I – Health and Public Policy
Social Policy is public policy that relates to health, employment, poverty, education and welfare issues and focuses on social services and welfare state. Social policy is the study of social welfare and how it relates to politics and society. Social policies refer to government policies relating to welfare, social security and protection of an individual in a state and the ways in which welfare is developed and administered in a state (Hill, 1986). The principal areas of social policy aimed towards government objectives of a welfare state are:
Administrative practices and policies of social services which include health, social security, education, housing, employment and community and social care
Policies towards tackling social crimes, and problems with unemployment, drug abuse, disability, mental health, learning difficulties and old age
Socially disadvantageous issues of race, gender, poverty and the related collective social responses and responsibilities towards these conditions
The broader subject area of social policy is heavily dependent on disciplines of sociology, management, political science, philosophy, law, psychology and social work. The aims and objectives of a British Welfare State highlight the importance of well being of every individual with a range of services provided to protect people in conditions such as sickness, poverty, old age and childhood and in such a sense , welfare is more than needs fulfillment and relates to complete well being of individuals. Welfare provisions are based on humanitarian, religious, democratic or practical concerns and involve economic and social benefits such as eradication of poverty and governmental duty and social responsibility (Hill, 1986).
In this essay we will deal with the relationship of welfare and social policy with health care, especially within the UK through the NHS systems and department of health. For an analysis of health and public policy within the UK we will analyze the stages of health policy, the rationale for such policies and how these policies are carried out through a health service network.
Health care coverage provided worldwide is given in a comparative chart below. UK, Sweden and France is seen to have the same level of hospital and ambulatory care services with USA showing lower levels of health care services when compared with worldwide standards.
Health Care and Social Policy
The definition of health can be given in terms of cultural standards in which health is a standard of mental and physical well being according to a particular society and a general good health is necessary to perform mental and physical activities optimally. Health is also defined normatively as an ideal mental or physical state. Health depends on several factors such as biological factors, environmental factors, standard of living, social factors, nutrition, and psychological or emotional factors (WHO, 2005). Improving sanitation systems, providing medical care and support systems and clean water supply to prevent infectious diseases are the general responsibilities of health authorities (Jones, 1995). Inequalities in health especially in the UK can be due to poverty, or differences in social class as certain categories of people may be more aware of their health and fitness needs than certain others (Graham and Kelly, 2004).
Health policy in the UK is implemented through a wide health care network provided by the Department of health and NHS. The different branches providing health care in the UK include the Hospitals which provide care to patients for both acute and long stay illnesses and provide medical facilities such as emergency treatment, psychiatric care or continuing nursing care. The governmental emphasis is to minimize all long term needs which can be considerably expensive and offer a full range of care in the hospitals providing acute services. Primary care is more basic medical treatment and refers to non-hospital care including general family practitioners and general physicians, professions ancillary to medicine and domiciliary health care such as occupational therapy (Allsop, 1995). Ambulatory care is distinct from, yet a category of hospital care as it includes primary care and day care in hospitals.
Public health policy is a general care strategy including preventive medicine such as screening and health education and several areas which may not be directly linked to health services such as housing, water supply, sewage disposal, food hygiene and general poverty and employment conditions which are also factors related to health.
For health of a population in a state, public health needs and related issues are very important under the health care policy at a governmental administrative level. For medical care in practice, primary care provided by primary care trusts of the NHS and services of general physicians are important at a more social level. Hospital care and medicines provided involves the highest costs for the NHS, is an important political issue for the UK government and has the highest priority for the NHS health policy implementation (Wall, 1999).
Some of the Health policy objectives and strategies on health care identified by the NHS and Department of Health are given below: (NHS, 2005)
Primary Care Policy
Secondary Care Policy
Integrated Care Policy
Patient Centeredness or Patient-centered Care Policy
Occupational Health and Safety Policy
Social Services Performance Assessment Policy
Within the organizational improvement plans, the NHS health improvement modernization plans (HIMPs) involve a three year planning framework and details roles and responsibilities for the NHS primary care trusts (PCTs) and builds on the Planning and Priorities Framework (PPF) guidance issued in 2002. Within this framework PCTs are responsible for developing new Local Delivery Plans (LDPs) and any additional PCT owned local plans (NHS, 2005).
The planning of Health Policies for modernization and improvement of services within the NHS consists of the following six steps that are to be maintained in every organization and community: This is given by the Department of Health official report 2003-2006:
identifying the national and local priorities and the key targets for delivery over the next three years
agreeing the capacity needed to deliver them
determining the specific responsibilities of each health and social care organisation
creating robust plans which show systematically how improvements will be made and which are based on the involvement of staff and the public
establishing sound local arrangements for monitoring progress and NHS performance management which link into national arrangements
improving communications and accountability to the public locally so as to demonstrate progress and the value added year on year
The areas of responsibility for NHS and Social services for health policy implementation are given in the table below.
In terms of Primary care policy, the NHS and social care long term conditions model laid down health policies and models for long term care to cases already under NHS treatment. Some of the key objectives and targets within the Primary care policy are given as :
earlier detection of the illness
good control to minimise effects of disease and reduce complications;
more effective medicines management;
reduction in the number of crises;
promoting independence, empowering patients and allowing them to take control of their lives, and
prolonging and extending the quality of life.
The three levels of the Health care delivery system are given by the Department of Health as follows: DH, 2005
Level 1: Supported self care – involves collaboratively helping individuals and their carers to develop the knowledge confidence and skills to care for themselves and their condition effectively.
Level 2: Disease-specific care management – This involves providing people who have a complex single need or multiple conditions with responsive specialist services using multi-disciplinary teams and disease-specific protocols and pathways such as the National Service Frameworks and Quality and Outcomes Framework.
Level 3: Case management – requires the identification of the very high intensity users of unplanned secondary care. Care for these patients is to be managed using a community matron or other professional using a case management approach to anticipate co-ordinate and join up health and social care.
The NHS social care long term conditions model is given as: Source: NHS
Organizational Health Policy
The implications of NHSD complaints policy have been emphasized in a recent NHS report and include the following conditions
Complaints Policy Implications:
It has been recognized that how well the policy works depends largely on attitudes of individual members and the culture of the organization and although complaints act as potential sources of improvement of health care services, these are also indicative of the high level of dissatisfaction regarding current health care procedures. There is considerably higher level of complaints for family health services as it has been identified that in primary care services are n a small scale and informally managed and the role of individual practitioners are more important than the organizational network. Satisfactory and prompt resolution of complaints has been identified as important to improving health care services (Allsop, 1995).
Three factors in particular are likely to be central to improving performance as given by the NHS and Department of Health
a realization that complaints management is an explicit part of the performance management framework.
The board of every NHS organization should be held accountable for the performance of the organization in handling complaints. And the board should ensure that: (a) all staff are adequately trained to deal with complaints (b) staff managing complaints have adequate administrative and technical resources and also access to managerial supervision and support; and (c) the complaints procedure is integrated into the clinical governance as well as quality framework of the organization.
Consideration should be given to the development of a National Service Framework or its equivalent for the management of complaints. (NHS, Complaints Procedure National Evaluation, 2001)
The National strategy for IT and computer services help deliver an up to date medical service to its people, through the NHS information policy. Some of the strategic directions of the information policy in the health care sector include: (See in Allsop, 1995; Wall 1995; NHS 2001 report)
Specifying the level of national direction given for IT by evolving and simplifying management structure and responsibilities within both the DH and NHS at regional and local levels;
to deliver change quickly following an implementation approach in phases – focus at a time on quickly delivering a limited portfolio of activity, nationally,that can be built on by subsequent phases;
management of increased levels of funding with clear central direction and control;
a structured partnering approach with IT Industry to deliver new IT systems across the NHS;
coordination, acceleration and simplification of procurements to ensure we get value for money while moving at a faster pace, and cutting down on unnecessary time and cost to the health care industry
Consideration of radical outsourcing options that can add pace and value to the programme;
Emphasis on changed working practices in the NHS;
Benchmarking progress against best practice companies
Building IT and networking connectivity, so that all staff have the access devices they need to share information; and
Creating national standards for data quality and data interchange between systems at local, regional and national levels so that even the public can have access to information stored and accessed at a national level.
A National Strategic Programme for Health care modernization and improvement and provisions of services in general can be given by the following architectural model provided by the Department of health:
Information Health Policy – Source DH
In this essay we discussed health care and social policy in terms of its stages of development through a three year plan and IT approach specifying levels of health care services that are provided and NHS social care through interaction of proper infrastructure, delivery strategies and desired outcomes of treatment. The focus is on reducing waiting times for emergency treatment or health services at hospitals and primary care centers. We highlighted the importance of modernization, updated IT systems, primary care services, complaints policy and patient centered care as important aspects of health policy followed by the NHS laying down strategic programmes, directions and objectives for an overall health care system as a social and public policy. In the next discussion we would examine the rationale and effectiveness of such policies within the context of political motivations and welfare objectives.
II – Effectiveness of Health Policy
In this section we would examine the policies that have been implemented in the last few years within the NHS and have served as political and administrative tools both as a means of political achievement and measure of social services provisions (Batchelor, 2005). Evaluation of health policy followed by the department of health can be done by comparing target objectives with the attained levels of service. Evaluation can also be done by analyzing research studies, news reports and NHS and Department of Health annual reports on what are the specific targets that were achieved and which are the objectives that were identified and yet could not be achieved through their policies. The discussion would thus show the flaws in the health framework, the differences in aims and achievements and analyze why certain objectives could not be reached along with the strengths and weaknesses of the policies in general.
According to the DH plans, ‘DH policies are designed to improve on existing arrangements in health and social care, and turn political vision into actions that should benefit staff, patients and the public’ (Department of Health, 2005). The DH notes that a DH health policy covers many areas of working including
the way patients and the public receive care
how NHS and social care organizations are run
information technology and other facilities that support the delivery of health care. (DH, 2005)
A policy is largely evaluated by three features as to whether it
can be implemented quickly
achieves its purpose
does not create an unnecessary burden on NHS and social care staff.
A policy is meant to help rather than hinder NHS working and thus it should be easy to implement, evaluate and give quick and significant results.
DH Annual Reports – Targets and Progress
The Target analysis given by the DH annual reports shows the targets and the extent to which the objectives have been achieved by the Department of health:
the aim to transform health and social care systems so that it produces better and faster services to tackle health inequalities was emphasized along with the objective of improving health outcomes for everyone. (DH report, 2004)
Reduce substantially the mortality rates from major killers by 2010: from circulatory disease by at least 40% in people under 75; from cancer by at least 20% in people under 75; and from suicide and undetermined injury by at least 20%. Key to the delivery of this target will be implementing the National Service Frameworks for coronary heart disease and mental health and the NHS Cancer Plan.
Death rate from circulatory disease amongst people aged under 75. Death rate from cancer amongst people aged under 75. Death rate from intentional self harm and injury of undetermined intent.
A small but statistically significant increase in the number of deaths coded to cancers was identified, A small but statistically significant increase in the number of deaths coded to circulatory diseases was identified. Data for 2000-02 (3 year average) show a rate of 16.0 deaths per 100,000 population – a rise of 0.6% from the baseline (1995-97). Single year data for financial year 2001-02 show a rate of 313.9 hospital admissions per 100,000 population – a decrease of 2.3% from the baseline estimate (1995-96). A National Suicide Prevention Strategy was published in September 2002 led by the National Director for Mental Health. As this is implemented it will contribute to reducing the suicide rate. Although not statistically significant, there has been a small increase in numbers of deaths recorded to suicide and intentional self harm.
2. the second aim is to treat people with illness, disease, or injury quickly, effectively, and on the basis of need alone (DH report, 2004)
Ensure everyone with suspected cancer is able to see a specialist within two weeks of their GP deciding they need to be seen urgently and requesting an appointment for: all patients with suspected breast cancer from April 1999, and for all other cases of suspected cancer by 2000.
Percentage of patients with suspected breast cancer and other cancers able to see a specialist within 2 weeks.
99% of patients referred urgently with suspected cancer were seen within 2 weeks during July to September 2003. For the same period for breast cancer this figure stands at 98.2%.
3. a third important objective identified has been to enable people who are unable to perform essential activities of daily living, including those with chronic illness, disability or terminal illness, to live as full and normal lives as possible.
Improve the delivery of appropriate care and treatment to patients with mental illness who are discharged from hospital and reduce the national average emergency psychiatric re-admission rate by 2 percentage points by 2002 from the 1997-98 baseline of 14.3%.
Average emergency psychiatric admission rate.
Psychiatric re-admission rate in 2001-02, the last year data was collected on a readmissions within 90 day basis, was 12.7% narrowly missing the target by 0.4 percentage points. However, with the implementation of new service models such as assertive outreach, early intervention and crisis resolution, further falls in readmission rates are expected, though this might not manifest itself until after 2002-03. (DH reports, 2001)
the fourth objective we have chosen for discussion is Improving patient and Carer experience of the NHS and Social Services.(DH annual report, 2004)
Patients will receive treatment at a time that suits them in accordance with their clinical need: two thirds of all outpatient appointments and inpatient elective admissions will be pre-booked by 2003-04 on the way to 100% pre-booking by 2005.
DH monthly central data collection from January 03. Supersedes the Modernization Agency monthly project progress reports.
On course: A monthly DH central data collection was introduced in January 03.The monthly data collection captures full bookings and partial bookings as they are added to the waiting list. This allows rigorous monitoring of progress towards booking milestones and targets. A Data Set Change Notice was issued in 2000 to the service in support of the new monitoring arrangements The Modernization Agency National Booking Team is assisting challenged Trusts to work towards achieving key booking milestones and targets. The Recovery and Support Unit (RSU) is also working with challenged Trusts. From April 2003, Strategic Health Authorities are responsible for managing and developing booking locally as part of their Local Delivery Plan (DH annual reports, 2004)
We have delineated four important objectives among several health care policy plans laid down by the NHS and Department of Health. The first objective discussed is aimed towards providing faster and better services for improving health outcomes of everyone. This was specified as reducing mortality rates from killer diseases such as cancer, coronary heart disease and accidents. The targets however have not been achieved as there has been significant rise in deaths from cancer, heart disease and accidents in the last few years since the target was set. Although there has been a decrease in the number of hospital admissions, deaths due to suicide and intentional self harm have also gone up. From this analysis it is only suggested that the target for improving general health outcomes by reducing mortality rates has not been achieved as specified by the Department of Health.
Examining the second objective of providing treatment to people effectively and quickly on the basis of need suggest that everyone with cancer or such ailments should be able to visit their GP within 2 weeks of their deciding to see their practitioner and waiting times should be cut down considerably. The progress report shows that 99% of the cancer patients were able to see their GP within 2 weeks of their decision and this suggests that the target objective in this case has been nearly met.
The third objective we have highlighted is that according to the NHS plan, most disabled or chronically ill patients should be able to support themselves and perform daily activities and lead as normal life as possible. This was effectively studied by using psychiatric illness as an indicator of chronic disability and hospital readmission rates as important measures of finding out to what extent chronically ill patients are able to lead normal lives or support themselves. Although the readmissions measure shows that targets and objectives were narrowly missed in previous years, in more recent times due to assertive outreach and early intervention and crisis resolution, there were considerable falls in psychiatric readmission rates suggesting that some progress is definitely being made on general improvement of health of people who are chronically disabled.
The fourth aim was improving patient and carer experience of NHS and social services provided by beginning pre-booking services and it is emphasized that all clinical services should be pre booked by the year 2005. This is largely a procedure under the aegis of the NHS modernization agency as pre booking services are also IT related and a general improvement of IT systems are associated with achieving this target. However according to DH reports, this target achievement is already on course and most of the health services are now pre booked and waiting times for appointment have reduced significantly.
Following an analysis of objectives and aims and the targets achieved by the NHS according to Health care policy, we would take a look at performance of the health care sector and the ratings obtained by primary, secondary trusts. The results of 2002-2003 are given below:
Overall there are 579 NHS trusts that have been rated for their performance in 2002/2003.
133 three stars
257 two stars
165 one stars
44 zero stars
63 three stars
68 two stars
31 one star
14 zero stars
10 three stars
7 two stars
9 one star
5 zero stars
Mental Health trusts
15 three stars
43 two stars
27 one star
3 zero stars
Primary Care trusts
45 three stars
139 two stars
98 one star
22 zero stars
Evidence on Health Policy Implementation – Issues
From an analysis of DH annual reports on progress and targets that have or have not been achieved in the past few years, we no move on to clinical evidence and research studies that have formed the basic evaluative tool for health policy implementation appraisal. Ujah et al (2004) provided an evaluative study to establish the nature, extent and organization of occupational health services provisions for people within the NHS and reviewed the systems for monitoring NHS performance. Within the NHS trusts, human resource managers and occupational health managers were selected for the study and were invited to complete an interviewer led questionnaire. All the 17 trusts in which the interview was carried out claimed that they do provide occupational health service to their employees and the provisions and organization of these services were under the human resource unit. However only 29% of the trusts could provide a written health policy with 87% of occupational health mangers claiming that they only provide a rather reactive service based on patient needs, rather than health policy objectives. The authors discovered considerable variation sin the level, nature and quality of services provided by the NHS trusts and concluded as a result of their findings that there are significant differences in the level of occupational health service available to staff across the NHS in London. From this study it is evident that health policy as an initiative only serves as a framework for achievement and may not ultimately be followed in the same way as there are significant differences in the way policies are implemented in different NHS trusts.
New health policies that tend to integrate education and training with research and implementation tend to support new practitioners to perform health care research and Bateman et al (2004) evaluate the policy of supporting health care professionals who have some interest in research. The authors claim that there may be considerable value in development of research objectives within the NHS R&D wing and mention that ‘Future policies may need to address: the indicators used in measuring the success of such schemes; the relationship between what individuals choose to do and its context within national policy on research and development; and the sustainability of involvement in research’ (Bateman et al, 2004, p.83)
Evaluating the information systems and up gradation of IT networking within the NHS, Wyatt and Wyatt (2003) argue that evaluating large scale health information systems such as in hospital systems can be lengthy and difficult procedure. However they discuss the reasons for which such evaluation is necessary and the appropriate methods to carry out these evaluations. This information as they suggest is supposed to be directed towards an assessment of health policy and is thus expected to provide feedback to health policy makers and help in improvement of health and public policies. The authors discuss many experimental designs to carry out their research and also study the impact of communications system within a laboratory setting, the potential problems and how they could be resolved. Wyatt and Wyatt conclude that the correct methods to evaluate health information systems in hospitals and clinics do not depend on the technology being evaluated but on the reliability of answers given for evaluation.
Health policies such as patient centered care approach (Webster, 2004), integrated clinical governance (Cauchi 2005) and nurse led intervention services (Lees 2003) have been effectively implemented and successful although posing major challenges to NHS to constantly improve policies according to targets and objectives.
Carter et al (2003) evaluated multi-disciplinary team working as a policy and the effectiveness of introducing new organizational structure within the NHS. Although the authors emphasized that as a result of this policy very little have changed so far, but the interests that such a multi-agency working approach has generated suggest that this may be the beginning of medical practice that can link the changes in work practices with improvements in quality of services. Within the NHS framework, multidisciplinary team working is developing to expand roles of traditional institutional boundaries and form complex clinical networks. However these networks could become increasingly autonomous from current NHS structures. The authors discuss the possibility of forming chambers for doctors as well as other professionals as a means of working together in groups. Multilevel working at the NHS is as of now a very effective health care policy but needs even further evaluation and suggestions for improvement.
Within this particular discussion we have tried to analyze the health care policies and targets and evaluated these objectives in terms of achievement and progress in policy implementation within the health care sector in the UK. For our purposes we have used targets and progress report from annual results published by the DH. Evidential information on policy effectiveness have also been provided where we suggested that health care polici