and the capacity of the frail elderly to co-pay for the service (Yeatman 2009b). This is certainly the direction of the MyAgedCare web portal that provides both an extensive geographical list of accredited providers, and a tracker for estimating costs, which must be verified by CentreLink before the private provider can establish the full cost to the consumer (Australian Government and Consumer-directed Care 2017).

Privatisation, Regulation and Quality of Care Consumer choice is also associated with a belief that competition between services will lead to service improvement because services must attract and retain custom (Yeandle et al. 2012; Mojberg et al. 2016). Bergman et al. (2016) question this assumption, arguing that for competition to lead to service innovation and quality improvement, the consumer must have a genuine capacity to respond to reputational issues. We argue that there is limited scope for older people to exercise choice in relation to residential aged care. Assessment of eligibility to access residential aged care in Australia places time of entry in the hands of external agents, resulting in consumers being vulnerable and frequently highly dependent on services when entering residential aged care. Further, government regulation of the number of places offered means that there are often limited places available when needed, leading to pressure on the consumer to take an available place without regard to preference or suitability. These factors together act to limit consumer capacity to choose placements on the basis of reputation.

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Conversely, privatisation may lead to poorer service quality due to incentives to cut costs to achieve profits and a focus upon measurable outputs over intangible aspects of care (Bergman et al. 2016). A number of international studies have found that privatisation of residential aged care is associated with fewer hours of resident care (Ross and Harrington 2016); poorer quality care and citations for care deficits (Akinci and Krolikowski 2005; Barron and West 2017; Horn et al. 2005; Harrington et al. 2000); lower total staffing levels and the employment of fewer Registered Nurses (Akinci and Krolikowski 2005; Pradhan et al. 2014). Australian data is more limited. A recent review of accreditation standards conducted for the period 1999 to 30 June 2012 found that for-profit facilities have a higher proportion of sanctions applied for failure to meet minimum care standards (Baldwin et  al. 2015b), while Henderson et  al. (2018) found that staff working in privately owned facilities reported that required resident care was more frequently not performed than staff working in public facilities. The Aged Care Act 1997 makes provision for the maintenance of quality of care through compliance with accreditation standards. There are 44 aged care standards grouped under four headings related to: management systems, staffing and organisational development; health and personal care; care recipient lifestyle; and physical environment and safe systems (AACQA n.d.). Continued government funding is dependent upon successful accreditation (Japara Health 2016). Kaine and Ravenswood (2014) argue that Australia has a strong regulatory framework with regards to funding and maintenance of quality of care standards, but a weaker framework with regards to employment conditions and staffing in residential aged care. Australia does not currently have mandated aged care staffing levels or legislative requirements for a Registered Nurse to be onsite. The only stipulation within the accreditation standards is that ‘there are appropriately skilled and qualified staff sufficient to ensure these services are delivered in accordance with these standards and the residential care service’s philosophy and objectives’ (AACQA n.d.). While the lack of a staffing mandate operates in the interests of service providers through enabling cost saving through the employment of fewer and less costly staff, it potentially undermines the quality of care provided. The 2015 Bentley Aged Care Survey found residents received 2.86 hours of care per day in Australian residential aged care, significantly below the

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4.55–4.85 hours/resident/day recommended by Zhang et al. (2006) in a literature review of minimum staffing levels for residential aged care in the United States.

Conclusion This chapter has shown that recent changes in aged care policy and legislation have opened care delivery in Australia to market forces. The deregulation of aged care ownership, guaranteed government funding and the establishment of mechanisms for user contributions to residential aged care have made aged care attractive to private investors resulting in increasing private ownership of aged care beds. The privatisation of residential aged care creates a market in residential aged care, the end result of which is a stratified system where those who can afford to pay for additional services receive better quality care. Issues of care quality are viewed as being addressed through service competition, with older consumers expected to choose between services on the basis of reputation and service satisfaction. In Australia, this philosophy is exemplified by policies promoting consumer-directed care. We argue that the degree of disability experienced by those entering residential aged care and limited aged care places limit capacity for consumer choice between services. When consumer choice is lacking, privatisation can lead to poorer quality services due to cost cutting. Further, there is limited evidence that the marketisation of residential aged care improves standards. Residential aged care facilities owned by private for-profit companies have a higher proportion of sanctions applied for failure to meet minimum care standards, and both private for-profit- and not-for-profit-owned facilities have been found to provide fewer hours of resident care per day than the public sector. Nurses and care workers working in private for-profit facilities also report the omission of more resident care than staff in not-for profit and publicly owned facilities. There is also evidence of a shift in staffing towards employment of care workers rather than registered and enrolled nurses and reduced resident care hours per day across the sector as a whole. These factors taken together suggest that market forces are not

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improving quality of care and that private for-profit ownership results in poorer outcomes for consumers of care.

References Aged Care Act. (1997). [Commonwealth]. Available at: https://www.legislation. gov.au/Series/C2004A05206 [Accessed 17 Aug. 2018]. Aged Care Amendment (Red Tape Reduction in Places Management) Act. (2016). [Commonwealth]. Akinci, F. and Krolikowski, D. (2005). Nurse staffing levels and quality of care in Northeastern Pennsylvania nursing homes. Applied Nursing Research, 18, pp. 130–137. Angus, J. and Nay, R. (2003). The paradox of the Aged Care Act 1997: marginalization of nursing discourse. Nursing Inquiry, 10(2), pp. 130–138. Antonnen, A. and Haikio, L. (2011). Care ‘going market’: Finnish elderly-care policies in transition. Nordic Journal of Social Research, pp. 70–90. Australian Aged Care Quality Agency [AACQA]. (n.d.). Accreditation standards factsheet. Available at: https://www.aacqa.gov.au/for-providers/residential-aged-care/resources/copy_of_BROCAH0011AccreditationStandard sfactsheetEnglishv14.1.pdf [Accessed 5 Apr. 2016]. Australian Government. (2014). Extra Services Principles, Federal Register of Legislative Instruments F2014L00809. Australian Government. (2014). Quality of Care Principles, Federal Register of Legislative Instruments F2014L00830. Australian Government, and Consumer-directed Care. (2017). My Aged Care Home Page. Available at: https://www.myagedcare.gov.au/help-home/homecare-packages/consumer-directed-care-cdc:. Australian Institute of Health and Welfare. (2017). Health Workforce Data. 2017. Available at: www.health.gov.au. Baldwin, R., Stephen, M., Sharp, D. and Kelly, J. (2013). The Financial Viability And Sustainability of the Aged Care Sector. Available at: https://opus.lib.uts. edu.au/bitstream/10453/36460/1/ACSAViabilityWhitePaper291113.pdf. Baldwin, R., Chenoweth, L. and de la Rama, M. (2015a). Residential aged care policy in Australia–are we learning from evidence? Australian Journal of Public Administration, 74(2), pp. 128–141.

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Baldwin, R., Chenoweth, L., de laRama, M. and Liu, Z. (2015b). Quality failures in residential aged care in Australia: the relationship between structural factors and regulation imposed sanctions. Australasian Journal on Ageing, 34, pp. E7–E12. Barron, D. and West, E. (2017). The quasi-market for aged care in the UK: do for-profit, not-for-profit or public sector residential care and nursing homes provide better quality care?Social Science and Medicine, 179, pp. 137–146. Bergman,M., Johansson, P., Lundberg, S. and Spagnolo, G. (2016). Privatisation and quality: evidence from elderly care in Sweden. Journal of Health Economics, 49, pp. 109–199. Brennan, D., Cass, B., Himelweit, S. and Szebehely, M. (2012). The marketisation of care: rationales and consequences in Nordic and liberal care regimes. Journal of European Social Policy, 22, pp. 377–391. Bulamu, N., Billingsley, K., Gill, L., Cameron, I., McKechnie, S., Fiebig, J., Grady, R. and Ratcliffe, J. (2016). Impact of consumer-directed care on quality of life in the community aged care sector. Geriatrics Gerontology International, 17, pp. 1339–1405. Carey, G., Riley, T. and Cramming, B. (2012). The Australian Governments’ ‘social inclusion agenda’: the intersection between public health and social policy. Critical Public Health, 22(1), pp. 47–59. Chan, G., ChinC., McKitrick, D. and Warne, R. (2014). Does the Aged Care Funding Instrument provide increased funding in residential care? Comparisons with the Residential Classification Scale. Australasian Journal of Ageing, 33(2), pp. 121–123. Dean, M. (1999). Governmentality: Power and Rule in Modern Society. London: Sage. Department of Health. (2017). Approved Provider Information. Available at: https://agedcarehealth.gov.au/aged-care-funding/approved-providerinformation[Accessed 15May 2017]. Department of Social Services. (2015). Accommodation Payments. Available at: http://www.myagedcare.gov.au/aged-care-homes-costs-explained/accommodation-payments[Accessed 5 Nov. 2015] Fournier, V. (2000). Boundary work and the (un)making of the professions, In: N.  Malin (ed.) Professionalism, Boundaries and the Workplace. London: Routledge. pp. 67–86. Gibson, D. (1998). Aged Care: Old Policies New Problems. Melbourne: Cambridge University press. Gordon, C. (1991). Governmental rationality: an introduction. In: G. Burchell, C. Gordon and P. Miller (eds.) The Foucault Effect: Studies in Governmentality. Chicago: University of Chicago press. pp. 1–51.

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Harrington, C., Zimmerman, D., Karon, S., Robinson, J. and Beutel, P. (2000). Nursing home staffing and its relationship to deficiencies. Journal of Gerontology, 55B(5), pp. S278–S287. Henderson, J., Blackman, I, Willis, E., Gibson, T., Price, K., Toffoli, L., Bonner, R., Hurley, J. and Currie, T. (2018). The impact of facility ownership on nurses’ and care workers’ perceptions of missed care in Australian residential aged care. Australian Journal of Social Issues. https://doi.org/10.1002/ajs4.50. Horn, S., Buerhaus, P., Bergstrom, N. and Smout, R. (2005). RN staffing time and outcomes of long-stay nursing home residents. AJN, 10(11), pp. 58–70. Howe, A. (2000). Rearranging the compartments: the financing and delivery of care for Australia’s elderly. Health Affairs, 19(3), pp. 57–71. Hughes, M. (2011). The productivity commission inquiry into aged care: a critical review. Australian Social Work, 64, pp. 526–536. Japara Healthcare. (2016). Overview of Residential Aged Care market in Australia. Available at: http://investor.japarahealthcare.com.au/FormBuilder/_Resource/_ module/dYCDKYylV0umYHC7KDqmOw/documents/PresentationAndrew-Sudholz-New-York-March-2016%2D%2D-FINAL.pdf [Accessed 6 Jan. 2018]. Kaine, S. and Ravenswood, K. (2014). Working in residential aged care: a trans-­ Tasman comparison. New Zealand Journal of Employment relations, 38(2), pp. 33–46. Kendig, H. and Duckett, S. (2001). Australian directions in aged care: the generation of policies for generations of older people. Sydney: The Australian Health Policy Institute at the University of Sydney. KPMG. (2015). Formative Evaluation of the Home Care Packages Program: Detailed Findings Report. Available at: https://agedcare.health.gov.au/sites/g/ files/net1426/f/documents/09_2015/formative-evaluation-of-the-homecare-packages-programme-detailed-findings-report.pdf: Macnicol, J. (2015). Neoliberalising Old Age. Cambridge: Cambridge University Press. Meagher, G. and Szebehely, M. (eds.) (2013). Marketisation in Nordic Eldercare: A Research Report on Legislation, Oversight, Extent and Consequences. Stockholm: Stockholm University. Meagher, G. and Wilson, S. (2015). The politics of market encroachment: policymaker rationales and voter responses. In: G.  Meagher and S.  Goodwin (eds.) Markets, Rights and Power in Australian Social Policy. Sydney: Sydney University Press. pp. 29–96. Meinow, B., Parker, M. and Thorslund, M. (2011). Consumers of eldercare in Sweden: the semblance of choice. Social Science and Medicine, 73, pp. 1285–1289.

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Mojberg, L., Blomqvist, P. and Winblad, U, (2016). User choice in Swedish eldercare  – conditions for informed choice and enhanced service quality. Journal of European social policy, 26(3), pp. 281–295. Pradhan, R., Weech-Maldonado, R., Harman, J.S. and Hyer, K., (2014). Private equity ownership of nursing homes: Implications for quality. Journal of Health Care Finance, 42(2), pp. 1–14. Productivity Commission. (2011). Caring for Older Australians: Overview. Report No.53, Final Inquiry Report. Productivity Commission, Canberra. Rose, N. (1996) Governing “advanced” liberal democracies. In: A.  Barry, T. Osborne and N. Rose (eds.) Foucault and Political Reason: Liberalism, Neo-­ liberalism and the Rationalities of Government. London: UCL Press. pp. 37–64. Ross, L. and Harrington, C. (2016). California Nursing Home Chains by Ownership Type: Facility and Resident Characteristics, Staffing, and Quality Outcomes in 2015. Available at: http://theconsumervoice.org/uploads/files/ general/CA-Chains-Report_20AUG2016.pdf [Accessed 15May 2017]. Ryan, S. (2014). Implementing Consumer-Directed Care. Available at: https://www. humanrights.gov.au/news/speeches/implementing-consumer-directed-care:. Stolt, R. and Winblad, U. (2009). Mechanisms behind privatization: a case study of private growth in Swedish elder care. Social Science and Medicine, 68, pp.903–911. Thornton, G. (2015). Growing With Age: Deal Tracker for the Aged Care Sector. Available at: https://www.grantthornton.com.au/globalassets/1.-memberfirms/australian-website/industry/hac/pdfs/gtal_2015_growing-with-age_aged-care-dealtracker.pdf [Accessed 15May 2017]. Vamstad, J. (2016). Exit, voice and indifference - older people as consumers of Swedish home care services. Ageing and Society, 36, pp. 2163–2182. Venturato, L., Kellet, U. and Windsor, C. (2007). Nurses’ experience of practice and political reform in long term aged care in Australia: implications for the retention of nursing personnel. Journal of Nursing Management, 15, pp.4–11. Willis, E., Price, K., Bonner, R., Henderson, J., Gibson, T., Hurley, J.,Toffoli, L. and Currie, T. (2016). National Aged Care Staffing and Skills Mix Project Report: Meeting Residents’ Care Needs: A Study of the Requirements for NUrsing and Personal Care Staff. Available at: http://www.anmf.org.au/documents/reports/ National_Aged_Care_Staffing_Skills_Mix_Project_Report_2016.pdf:. Yeandle, S., Kröger, T. and Cass, B. (2012). Voice and choice for users and carers?Developments in patterns of care for older people in Australia, England and Finland. Journal of European Social Policy, 22, pp. 432–445.

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Part VI Conclusion

Chapter Thirteen: Navigating Private and Public Healthcare Fran Collyer

Health, Medicine and Sociology The sociology of health and medicine, in its institutional form as a speciality of sociology, has a history that in some countries is shared with its parent discipline, and elsewhere has had a more independent trajectory of development. As an ‘imagined community’ (Anderson 1991), the sub-­ discipline has its own founding intellectuals as well as institutional idiosyncrasies, although even these have varied cross-nationally (Collyer 2012). Initially, in countries such as the US, Britain and Australia, the sub-discipline was primarily a sociology of medicine, with its emphasis on the clinical context, the relationship between patient and medical doctor, and the profession of medicine. The professions were a primary interest of many in the parent discipline at that time, including Alexander Carr-Sanders and Paul Wilson (1933), but medical sociology is often said to have developed an identity as a speciality discipline when Talcott F. Collyer (*) Sociology and Social Policy, University of Sydney, Sydney, NSW, Australia e-mail: [email protected] © The Author(s) 2020 F. Collyer, K. Willis (eds.), Navigating Private and Public Healthcare, https://doi.org/10.1007/978-981-32-9208-6_13

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Parsons (1951) took medicine as an example of a social sub-system. In a now famous case study, Parsons sought to reveal the unique set of norms and behaviours characteristic of the sub-system, and, taking a leaf from Durkheim, who first proposed disease and ill-health to be ‘social deviance’, a deviation from the normal (Durkheim 1982: 49, 72), Parsons theorised medicine’s functional role in the maintenance of social order. From this Parsons developed a theory of the ‘sick role’—a set of rights, responsibilities and rules—to explain the behaviour of patients and doctors in, and beyond, the clinical encounter (Willis 2015: 212). An alternative narrative of the origins of medical sociology might focus on the response to Parsons’ somewhat rose-coloured view of the medical profession; for this, and his other works (e.g., Parsons 1958; Parsons and Fox 1953), engendered a wealth of debate and publications challenging his benign view of medical power (e.g., Zola 1972; Berlant 1975; Illich 1976). The term ‘medical dominance’ was introduced in Eliot Freidson’s twin publications of 1970, Profession of Medicine and Professional Dominance, both concerned with the status and power of medicine (Freidson 1970a, b). For Freidson (1994: 32), the concept signified a new professional strategy for attaining control over the labour process, and he differentiated this from consumer control in the market place and the managerial control of a centrally planned system. Freidson’s publications likewise stimulated a spate of Weberian and neo-Marxist analyses of the privileged status of the medical profession, including works by Parry and Parry (1976), Johnson (1972) and Larson (1977). By the 1980s, the concept of medical dominance was firmly established within medical sociology. It was perhaps given its final polish with Evan Willis’ (1983) monograph, Medical Dominance: The Division of Labour in Australian Health Care. In this, Willis demonstrated the specialised and hierarchical nature of the health division of labour, arguing for its dominance by one occupation, the medical profession. Through an historical study of the health division of labour, Willis argued against heroic views of the rise of modern medicine as a consequence of medical progress in the treatment of disease, and instead demonstrated the way medicine was established as a profession through the subordination of some practices (e.g., midwifery), the limitation of the practices of other health practitioners (e.g., optometrists) and the exclusion of certain occupations from legitimate health practices

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(e.g., chiropractic). On the basis of this ­historic achievement, Willis goes on to suggest, medicine experienced autonomy over its own work practices, authority over other health practitioners and medical sovereignty over the definition of health issues in the wider society (1983; also 2006: 422). In short, medical dominance was the outcome of historical, and fundamentally social, processes. This alternative narrative suggests it was widespread critique of the medical profession during the 1970s and 1980s that brought sociologists together as a sub-discipline. The rise of the women’s and feminist movements also played significant roles. In the 1980s, British sociologist Margaret Stacey, for example, wrote about the centrality of gender inequality in healthcare, specifically with regard to reproduction and child-rearing, and the growing practice of treating women as consumers, rather than patients, in the health services (Stacey 1976; Stacey and Price 1981; Bradby 2015). The concerns of women in the healthcare system also figured prominently in Australian texts of the period, for instance, in the early textbook of Cherry Russell and Toni Schofield (1986), Where It Hurts, and Erica Bates and Helen Lapsley’s (1985) The Health Machine: The Impact of Medical Technology. Feminist critiques of the medical profession within sociology were offered alongside broader critiques of science, particularly with regard to the introduction of many new reproductive technologies, including IVF and the contraceptive pill. Some of the better known American texts of the period include Shulamith Firestone’s (1970) The Dialectic of Sex, Gena Corea’s (1985) Man-Made Women and Donna Haraway’s (1985) ‘A Manifesto for Cyborgs’. There was an enormous growth in the sub-discipline throughout the 1970s and 1980s, and a significant broadening of the issues it dealt with as it headed into the 1990s. Examining a selection of sociology of health and medical sociology journals between 1990 and 2010 (Collyer 2012), it is evident that, while there has been a continuation of interest in the professions and the work context, the experience of illness and a focus on the patient became increasingly common, particularly in British medical sociology. In contrast, American medical sociology has concentrated to a greater extent on the inequalities of health, and on specific diseases and conditions (often as quantitative analyses where diseases and social groups are treated as variables). Australian medical sociology (more often referred

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to as health sociology) reveals a broad mix of interests, mirroring ­concerns raised in both Britain and the US (Collyer 2012: 239). Of particular significance to this chapter is the rise in interest in the health industry (i.e., in a healthcare market as distinct from a healthcare sector or system), particularly within the US, and noticeable from the 1970s. Though this interest has been sustained in only a small group of sociologists in these three countries, it nevertheless reflected important changes in the provision of healthcare services which was eventually to become global. First apparent in the US, where the private sector had long been dominant in the provision of health services (Light 2004), medical sociologists began writing about the rising strength of the healthcare market and its threat to medical autonomy, the quality of health services and its rising costs. Paul Starr’s (1983) The Social Transformation of American Medicine is a well-known example of this literature, demonstrating the role the medical profession has taken in the development of marketplace medicine. Others however envisaged the threat to the quality of care as originating not so much from the profession, and its power to satisfy its own interests, but from the intensification of capital investment in the healthcare sector and the shifting patterns of ownership of healthcare services and its insurance systems (Waitzkin and Waterman 1974; Navarro 1976; Salmon 1977; McKinlay 1978; Relman 1980). This political economy approach to the healthcare system strengthened in the 1980s, as sociologists in the US examined the new phenomena of growing ‘chains’ of private hospitals, of the formation of large Health Maintenance Organisations (HMOs) (which combine ownership of insurance companies, diagnostic laboratories, hospitals and primary care clinics) and of systems of Managed Care (e.g., McKinlay and Stoeckle 1988; Stoeckle 1988; Lindorff 1992; Light 1995). In that country, debates over medical dominance thus took a new twist: the ‘golden age’ of the medical profession was claimed to be finally over with the growth of private medicine and the medical-industrial complex of capitalism. In this context, the concepts of proletarianisation and deprofessionalisation were developed and hotly debated (e.g., Oppenheimer 1973; McKinlay and Arches 1985; Haug 1988; Coburn 1988; Navarro 1988; McKinlay and Marceau 2002). In the British context, with its small private sector dominated by the much larger, publicly owned and managed National Health Service

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(NHS), change since the establishment of the Service in 1948 has come in various guises. In 1990, the Thatcher government encouraged the use of private healthcare services and introduced ‘market reforms’ that laid the groundwork for the private finance initiative and the establishment of an ‘internal market’. Health Authorities/Boards and some general practitioners became purchasers, having to work with a set budget to purchase services from hospitals and other health service organisations in either the public or private sectors. Hospitals and other services became providers, with their incomes dependent on the contracts they could attract. In 2000, the Blair government brought in the NHS privatisation plan, inviting consortia to bid for 18 new private finance initiative hospitals— essentially private-public-partnerships (PPPs), which we discuss further below—where private companies build new hospitals and the NHS rents these from the companies. These ‘reforms’ mean that an increasing number of healthcare services are conducted within facilities owned and/or run by the private sector in Britain, many of which are transnational companies (including Virgin Care, Hospital Corporation of America, BMI, Care UK and Serco). Pollock (2016) outlines a number of implications from these changes, such as the amount of time health workers (including doctors and nurses) spend preparing bids and managing contracts, rather than undertaking preventative or clinical work. Other impacts involve increases in waiting lists and reductions in services, and the amount of money that is ‘leeched out’ of the system into the private sector. Estimates from the US suggest that privatisation takes 30 per cent of the funds for these kinds of costs, compared with only 5 per cent of running the NHS as a public system (Pollock 2016). Across the broader sociological literature in Britain, critiques of their healthcare system tend to be divided. Some debate issues of de-nationalisation (a form of privatisation) and the creation of internal markets (Light 1998; Britten 2001; Pollock 2004), while others focus more on the threats to professionalism arising from bureaucratic forms of management and the encroachment of new discourses or ideologies: neoliberalism, managerialism, the ‘new public management’ and consumerism (Calnan and Williams 1995; Clarke 2004; Dent 2006). In Australia, with its mixed public and private healthcare services and universal health insurance system, various policy changes have occurred.

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In 1984, the inception of a universal health insurance scheme (Medicare) brought increased revenue into the private sector, as did the establishment of Medicare and Medicaid in 1965 in the US. In the latter, in the ten years following the introduction of these programmes, new corporate investors entered the US hospital market and the for-profit hospital sector grew by 55 per cent in comparison to 28 per cent for the non-profit sector (Sax 1990; Collyer and White 2001). Likewise, in the Australian context, Medicare stimulated the growth in private medical and health services, allowing the private sector to benefit substantially from the public purse, and subsequent ‘reforms’ in health policy have produced further growth. For example, the conservative government (1996–2007) explicitly sought to increase the size of the private healthcare sector by encouraging the uptake of private health insurance through a series of measures, including both policy ‘carrots and sticks’ (these are described by Willis and Lewis; see Chapter Eleven of this book). Private health insurance (PHI) premiums were subsidised for low-income earners, while high-income earners who didn’t purchase cover were penalised with a Medicare Levy Surcharge. The combination of government measures and the ‘fear factor’ about being uninsured arrested and reversed the decline in insurance membership rates, such that approximately half the population now have PHI (Collyer et  al. 2015). The sale of the state-owned private insurance company (Medibank Private) also contributed to the growth in private medicine, as the major proportion of the health insurance business is now conducted by for-profit funds, even though the industry is protected from market competition and market down-turns through government subsidies and a suite of legislation. The insurance industry also receives a large state subsidy of approximately $6 billion annually. State support for the private health insurance sector readily translates into support—and profit—for private providers of healthcare services. This is evident in the funding of hospitals by state and territory governments, for they increased support for public hospitals by −0.1 per cent, 3.6 per cent and 0.1 per cent for the years 2014–2015, 2015–2016 and 2016–2017 respectively, but private sector hospital expenditure has grown at rates of 19.5 per cent, 28.9 per cent and 18.2 per cent for the same years (AIHW 2018: 34). It is also evident in the increases in net profits for the largest health service providers that immediately followed

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the government’s promotion of private health insurance. These increases ranged from 34 per cent for Healthscope to 142 per cent for Ramsay in 2000–2001 (both for-profit providers) (Collyer et al. 2015). Although the relationship between the private health insurance sector and the private provision of healthcare services is a complex one, these figures are indicative of the importance of private health insurance to the sustainability of the private healthcare sector—a particularly important factor, given that 37 per cent of the funding for private hospitals is derived from the state, including 21 per cent from the private health insurance rebate. Among Australian sociologists, analyses of the healthcare system have varied, with some sociologists taking an explicit interest in the private healthcare market and for-profit medicine (e.g., White and Collyer 1998; Collyer et al. 2001, 2015, forthcoming; Collyer and White 2001); while others have developed a concern with the discourses or ideologies which they see as driving the growth in private medicine: neoliberalism, managerialism and consumerism (e.g., Coburn 1993; Henderson and Petersen 2002; Germov 2005). Thus, the sociological literature on the healthcare sector has reflected changes that have taken place in the US, Australia and Britain over recent decades. And the same is true if we look at the issue of private medicine at a global level, whether it be Australia (Collyer et  al. forthcoming), Britain (Pollock 2016), Europe (Maarse 2006), America (Chan et  al. 1997), Korea (Yang 1996), Argentina, Chile, or Mexico (Waitzkin et al. 2007). While there are some countries which have strictly controlled the growth of private, for-profit medicine, such as Japan (where healthcare services are primarily delivered by public and not-for-profit organisations) and some of the Nordic countries, many developing countries that are without established, effective healthcare systems have—quite understandably—welcomed the interest of sizable transnational companies such as McKesson, United Health, CVS Health, Amerisource Bergen, Cardinal Health, Kaiser Permanente and Humana. Such corporations trade variously in health insurance, medical devices and pharmaceuticals, own hospitals, clinics and diagnostic laboratories, as well as providing hospital construction and hospital management services. These corporations are increasingly attracted to countries where there is a growing middle class capable of paying for private insurance and services, leaving the

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state to provide services for the poor (when, and if, they can do so). In countries where the state has sufficient capital for investment in services, such as China, internally funded private-public partnerships (PPPs) have become increasingly popular. Where states have little capital—such as Kenya and Gambia—investment finances are usually supplied through development organisations, including the Asian Development Bank and the African Development Bank, and are seen as ‘good financial investments’. PPPs vary, but are basically a contractual agreement between government and corporations to build infrastructure (such as hospitals), operate and maintain these facilities, and either continue to manage them on behalf of government or transfer the facility back to government. In these agreements, government generally remains accountable for the services provided and enters into PPPs in the expectation they will bring new technologies, new operational efficiencies and better-quality public services. In the longer term, PPPs are intended to boost economic growth and, through a ‘trickle-down’ effect, reduce poverty (Bayliss and van Waeyenberge 2018: 580). Yet, PPPs arrangements are highly contentious, with critics claiming the costs are too high, the contracts too long and too rigid, and the outcomes inefficient and risky (Bayliss and van Waeyenberge 2018: 577). International actors, such as the World Bank, have been instrumental in growing private, for-profit medicine at the expense of maintaining government services and in encouraging private health insurance (Sbarbaro 2000: 2). Indeed, private medicine has grown despite it being well known that cost efficiencies are highly dependent on strong states capable of enforcing contracts across space and time, and that strength is a crucial difference between first and third world economies (North 1993: 247). The solution, firmly embedded in the neoliberal, neoclassical economic paradigm, has been to tie foreign healthcare contracts into trade agreements, thus locking the countries into a ‘regulatory system imposed from outside by the governments of richer countries under the auspices of the WTO, the World Bank, the OECD and the WHO’ (Keaney 2010: 349). The past four decades have seen a burgeoning literature about the ‘costs’ and ‘savings’ of privatisation—with much of this stemming from other disciplines, particularly economics, rather than sociology—but

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very little commentary on the growth of private medicine as a broader issue. The privatisation of healthcare services and facilities has become increasingly popular with governments across the globe, even though studies from the US have repeatedly shown for-profit hospitals to be more expensive to run than not-for-profits, despite the for-profit hospitals spending less on staff, offering shorter stays for patients and avoiding the provision of services for charity cases (Woolhandler and Himmelstein 1999). There are a number of reasons for this higher cost. For-profit hospitals charge American Medicare (i.e., the state) substantially more per admission (Chan et al. 1997) (as they do in Australia), ‘suggesting the prevalence of not-so-hidden subsidies in the very sector that is supposed to be lean and efficient’ (Keaney 2010: 341). In addition, the higher administration costs and the need for profit to be taken from funds that would otherwise go towards services all add to the monies that need to be found from the state, from employers (in many health systems) and from individuals. Australian studies, including official government inquiries, have likewise revealed the higher costs of privatised hospitals—where the government pays the private sector to build and/or manage public (Medicare) hospitals—despite rhetoric to suggest that the private sector is more cost-efficient (PAC 1992: 2, 4; NSW Auditor 1996; Collyer 1997). The evidence is that rather than controlling costs, market systems exacerbate them, and this is the case whether the unit of analysis is the hospital, the health insurance system or the healthcare system as a whole (McIntyre and Ataguba 2012).

 he Growth of Private Medicine T and the Changing Healthcare System The previous section demonstrates the keen interest sociologists have taken in medicine and health since the middle of last century and the way some have investigated the historically unique and radical shift towards private, for-profit medicine since the 1980s. This volume has focused attention on the growing trend towards privately provided, medical and health services, revealing many previously hidden aspects of its growth.

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The final section of this chapter addresses the substance of this volume— how the growth in private medicine, a growth we are seeing in most countries of the world, is profoundly re-shaping healthcare systems: significantly raising costs; altering governance structures; intensifying the labour process; changing occupations, workloads and tasks; transforming the meaning of care work; modifying the treatment of bodies and undermining the principles of universalism and equality of access to services. Measuring the effects of privatisation has been highly contentious, is very much ideological (Braithwaite et  al. 2011) and is equally an outcome of disputes between disciplines and their legitimacy or status within the hierarchy of knowledge. Several disciplines have been part of this dispute, each offering a distinctive perspective on privatisation. Orthodox economics seeks to treat privatisation as a politically neutral, ‘technical issue’, defining it as a transfer of assets or activities from the public to the private sector, and a fiscal technique for achieving market liberalisation, enhancing competitiveness, increasing the role of market forces and/or improving public sector performance (e.g., Beesley and Littlechild 1983; Piggott 1987). Within political science, privatisation is deemed a political strategy involving the transfer of control from the public to the private sector and the shifting of power relations between various constituencies (Henig et al. 1988). It is also seen as an attempt to de-­ politicise the activities of government, allowing government to deflect political pressures for policies that are not in its own interests, are ethically or politically unattractive, or where rising costs make the government appear to lack competent management skills. Privatisation is argued to have the effect of altering existing exchange relationships between individuals, organisations and institutions. This theory suggests governments may also use privatisation as a political strategy to control interest groups or class conflict (Mansfield 1987: 71; Henig et  al. 1988: 463), particularly given the fact that privatisation has vastly different implications for the distribution of power and resources between groups such as unions, employers, consumers and governments (Aharoni 1991: 75–81). Sociology, like political science, offers a critical perspective on privatisation and focuses on power relations, but broadens this from political to cultural and structural forms of power, and may analyse it as a class process in accordance with the ‘privatise the profits, socialise the costs’

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rationale of capitalism (Keaney 2010: 340). Samson, for instance, suggests privatisation is a ‘cultural mission’ in which political strategies ‘reorder the political landscape’ (Samson 1991: 90). From this perspective, privatisation is a tool of neoliberalism, the political ideology or discourse that Pusey (1991) first named ‘economic rationalism’ when it made its appearance in the 1980s in Australia. The term ‘economic rationalism’ pointed to a fundamental alteration in the role of government, from ‘nation building’—providing services, monitoring, regulating, protecting the population from harm and ensuring national development—to a new and singular focus on building the economy, supporting the market as the primary means of social and economic co-ordination, encouraging self-regulation and protecting the accumulation of private capital within or across the country’s borders. What sociology offers, that other disciplines generally do not, is an analysis of privatisation and private medicine that includes, but looks beyond costs and party politics, to other impacts of government policies, particularly how these effect the people who work in healthcare and those who use the healthcare system. These are issues explored in the sections below.

Privatisation, Private Medicine and the Professions As noted above, sociologists have researched the way various governments have used privatisation to ‘reorder the political landscape’ (Samson 1991: 90). Light (1993: 284), for example, has argued that in Britain, privatisation programmes have explicitly been implemented to limit the power of the medical profession—a profession that has often challenged government and resisted policy reform and regulation. Bachman (1996) has examined similar issues in the American context. An example where privatisation was used in this manner occurred in Australia with the privatisation of the Port Macquarie Base Hospital. Privatisation instantly transformed all staff into private sector employees and gave the hospital operators—and therefore ‘the market’—the responsibility for providing hospital services and managing professional, administrative and support staff (Collyer 1997). Government justified the action on the grounds that

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a division between the provider and the funder would reduce political conflict, because the funder (the government) would cease to be dominated by providers (i.e., by the medical profession or the hospital). It was also hoped that the division would remove the contradiction between the delivery and the regulatory roles of the public sector (PAC 1993: 9, 12). In this case of privatisation, the government’s strategy to replace professional power with market power was spectacularly unsuccessful. Efforts by the new managers to place restrictions on the autonomy of medical staff led to an effective boycott, the inability to maintain service levels, profitability fell and the hospital was eventually returned to public hands. Sociologists propose that privatisation and the introduction of market principles and practices into national healthcare systems represent significant challenges for the medical profession, other healthcare workers and carers. In Chapter Eight of this volume, Rudge and Toffoli demonstrate some of the changes that occur in the working environment under privatisation and, like Zullo and Ness (2009), argue that working conditions are more favourable in public systems for healthcare support staff. Other sociological studies indicate that the effects of privatisation on doctors— who generally have greater professional and market power—are more variable, with some actively resisting reform and others seeking to comply (e.g., Waring and Bishop 2011). Of particular interest to sociology is the way decision-making practices in government, and in public and private organisations, are altered with privatisation. In Chapter Seven of this volume, Calovski and Calnan investigate the way managers and administrators in the British healthcare system make decisions about whether to engage and contract with public or private sector providers. Their study reveals the many constraints on the decision-makers, slowing (but not halting) the privatisation process. A similar issue is raised by Collyer (Chapter Six, this volume) with regard to the gatekeepers of the Australian system, showing that the process is neither inevitable nor straightforward. The chapter explores the contradictions and tensions emerging when individuals in critical decision-­ making roles are confronted with a set of values based on the administrative rationality of managerialism and the discourses of neoliberalism, which are in sharp contrast with their own ethos of public service and professional ethics. The study finds that most participants perceive a distinct

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contrast between the values, expectations and practices of the publicly run hospital or clinic and the private, for-profit organisation. While all individuals working in the healthcare system seem ready to express an interest in social justice and caring for others, there are differences between those working in the for-profit, as opposed to non-profit and public sectors. Like other studies of ethics and values across the public/ private divide (e.g., Andersen et al. 2011), it seems working in the private for-profit sector encourages healthcare practitioners to focus on providing care for individual users of services—customers—while public sector employment builds a broader orientation of caring directed towards the community or ‘general public’. These differences are noticeable to observers but also to the participants, as we see in Collyer’s chapter. Larsen and Harsløf ’s chapter (Chapter Ten, this volume) also analyses the way privatisation is experienced by those working within the system. The chapter draws on a study from Denmark where the state now pays private sector organisations for rehabilitation services previously undertaken within the public sector. In this study, we see the state paying for individuals to attend private clinics in order to ‘improve their employability’ and accelerate the ‘return to work’ process. In the new context of private clinics, with both public and private clients (some paid for by the state, and others through private health insurance), Larsen and Harsløf note the movement away from traditional practices of physiotherapy, where the aim is to increase bodily movement and strength after injury or illness, and ‘help people with problems’, towards a new emphasis on individual beauty, appearance and bodily training. Staff of these facilities who have come from the public sector find the new private sector environment to be making new demands on them. They are now required to ‘invest’ in their own body, to obtain and maintain a bodily appearance that is ‘authentic’ (i.e., athletic, lean and healthy), and become a ‘personal trainer’ rather than a clinician. These individuals, in order to keep their careers or forge new ones, are expected to give up what was once meaningful about their jobs and replace it with a new set of values based around the ‘commodified healthy body’.

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Governance It is clear that despite evidence to the contrary, support for private healthcare, for private insurance and private-public financing arrangements, is predicated on neoliberal doctrines that portray the state as incapable of timely decision-making and providing services efficiently and effectively. This is particularly the case for developing societies, where the state is associated with corruption and incompetence. Conversely, in neoliberal doctrine, the private sector is assumed to be less corrupt and more capable of achieving cost efficiencies and improvements in equality of access (Bayliss and van Waeyenberge 2018: 583–589). These are however, doctrines, not facts, and the evidence suggests all sectors—whether private for-profit, private not-for-profit or public—provoke different governance issues for nation states. Public systems of care (e.g., the British NHS) present government with problems of co-ordination between layers of government, of implementing change and bringing about improvements in the quality of care (OECD 2016). Primarily private, for-profit systems of care (e.g., the US) tend to be dominated by the hospitals, with insufficient attention given to primary and public health. These systems are also likely to have very high costs, making services unaffordable for many patients, and are unlikely to provide comprehensive access to all social groups (OECD 2015; and as reported in Brodwin 2017; Schneider et al. 2017). Mixed private-public systems (e.g., in Australia) are likely to be highly fragmented, hard for patients to navigate, difficult to ensure an even spread of accessible services, have high out-of-pocket costs for patients (because cost structures are open-ended), and difficult for governments to monitor and control (OECD 2015). Where healthcare services involve the private sector, the state’s capacity to govern, that is, to maintain legitimate control and authority, is generally more difficult to achieve than in a fully public system. In capitalist, democratic societies, the system of legislation is designed to protect private property, and hence the state’s capacity to, for example, provide services for all citizens on an equal basis, will be curtailed by these property rights. An example can be found in Australia with the approval processes for construction of a private hospital. Approval was initially declined on

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the basis that the area was already well-served with hospital beds; however, the applicant appealed and approval was granted. The case illustrates the limitations of effective state control over the planning of appropriate hospital services according to the principals of medical need across geographic areas and its ability to ensure neither under- nor over-supply (White and Collyer 1998: 19). While legislation ostensibly provides for the power to register or refuse to register private hospitals to ensure they are built in appropriate areas, the legal framework within which the claims are heard is based on the needs and property rights of entrepreneurs, not the user rights of consumers, nor the service responsibilities of government (Duckett 1989). In this case the court determined that the entrepreneur had the right to construct a hospital where it would maximise patients and therefore profits. Consequently, the Health Commission has been unable to prevent the private sector from building hospitals in  localities which will maximise revenue for the entrepreneurs. This undermines the public system, because these new hospitals compete with nearby public hospitals for patients, rather than providing new beds in under-supplied areas. Given that all medical services in private hospitals (as distinct from hotel-type services in private hospitals) are paid for by government through Medicare, this situation ‘wastes’ scarce public resources and produces no net gain in health services for the community. Another issue arising with private medicine concerns the sharing of statistical information about disease infection rates, about the effectiveness of alternative approaches to treatment and about the relative financial performance of healthcare programmes. In all countries, though to varying extents, corporations have the right to withhold such information on the basis of ‘commercial sensitivity’, and this encourages competition rather than co-operation (Light 1995). And wherever private providers are involved, regulating the use of particular products or services is more difficult. This is made evident in a study by Broom et al. (2018), where the state is unable to pursue certain public health measures, such as reducing antimicrobial immunity in the population by limiting the use of antibiotics in private hospitals. Without comprehensive information-sharing practices, the state is unable to effectively and efficiently monitor, regulate and control essential services (Ernst 1994: 128).

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While the capacity of the state to effectively regulate is often discussed with regard to developing societies, concerns are also raised in developed economies with fully functional state apparatus. This occurred in the case of the Port Macquarie Base Hospital, a private-public financing arrangement, where the capacity of government to negotiate ‘acceptably balanced deals’ with the private sector, and engage in projects with the private sector that are in the State’s best interest, was publicly disputed (NSW Auditor 1996). In this case, it was found the state had paid the capital cost of constructing the hospital twice over, and, moreover, at the end of the contract period, the state owned neither the building nor the land (Collyer 1997). Auditors concluded that the cost of financing the hospital through privatisation was substantially higher than it would have been through the use of a public option (1996: 18). Similar issues are taken up in this volume by several contributors. In Chapter Four, Fernando De Maio, Raj Shah and Kerianne Burke examine the community needs assessments required of not-for-profit hospitals in the US. While it is laudable to see these hospitals addressing the fundamental inequalities of their communities, it is evident that the state cannot, for political and legal reasons, require for-profit hospitals to undertake such assessments. Clearly, the expectations for for-profit entities are quite different: these need not take an interest in improving the health of the communities, after all, for-profit hospitals thrive only where there is significant ill-health, and improving the health of communities reduces corporate profits. Corporate profit is also the focus of Chapter Five by Pat Armstrong and Hugh Armstrong, where contracting with the private sector to deliver services to aged care facilities in four countries is shown to produce lower-quality services at higher costs. In Chapter Twelve, Julie Henderson and Eileen Willis show the damage wrought by introducing market forces into aged care in Australia, particularly when accompanied by deregulation and/or self-regulation. One of the more fundamental impacts of private medicine is inequality. The opening chapters of this volume tackle, head-on, the way the growth in private medicine threatens the universalism that public healthcare systems are designed to provide. Paula Blomqvist, in the second chapter, reminds us that the World Health Organization has declared universalism to be a goal for all healthcare systems, and offers a definition:

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The concept of universalism can be understood as a value, or ethic, that applies to all individuals in a society, regardless of culture, religion, class, race, nationality or sexual orientation. In health policy, it relates broadly to a way of arranging health services provision so that all members of a society, or citizens, have access according to need.

The chapters by Paula Blomqvist and Monica Budowski demonstrate the ways these goals of universalism are impacted in European and Latin American countries, respectively, with the increasing use of private sector providers and contractors. Regardless of how universalism is defined, a greater dependence on private sector medicine is associated with the entrenchment, not the amelioration of inequalities in healthcare service provision.

The Undermining of ‘Real’ Choice The introduction of private contractors and companies into the world’s healthcare systems is often justified by governments as a means to increase ‘choice’ for patients and the ‘consumers’ of medicine. Given that numerous studies have shown choice to be a highly valued commodity in modern democratic societies, this is a politically astute strategy. Moreover, the same package of discursive claims equates private medicine with greater choice, and public medicine with less choice. This is one of the findings discussed in Chapter Eleven, where Karen Willis and Sophie Lewis examine the discursive presentation of private medicine to the public as a solution to poor quality, ‘inconvenient’ and ‘untimely’ care. Public healthcare is also represented as less responsive to the needs of the individual, associated with longer waiting times and a lower standard of care. Although these claims have no basis in evidence, they appear true, primarily because of a fundamental asymmetry in knowledge—public health has no one to ‘speak’ for it. In contrast, private medicine is widely lauded in the media, with authoritative figures, including government, constantly claiming its benefits and pointing to ‘problems’ with public medicine (Lewis et  al. 2018a, b).

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Sociological studies of choice in healthcare have consistently found this concept highly problematic, and demonstrated the way individuals are not entirely free to choose. Instead, the capacity to choose one’s healthcare service, provider and treatment process is limited, not simply by income, level of education and geography, but by access to information and knowledge about the healthcare system. In a society where information is skewed in favour of the more powerful actors in the system—the private healthcare industry—‘choice’ is reduced to the ‘choice to go private’.

A Final Word In sum, the chapters of this book provide critical evidence of the impact of private medicine, and the incapacity of the nation state to design and implement effective forms of regulation to mediate the negative effects of privatisation. Kumaranayake (1997) is not alone in arguing that the ability of regulatory mechanisms to influence private sector activity is limited, and that contrary to the neoliberal idea of ‘small government’, privatisation requires more, not less regulation, and if private services are to be successfully integrated into the healthcare system, additional—not fewer—resources are required. The choice for governments then, and for all those working in healthcare systems or in need of the healthcare system—that is, all of us— should be evident. Encouraging the private sector to develop and deliver healthcare services promotes a set of values and agendas based on the primacy of private property and market principals. This, in itself, threatens the very basis of universalism and the achievement of hard-earned milestones in equity and preventative health.

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Index1

A

Access, 3–6, 9, 15–17, 19–26, 28, 30–35, 42–47, 49, 51, 55, 57, 64–69, 74, 81, 82, 89, 96, 98, 100, 108, 123, 126, 132, 133, 138, 139, 182–184, 186–193, 195, 201, 203, 227, 228, 235, 237, 241, 242, 245, 256, 258–260, 280, 284, 287, 288 Accessibility, 98, 100 Administration, 43, 97, 116, 132, 164, 190, 279 Affordability, 19, 21, 26, 32 Aged care, 7, 249–263 Agency, 22, 26, 44, 64, 83n2, 76, 91, 96, 108, 165–170, 175, 231 Agency nurses, 165–167, 174 See also Nurses

Agents, 2, 74, 108, 124, 207, 219, 220, 260 Armstrong, Hugh, 7, 89, 286 Armstrong, Pat, 7, 88, 90, 92, 93, 97, 286 Asian Development Bank, 278 Australia, 9, 113, 115, 116, 121, 157, 161, 177, 227–231, 239, 242, 243, 245, 249–263, 271, 275, 277, 279, 281, 284, 286 B

Blomqvist, Paula, 6, 50, 286, 287 Body, the chemical, 208, 209 mental, 208, 209, 211–213 nutritional, 208, 209, 211–213, 215

 Note: Page numbers followed by ‘n’ refer to notes.

1

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295

296 Index

Body, the (cont.) physical, 208, 209, 211–213, 215, 217, 219 surgical, 208, 209, 215 unemployable, 212–213 Bourdieu, Pierre, 112–117, 119, 206–208, 210, 219, 228, 230, 235, 246 Britain, 271, 274, 275, 277, 281 Budowski, Monica, 6, 287 Bureaucracy, 2 Burke, Kerianne, 4, 7, 286 C

Calnan, Michael, 7, 131, 132, 185, 275, 282 Calovski, Vid, 7, 137, 282 Canada, 88–100, 162 Cancer, 73, 75, 186, 193 Capital cultural, 213, 215, 217, 235–239 economic, 207, 211–212, 235, 236 health, 208–211, 213, 217, 219, 237, 238 social, 238 Care related services, 7 Chicago, 63–83 Chile, 15–35, 277 Choice, 2, 4, 6, 8, 9, 22, 23, 69, 97, 107, 131–150, 185, 204, 227–246, 287–250, 288 Chronic disease/condition, 4, 75, 81, 230 Citizen, 2, 4, 8, 22–25, 28, 29, 31, 32, 41, 43–46, 49, 55, 57, 91, 113, 114, 205, 206, 229, 242, 257, 284, 287

Citizenship, 6, 15–35, 229, 243 Class, 3, 42, 67, 109–111, 116, 119, 122, 126, 218, 258, 277, 280, 287 social class, 16, 110, 116, 182, 208, 231 Collyer, Fran,7, 9, 108, 110, 115, 116, 208, 228, 232, 239, 242, 244, 245, 271, 273, 274, 276, 277, 279, 281–283, 285, 286 Commercialisation, 202 Commissioner, 123, 133, 135–150 Community health, 63–65, 83 needs, 7, 64, 286 Competition, 2, 5, 9, 22, 26, 42, 50, 98, 134–136, 141, 142, 149, 183, 194, 203, 204, 211, 218, 231, 252, 256, 260, 262, 276, 285 Complementary services, 27 Conservative government, 133, 228, 250, 276 Conservative welfare regimes, 18, 33 See also Welfare regime Consumer, 2, 8, 20, 22–24, 91, 114, 158, 228, 244, 249, 251, 252, 255–260, 262, 263, 272, 273, 280, 285, 287 Consumerism, 275, 277 Contracting-out, 3, 7, 88–100, 110, 204 Convenience, 28, 241 Cook County, 71, 77 Correia, Tiago, 8, 111, 112, 184, 186–189, 194 Costa Rica, 15–35 Cost effectiveness, 98, 161

 Index 

Costs, 3, 48, 52, 88–90, 93, 96, 98, 100, 108, 118, 134, 141, 142, 169, 175, 177, 181–196, 211, 229, 235, 239, 241, 250, 252–254, 256, 260–262, 274, 275, 278–281, 284, 286 Cultural values, 5 Customers, 8, 53, 91, 162, 178, 202, 219, 283 D

De Maio, Fernando, 7, 67, 75, 76, 286 Decision-maker, 7, 109, 125, 133, 134, 136–138, 282 Decision-making, 2, 20, 30, 107, 108, 126, 133, 135–137, 139, 147, 148, 184, 188, 192, 233, 258, 259, 282, 284 Delivery, 19–27, 29–31, 34, 64, 92, 93, 110, 122, 124, 132, 146, 162, 166, 171, 184, 191, 192, 194, 195, 250–252, 262, 282 De-nationalisation, 275 Denmark, 46, 47, 191, 203–205, 217, 283 Diagnosis Related Group (DRG), 159, 161, 163, 176, 178, 204 Disability, 23, 27, 30, 80, 122, 206, 259, 262 Discourse, 113, 114, 132, 171, 195, 208, 229, 235, 238, 239, 244, 275, 277, 281, 282 Disease, 73, 75, 81, 216, 272, 273, 285 Doctors, 8, 48, 89, 107, 108, 111, 112, 116, 121, 122, 125,

297

161–163, 175, 176, 208, 219, 228, 234, 238, 240, 241, 271, 272, 275, 282 See also Physicians; Specialists Doxa, 115, 119, 125, 229, 242–243 E

Economic rationalism, 281 Economics, 2, 17, 35, 49, 72, 80, 82, 109, 112, 119, 158, 161, 174, 178, 181, 185, 191, 192, 204, 207, 210, 211, 213, 215, 217, 229, 231, 235, 236, 238, 239, 250, 278, 280, 281 Efficiency, 3, 90, 93, 96, 136, 161, 163, 172, 176, 184, 187, 204, 250, 252, 278, 284 Employment, 5, 8, 18, 30, 44, 49, 56, 72, 91, 98, 125, 126, 202, 204–206, 208, 212, 213, 216–220, 261, 262, 283 England, 90, 131–150 Enrolled Nurses (ENs), 162–164, 169, 174, 175, 177, 262 Equality, 16, 19, 46, 47, 57, 79, 280, 284 Equity, 9, 16, 19, 35, 42, 47, 48, 51, 64, 65, 68, 79, 113, 121–124, 242, 243, 260, 288 Esping-Andersen, Gøsta, 18 Ethics, 42, 121–123, 258, 282, 283, 287 Ethnicity, 67, 182, 208 Ethnographic, 92, 133, 137, 160 Ethnography, 92, 133, 137–139, 142, 146 Europe, 183, 184, 191, 205, 277

298 Index

European Central Bank, 181, 187 European Commission, 181, 187 Exercise, 73, 74, 147, 212, 213, 216, 234–236, 240, 244, 245, 250, 258, 260 F

Faster access, 5, 45 Feminism, 98, 273 Finance financial, 3, 4, 8, 15, 20, 23, 24, 29, 30, 33, 48, 49, 63, 77, 90, 99, 109, 110, 112, 123, 124, 126, 131, 136, 139–150, 160, 169, 176, 177, 181, 185, 188, 189, 191–195, 205, 227, 235, 236, 250–253, 255, 285 financing, 2, 5, 16, 19–22, 24–30, 34, 42, 44–47, 49, 52, 55, 64, 92, 186, 194, 203–205, 228, 284, 286 Financial, 187 For-profit, 26–28, 51, 53, 69, 88, 89, 94, 96, 99, 116–118, 121, 161, 183, 185, 187, 193, 194, 202, 208, 250, 251, 255–257, 259, 261–263, 276, 277, 279, 283, 284, 286 Freidson, Elliot, 111, 185, 272 G

Gatekeepers, 7, 107–126, 253, 282 gatekeeping, 108, 112, 118 Gender, 75, 182, 208, 258, 273 Geography, 167, 173, 182, 288 Globalisation, 231

Governance, 9, 50, 52, 77, 78, 159, 250, 280, 284–287 Government, 2–5, 8, 22, 31, 43, 46, 48, 50, 51, 77, 89, 108–110, 112, 115–118, 122, 123, 131–134, 159, 161, 178, 203, 204, 206, 208, 227–229, 233, 235, 242, 246, 249–258, 260–262, 275–282, 284–288 H

Habitus, 7, 112, 113, 115, 118, 119, 125, 219, 228, 230, 233–235, 246 Hand, 220 Harsløf, Ivan, 8, 205, 206, 283 Health assessment, 47, 79 commission, 285 inequalities, 15, 121, 273 insurance, 4, 5, 23, 43–45, 55, 67, 69, 74, 80, 115, 117, 121, 161, 186, 188, 216, 217, 220, 227–229, 231, 234, 275–277, 279 policy, 1, 6, 8, 42, 43, 45, 47, 117, 123, 132, 137, 276, 287 services, 3, 15, 22, 26, 41–43, 45, 47–49, 55–57, 64, 94, 97, 110, 113, 114, 116, 132, 138, 150, 194, 195, 202, 210, 212, 215, 219, 251, 254, 273–276, 279, 285, 287 Healthcare organisation, 112, 231 professionals, 8, 201–221 workers, 188, 282

 Index 

Henderson, Julie, 8, 261, 277, 286 Hospital, 3, 23, 41, 63–83, 89, 108, 133, 157–178, 185, 202, 227, 274 Human rights, 23, 257 See also Rights I

Ideology, 5, 111, 113, 250, 257, 275, 277, 281 Imperative of choice, 8, 227–246 Income, 7, 18, 20, 23, 24, 27, 30, 33, 43–45, 49, 52, 55, 56, 66, 67, 111, 192, 237, 275, 288 Individualisation, 202, 258 Inequality/ies, 2, 4, 5, 9, 15, 20, 22, 67, 121, 123, 125, 194, 273, 286, 287 In-patient, 52, 117, 157, 171, 178, 183, 193, 195 Institutionalisation, 17 Institutions, 3, 7, 17, 26, 28–30, 32, 49, 64, 69, 73, 78, 81, 82, 114, 123, 131, 141, 202, 205, 206, 208, 213, 217, 220, 280 Insurance, 6, 15, 23–27, 29–34, 43–46, 48, 53, 56, 107, 115–118, 161, 183, 186, 188, 193, 203, 204, 216, 217, 228, 234, 235, 251, 274, 276, 277, 284 See also Health, insurance; Private health insurance Intensification (of work), 169, 172, 177 Interests, 2, 5, 50, 99, 100, 109, 110, 112, 116, 124, 137, 159,

299

209, 211, 214, 220, 261, 271, 273, 274, 277, 279, 280, 282, 283, 286 International Monetary Fund, 181, 187 Interviews, 92, 96, 113, 114, 121, 138, 141–145, 160, 172, 209, 210, 214, 228, 232, 259 K

Knowledge system knowledge, 238, 245 L

Larsen, Kristian, 8, 205, 208, 209, 283 Leisure, 211, 213, 214 Lewis, Sophie, 8, 113, 114, 120, 134, 232, 241, 244, 245, 276, 287 Liberal welfare regimes, 18 See also Conservative welfare regimes; Social democratic welfare regimes Lifestyle, 202, 206, 215, 216, 219, 232, 261 M

Managed Care, 112, 274 Management, 50, 89, 96, 97, 99, 111, 148, 161, 165, 168, 171–178, 183, 186–188, 204, 211, 217, 220, 233, 261, 275, 277, 280

300 Index

Managerialism, 111, 112, 275, 277, 282 The market, 2–3, 18, 64, 93, 109, 132, 183, 202, 231, 249, 272 Market-driven, 126, 183, 194, 258 Marketisation, 1, 4, 8, 9, 41–57, 97, 98, 108, 110, 111, 132, 145–146, 149, 193, 196, 202, 243, 249–263 Market principles, 2, 3, 132, 149, 282 Marmot, Michael, 74, 76 Maternity, 239 Means-tested, 161, 229, 254, 256, 260 Medibank, 115, 228 Medical autonomy, 274 Medical-industrial complex, 4, 274 Medical profession, 272–274, 281, 282 Medicare Australia, 107, 108, 115–117, 119, 123, 124, 227, 228, 231, 243, 276, 279, 285 United States, 279 Medication, 89, 162, 164, 167, 171, 172, 174, 185, 188–193 See also Pharmaceuticals Middle class, 126, 277 Midwifery, 272

Nation state, 114–117, 284, 288 See also State, the Navigation (of systems), 6, 113, 230 Neo-institutionalism, 184 Neoliberalism, 2–3, 7, 108, 113, 115, 118, 124–126, 250, 257, 275, 277, 281, 282 Neoliberal state, 42 See also State, the Non-profit, 18, 20, 89, 96, 114, 118, 208, 276, 283 Nordic countries, 45–47, 57, 203, 277 Norway, 5, 45–47, 92 Not-for-profit, 7, 63, 64, 77, 82, 119, 121–125, 161, 175, 178, 186, 187, 194, 251, 256, 259, 262, 277, 279, 284, 286 Nurses agency, 165–167, 174, 175 enrolled (EN), 162–164, 166, 169, 174, 175, 177, 262 licenced practical, 162 registered (RNs), 161–164, 169, 170, 173–175, 177, 178, 261, 262 second-level, 162 State Enrolled, 162 technical, 162 Nursing, 7, 8, 116, 158–166, 168, 169, 171–178, 254 Nursing homes, 52, 88–100, 116, 253

N

National Health Service (NHS, Britain), 3, 46, 48, 57, 112, 131–150, 183, 274, 275, 284 National Health Service (NHS, Portugal), 185–195 Nation-building, 2, 281

O

Obese or obesity, 68, 69, 72–74, 82, 206, 213 Observation, 55, 92, 138, 160, 170, 171, 173, 177, 209, 219

 Index 

Obstetric care, 157 Out-of-pocket costs, 188, 284 Out-of-work, 205 Out-patient, 48, 49, 52, 57, 183 Overweight, 211, 213, 216, 220 See also Obese or obesity P

Parsons, Talcott, 271, 272 Passive privatisation, 7, 148 Patient (s), 6–8, 43, 45, 49–53, 56, 72, 83n1, 90, 91, 97, 107–109, 111–113, 118, 121–124, 132–134, 141, 142, 148, 157, 159–178, 182, 184, 185, 187–194, 196, 202–205, 208–210, 212, 214, 216, 218–220, 227, 231, 234, 235, 237, 240, 242, 244, 245, 271–273, 279, 284, 285, 287 Peer pressure, 202 Performance, 52, 90, 141, 143, 160, 183, 184, 211, 219, 245, 280, 285 Performance-related, 50 Personal trainer/training, 210, 216, 218, 283 Pharmaceuticals, 29, 115, 208, 277 See also Medication Physicians, 8, 47–49, 91, 112, 163, 178, 182, 185, 187–195 See also Doctors Physiotherapists, 209, 215, 217 Physiotherapy, 138, 143, 146, 147, 204, 215, 217, 220, 283 Policy analysis, 183–185

301

initiatives, 2, 4, 228, 233 -maker, 6, 46, 97, 108, 112 reform, 181, 281 Political economy, 108, 274 Political science, 280 Population coverage, 15, 32 Portuguese Medical Council, 186, 189 Post-graduate, 190, 191 Post-industrial, 205, 218, 221 Post-war, 47, 57, 249 Prescribing, 187 Prescriptions, 89, 189, 190 Primary care, 41, 42, 47, 49–52, 57, 121, 149, 150, 274 Private health insurance (PHI), 4–6, 8, 43, 44, 52, 53, 55, 56, 107, 114, 116–119, 161, 193, 202–204, 218, 227–246, 276–278, 283 See also Health, insurance; Insurance; Social insurance; Voluntary insurance Private medicine, 1, 2, 6, 8, 9, 109, 110, 118, 119, 122, 124, 126, 181–196, 274, 276–283, 285–288 Private providers, 5–7, 22, 24, 27, 28, 31, 34, 42, 50–52, 123, 132, 134–140, 143, 145–147, 149, 150, 186, 190, 203, 250, 260, 276, 285 Private-public-partnerships (PPPs), 275, 278 Privatisation, 2–4, 7, 88–91, 108, 110, 111, 131–150, 202, 205, 243, 251, 252, 257–260, 262, 275, 278–283, 286, 288

302 Index

Profession professionals, 8, 26, 111, 114, 115, 135, 137, 168, 184–186, 188, 193, 194, 201–221, 235–239, 244, 245, 281, 282 Profit, 4, 9, 94, 98, 99, 112, 118, 147, 161, 210, 219, 261, 276, 280, 285, 286 Profitability, 282 Providers, 2, 21, 41, 74, 90, 108, 132, 163, 185, 202, 227, 250, 275 Public ethos, 282 healthcare, 9, 21, 22, 24, 25, 27–29, 31, 49, 50, 109, 110, 113, 114, 116, 119, 173, 202, 239, 240, 245, 246, 271–288 -private partnerships, 3, 89, 187 provision, 2, 3, 46, 110, 113, 122, 183, 251 relations, 162, 163 sector, 2, 3, 22–24, 26, 32, 33, 43–46, 48, 50, 55, 57, 92, 116, 118, 120, 163, 176, 186, 189, 220, 239, 251, 262, 280, 282, 283 Q

Qualitative, 16, 45, 72, 112, 124, 163, 173, 258 Quality of care, 24, 147, 158, 166, 175, 176, 184, 190–191, 195, 235, 238–242, 245, 252, 261, 263, 274, 284 of services, 252

Quantitative, 80, 109, 186, 273 Quasi-market, 50, 52, 251 R

Race, 42, 67, 68, 75, 287 Rationed care, 253 Rationing, 25 Registered nurses (RNs), 161–164, 169, 173–175, 177, 178, 254, 261 See also Nurses Regulation, 9, 43, 44, 48, 51, 77, 83, 117, 131, 159, 175, 185, 193, 203, 207, 208, 219, 253, 255, 260–262, 281, 288 Reproduction, 219, 232, 273 Reputation, 157, 158, 163, 176, 177, 260, 262 Resource distribution, 29, 45, 47, 55, 280 Responsibilities, 2, 8, 18, 20, 26, 31, 47, 49, 51, 66, 77, 83, 98, 107, 108, 118, 121, 122, 124, 125, 135, 136, 173–175, 229, 231, 235, 243, 244, 250–253, 255, 272, 281, 285 Rights, 15–25, 28, 31–34, 43, 45, 46, 50, 56, 93, 116, 119, 121, 185, 208, 215, 228, 231, 235, 241, 242, 257–259, 272, 284, 285 See also Human rights Risk, 7, 15, 18, 20, 23–25, 30, 33, 43–45, 47, 55–57, 73, 75, 177, 181, 183, 229, 231, 233, 240, 256, 259 Rose, Nikolas, 250

 Index 

Rosters, 164, 165 Rudge, Trudy, 8, 161, 174, 177, 282 S

Scandinavia, 253 Self-responsibility, 250 Service coverage, 4, 44 Shah, Raj C., 7, 286 Skill mix, 160–162, 164, 165, 168, 171, 174, 175 Small government, 288 Social democratic welfare regimes, 19 See also Conservative welfare regimes; Liberal welfare regimes Social democratic health system, 2 Social insurance, 29, 44, 183 Social science, 109 Social values, 3 Socio-economic, 66, 67, 74, 79, 237 Sociology, 82, 271–279, 282 sociological, 1, 8, 9, 108, 184, 185, 275, 277, 282 Space, 113–115, 119–121, 158–160, 165, 177, 211, 219, 220, 246, 251, 278 Specialists, 50, 52, 55, 108, 112, 114, 123, 133, 163, 185, 186, 208, 234, 240, 241 See also Doctors; Physicians Sport, 211, 213, 216–218 Stakeholder, 2, 19, 20, 22, 26, 28, 30, 31, 34, 68, 76, 77, 79 Standards of care, 9, 176, 256 State, the left hand of, 207 right hand of, 207, 220

303

Status, 5, 16–20, 31, 32, 34, 63, 64, 74, 79, 109, 123, 150, 202, 230, 258, 272, 280 Stewardship, 19–22, 24–26, 28–30, 34 Stigma, 17, 32 Supplementary services, 5, 183 Surveillance, 164, 169, 175 Sweden, 6, 7, 42, 45–48, 50, 53, 56, 57, 92, 93 The Swedish healthcare system is, 41–57 Symbolic interactionism, 184 System knowledge, 238, 245 See also Knowledge Systems, 2, 15, 41–57, 107–126, 133, 157, 181, 201, 251, 272 T

Tax benefits, 5 Technology, 29, 158, 159, 163, 173, 176, 178, 186, 195, 273, 278 Toffoli, Luisa, 8, 157–163, 175–177 Transnational, 205, 208, 275, 277 Trusts, 78, 79, 98, 141, 142, 144, 146, 147, 185, 241 Two-tier system, 6, 7, 56 Typology, 17, 18, 208 U

Unemployed, 24, 27, 67, 204, 212 See also Out-of-work United Kingdom, 3, 7, 67, 89, 90, 92, 131, 147, 149, 150, 162, 250, 251, 253, 260

304 Index

United States of America, 4, 7, 43, 64, 66, 69, 74, 82, 89, 90, 92, 98, 99, 112, 162, 260, 262, 271, 274–277, 279, 284, 286 Universalism, 6, 15–35, 41–47, 56, 57, 280, 286–288 characteristics of, 32 Uruguay, 15–35 US, 82 V

Value reorientation, 6, 52 Values, 2, 3, 5, 6, 8, 42, 43, 57, 63, 64, 79, 80, 91, 92, 99, 111, 113, 120, 125, 140, 142, 145, 158, 163, 171, 174, 175, 177, 178, 205–207, 209, 216, 228, 231–235, 241, 243, 246, 251, 282, 283, 287, 288 Voluntary insurance, 115

See also Private health insurance (PHI); Insurance; Health, insurance; Social insurance Voluntary organisation, 46 W

Welfare regime, 17–19, 33, 34 See also Conservative welfare regimes; Liberal welfare regimes; Social democratic welfare regimes Welfare state, 46, 50, 116, 206, 220, 259 Willis, Eileen, 8, 249, 254, 259, 272, 286 Willis, Karen, 8, 113, 229, 233, 238, 244, 245, 287 Workforce, 109, 162, 164, 187, 254 Work intensification, 169, 172 World Bank, 188, 278 World Health Organisation (WHO), 3, 15, 43, 278