Healthcare in Transition Understanding Key Ideas and

Tensions in Contemporary Health Policy - 1st Edition

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 Contents
Acknowledgements iv
Preface v

one Building blocks 1

two Taking less medicine 27

three Choosing care 55

four Systems and lives 79

five Especially for you 103

six The challenge of integration 129

seven Shaping the future 153

References 185
Index 193

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 Healthcare in transition

Acknowledgements
Thank you to all my colleagues in the Centre for Public Policy
Research for creating a warm and intellectually stimulating academic
home for me. Particular thanks go to Sharon Gewirtz, John Owens,
Teo Mladenov and Sara Donetto for collaborations on themes that
overlap with the themes of this book. In addition John graciously
agreed to read the first draft and provided me with extremely helpful
comments for the revision, and Sharon and Sara helped me to finalise
the manuscript.
I am also especially grateful to Vikki Entwistle, with whom I have
collaborated for several years and who has read and commented on
much that I have done – including this work – and has been a partner
in many scholarly endeavours. At the same time that the chapters of this
book were being drafted I was working with Vikki and John Owens
(and others including Ian Watt, Heather Morgan, Simon Christmas
and Zoe Skea) on a project focused on support for self-management.
Conversations within that research team helped to sustain and motivate
me – not least because of the number of treats we somehow fitted
around our project meetings.
I am indebted to the Health Foundation for funding and practical
support. This book project was started and finished while I have been
a Professorial Fellow with the Foundation, and it is extremely unlikely
that it would have been completed without that support. I would
like to thank Nick Barber, Helen Crisp, the Improvement Science
Fellows and the other members of the erstwhile Improvement Science
Development Group. It has been a privilege to work alongside these
colleagues even though I am very conscious that I have not learned as
much from them as I should have done.
Of course I must, and am happy to, acknowledge my wonderful
family. First and foremost thank you to Jacky for supporting me so
wholeheartedly even when my work is a nuisance. But thanks also go
to the entire ‘Cribb and Ballard’ clan, and not least to my much missed
mother, Joan Ashton Cribb:

Her gentle being was possessed by love and joy and

tolerance. (Will Cribb, 2015)

iv
 Preface
Ideas are key components of health policy and health systems. They
shape everything that happens and is done, including all healthcare
practices. In this book I explore the ways in which key ideas about
healthcare are changing, focusing in particular on the rise of a ‘social’,
as loosely contrasted with a ‘clinical’, approach to healthcare. I argue
that these changes – in which biomedical concerns are increasingly seen
as nested within (often contentious) personal and social concerns – is
part of a major historical transition. This transition is not just about
the changing patterns of ill-health (with, for example, the growth in
salience of long-term conditions) or even the broader social transitions
manifested in trends such as the decline in deference or the rise in
patient or public expectations, but is also a deeper philosophical
transition in our conceptions of the nature and purpose of healthcare.
While welcoming this transition I set out and explore the additional
challenges that it produces for health policy, and argue that these
challenges should push us towards building a ‘learning healthcare
system’ in a very expansive sense.
In Chapter One I introduce the notion of a philosophical transition
as part of a discussion about ideas being the building blocks of health
policy. Using the examples of ‘cure’ and ‘care’ I illustrate the ways in
which ideas are embedded in healthcare settings and practices and begin
to indicate the many broader questions that surround the relationships
between medicine and persons. Then, using a simplified priority-setting
case, I introduce the challenges facing policy makers who, in trying to
bring about ‘policy futures’, have to arbitrate between different visions
of healthcare. Chapter Two examines the premise that health policy
is ‘out of kilter’ and needs reform. It suggests that much of the debate
about reform can be seen, in crude terms, as a debate between ‘more
medicine’ and ‘less medicine’ or, more precisely, between continuing
processes of medicalisation and forces of ‘de-medicalisation’, where
the latter refers to the erosion of, or a diminished role for, a narrow
focus on bodies rather than on persons. Chapter Two concludes with
the discussion of a multi-dimensional account of person-centredness,
seen as a contrast to a heavily biomedical model of healthcare.
Chapters Three, Four and Five focus in much more depth on
themes arising from person-centred models of healthcare – patient
agency, holism and personalisation, respectively. Each of these chapters
highlights tensions that emerge within each theme – tensions between
‘independent choice’ and ‘relational autonomy’, between holism as

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applied to systems and as applied to persons, and between biological

and biographical dimensions of personalisation. They also analyse
tensions that cut across these themes – notably the tension between
more individualist and more social conceptions of persons. The
insights that animate discourses of person-centredness are invaluable
– pushing us, for example, towards much broader constructions of
health-related practices and actors, increasing the ‘bandwidth’ of
conventional healthcare thinking to encompass the multiple layers –
internal and external – that make people what they are; and towards
understanding the potential importance of better ‘tailoring’ care. All
these things are arguably central if we want healthcare to be effective.
But at the same time these ideas, especially in combination, produce
many challenges. For example, can we pursue individual autonomy and
personalisation without building stronger forms of social coordination
and reciprocity; and can it make sense to talk about ‘person-centred’
policies if these policies risk exacerbating health inequalities? In other
words these chapters illustrate that person-centred models cannot be
seen as simple ‘solutions’ to health policy problems but should, rather,
be seen as a – valuable – opening up of competing policy and practice
possibilities and dilemmas.
In Chapter Six I analyse the increasingly influential idea that
healthcare systems, or health and social care systems more broadly,
need to be better integrated – that both services and the experiences
of individuals need to be less ‘fractured’ and that this depends upon
attending to the overall architecture of systems. While strongly
endorsing this idea I unpack different conceptions, elements and
purposes of integration and suggest that we should go forward with
a clear understanding that – because multiple value tensions pervade
healthcare – such moves towards integration will inevitably involve
conflict and can, for very good reasons, only ever be partial. This,
I argue, is because a sufficiently rich health system must encompass
currents and vantage points that are, to some degree, incompatible
with one another. Nonetheless, I suggest, the aspiration towards
greater integration – including the focus on system architectures and
the stresses they hold together – is of critical importance.
The final chapter – Chapter Seven – asks how health policy needs to
change character in the light of the transitions and tensions reviewed
in the book. My suggestion is that the emphasis in health policy has to
move more decisively from a delivery model to a deliberative model of
healthcare; or, in other words, from an assumed model of ‘top-down’
service provision towards a more diffused and democratic model. I also
argue that the philosophical transition that I have explored should, in

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part, be seen as a transition towards philosophy, because philosophical

questions are now manifestly at the centre of healthcare debate and
activity. Finally, I pull together some substantive conclusions about
the key balancing acts that need to be struck in shaping the future
of healthcare, including the balance between the responsibilities of
policy makers and professionals, on the one hand, and the collective
responsibility of patients and publics, on the other. Overall, my message
is that health policy thinking is becoming more expansive and thereby
more difficult and that if we care about the things we claim to – such
as system effectiveness and equity – this is something we must embrace.

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Building blocks

In this book I argue that healthcare is undergoing a major ‘philosophical

transition’. In what follows I will review this transition (beginning by
outlining its nature in the next section of this chapter) and I will show
why it is valuable – in brief, because it is about better connecting
healthcare processes to people. At the same time I will show why this
transition is extremely challenging. In summary, this is because it both
brings forth and highlights fundamental dilemmas. It is commonplace
for people to call for broad-ranging ‘culture change’ in healthcare; and
I will be doing something similar. But I would argue that the ‘culture
change’ needed is more radical than is often recognised. It means, I
suggest, not only applying new sets of ideas to healthcare but also
making space for very different ways of thinking.
The book explores some of the key ideas shaping, and being debated
within, contemporary health policy in the relatively affluent regions
of the world, sometimes simplified as the ‘West’ or ‘Global North’. In
particular I focus on ideas about the fundamental kinds of ‘good things’
or ‘goods’ at stake in health policy, the evolution of thinking about
these goods and their translation into practice, and on the challenges
and tensions generated by this evolution and translation. To make this
agenda appear less abstract and more practical I will use the familiar
ideas of ‘cure’ and ‘care’, and the contrast that is often drawn between
them. We can ask: How do the ideas of ‘cure’ and ‘care’ shape health
policy or practices in particular healthcare settings? What are the
tensions between ‘cure’ and ‘care’, do we have the right kind of balance
between them, and what further tensions are generated by trying to
change the balance? Throughout this chapter I will return to these
questions to introduce my main themes.
But I will begin by sketching an even more concrete and everyday
example.

Like all of us Freida engages in many ‘health-related practices’. She engages with
health services on her own behalf and with her family and, partly prompted
by her experience of supporting her sister through a long period of cancer
treatment, she has even joined a local consultation group reviewing innovations
in local health provision. In addition, she takes exercise and does other things
to look after herself that fall outside of formal health services. This morning, for

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example, on the way to work, she has dropped into the pharmacist to buy some
over-the-counter medicine that she knows helps her manage her sinusitis. Even
before that she has rung a friend, Cory, to help her decide whether she should go
into work at all. Increasing demands and targets from her employer are making
her anxious and sometimes it feels as if this is unbearable and her working
life is unsustainable. Talking it through with Cory always helps but they both
recognise that this pattern of day-to-day coping may not be wise. A few years
ago Cory took a course of prescribed drugs to help her with depression and they
occasionally talk about the possibility of Freida’s seeking some similar kind of
medical treatment, but Cory recognises that Freida is reluctant to go down this
avenue and she concentrates, in the main, on listening to Freida and on providing
moral support with Freida’s efforts to be OK. Today, though, Freida is feeling more
optimistic – her boss is leaving and she suspects the way he treats her might
exacerbate the pressures from targets and play a big part in the work-related
stress. She also decides it will do her good to get out of work for 30 minutes at
lunchtime and go for a run. She values the space and the exercise. Tomorrow, she
thinks, she will take a ‘healthy lunch’ and her ‘activity tracker’ with her, so with
these adjustments to her diet and exercise pattern, she is looking after her body
too. As she walks towards her workplace she tries to form a strong resolution to
take a lunch outing and not to get trapped in all day.

This description of a fragment from someone’s day illustrates a few

of the things that are relevant to thinking about health and health
ecologies, and some of the ‘goods’ involved. It also illustrates some
of the contrasts between different goods. Although they are both
important, the help that Freida gets from the over-the-counter
medicine seems very different from the help she gets from her friend.
The former kind of good – a physical remedy for a physical disorder
or disease – seems to operate in a way that is unmediated by human
relationship. The latter kind of good – support through talking and
listening – seems to operate essentially through a human relationship.
The distinction between the ‘medicine-taking’ and the ‘human support’
facets of healthcare is also reflected in Freida and Cory’s discussions
about how Freida might best deal with her long-term anxiety. How
much should she be thinking in terms of ‘treatment for disease’ and
how much in terms of ‘support for dis-ease’? In very broad terms this
corresponds with the tension introduced above, and that arguably runs
through all healthcare – the well-worn contrast between ‘cure’ and
‘care’. To repeat the questions I have already raised: what difference
does it make if we stress one or other of these two ideas – ideas about
what healthcare is and is for – within a service or area of policy? And,

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 Building blocks

assuming we think that both ideas are very important, what are the
challenges of combining them?
Another issue that is thrown up by Freida’s case is the question of
agency – who are the actors in health policy and healthcare? How far
should we think about ‘health work’ as the responsibility of expert or
professional groups of people, or how far is it something that we all do
for ourselves or for those around us? It is tempting sometimes to think
of health as essentially the province of specialist workers – especially in
a society with a highly developed division of labour and the extensive
professionalisation of health-related roles. But both the importance
of Freida and Cory’s conversations and the related reflections on
the workplace should remind us that this is a mistake. The Freida
example says comparatively little about formal health services or health
professionals, highlighting other relevant actors including Freida herself,
although professionals are certainly there in the background and I will
come back to them very shortly.
The Freida example also points to broader factors, sometimes
referred to as the ‘social determinants of health’ – the things that
influence her present and future health and well-being, such as her
working conditions and diet and so on – and indicates that at least
some of these things are not within her control. Of course a full
discussion and list of social determinants would be very long and
would potentially encompass everything in Freida’s socioeconomic
and cultural environment (including the results of her own actions).
There is a sense in which if we want to ‘zoom in’ on Freida’s health
this requires us to ‘zoom out’ to the whole world. This provides
another sense in which everyone is implicated in, and arguably shares
some level of responsibility for, health policy. Policy, in this sense,
is not something that simply arises from official authorities through
‘top-down’ processes, but is something that emerges and is shaped
more diffusely. Furthermore, from this vantage point it is difficult to
make clear separations between health policy and practice and other
areas of policy and practice – social, economic, environmental policies
and practices and so on – given that the latter have very significant
implications for health.
This little case study could easily be constructed with a different
emphasis that highlights official healthcare systems and health
professionals. Freida may have one or more chronic illnesses (including
and on top of the sinusitis) and may well have regular appointments
to review and revise treatment regimes and so on, but even if she is,
as yet, free from these kinds of health services routines she still has
occasion to consult medical and other professional advice from time

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 Healthcare in transition

to time. Indeed all of the factors briefly reviewed here are relevant to
planning health services and health-professional roles. Health services
need to cater for multiple aspects of physical, mental and social well-
being, and they need to be able to support and provide both ‘health’
and ‘care’. In addition, people who plan and work in services also need
to attend to broader health ecologies. This is because these broader
ecologies help to shape individual and community health experiences
and thereby health service agendas, and also because health services
can in turn help to influence broader ecologies, including the ways in
which populations live their lives.
Freida and Cory, let us imagine, discuss whether or not it is time for
Freida to present her anxiety to a mental health professional and regard
that as an important ‘back stop’ to their ongoing conversations. In
addition, either or both of them might have recourse to professionally
informed websites or other texts about different approaches to anxiety
management. The role of professionals is relatively conspicuous in
the case of the sinus medication. Lying behind, and making possible,
Freida’s purchase is, of course – as well as a retail system – a giant
system of medical and pharmacy research and clinical practice staffed
by clinical scientists, doctors and pharmacists. On other occasions
Freida may have been acutely unwell and have sought clinical help
and possibly had medicines or treatments that are not available without
medical authorisation. Indeed all of Freida’s health-related concerns
may become part of the focus of formal health services – she could,
for example, talk through, and sometimes may be encouraged to talk
through, her life-style change plans with her doctors or other health
professionals.
But starting from Freida’s case and point of view allows me to
underline something that has become a health-policy mantra – that
there are individual persons, and groups of people, at the centre of
health systems. This means that those professionals who might become
involved in Freida’s life will, to some degree, have to engage with, and
work with, individuals such as Freida and their families, friends or care-
givers. In order to be effective, professionals are likely to have to be in
some sense responsive not only to the specifics of Freida’s life, but also
to Freida as an agent – to her agendas and preferences. The questions
about agency and responsibility that I have noted are partly questions
about the ‘division of labour’ between healthcare professionals and ‘lay
people’ or ‘patients’ and so on, but they are also questions about if and
how these different kinds of agents can ‘work together’, combine their
agency and share responsibility for decisions, processes and outcomes.

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 Building blocks

I will come back to Freida later in the chapter but perhaps I have said
enough already to begin to indicate how our approach to healthcare
depends upon what kinds of ideas we stress. This applies not only to
the ‘cure versus care’ question but also to the assumptions we make
about what counts as health-related action and where the locus of
responsibility for health sits.

The philosophical transition in healthcare

The factors briefly rehearsed through the Freida scenario evoke
something important about the nature of contemporary health policy
in the relatively affluent regions of the world. The health agenda
has become ‘open-ended’ – it is not clear where it starts or finishes
and lines of responsibility are also unclear. Partly this is as a result of
what is sometimes called the ‘health transition’ or ‘epidemiological
transition’ (Caldwell, 1993) – that is, in simple terms, the changed
patterns of ill-health associated with socioeconomic development,
notably a decline in the relative salience of infectious disease and
a rise in the relative salience of chronic diseases (such as diabetes,
cancer and cardiovascular disease), resulting in proportionately fewer
acute life-threatening conditions and many more longer lives often
accompanied by long-term conditions. But overlapping with this
are the effects of other aspects of social change – for example, less
deference to authority alongside the spread of both sceptical and
consumerist dispositions, more diffusion of knowledge about health
and illness, including knowledge about social determinants, which have
led to changing relationships and expectations between professionals,
individuals and publics. These changes in the expectations on health
services are also set in the midst of broader changes in expectations
about what constitutes well-being, or a good life more broadly – in
particular with the normalisation of the idea that individuals should
be self-determining; that is, that they should shape their own lives and
environments and define what matters to them. Indeed our individual
identities are themselves increasingly seen as ‘self-made’. In a rapidly
changing world with – at least for many people – an accelerating level
of information and choice flowing from every direction, and in which
traditional ‘scripts’ are less available (because they are seen as no longer
either relevant or acceptable), then people are expected to continuously
engage in ‘projects of self-making’ as they write and rewrite their own
scripts over time (Giddens, 1991).
In this context there is a lot of talk about ‘new’ things needing
to replace ‘old’ things; for example, the need for new models of

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 Healthcare in transition

professionalism and healthcare – including models that harness the

participation of people and are embedded in communities. I will
return to this theme in several places but, to simplify, it might be said
that health policy is undergoing a slow and multi-faceted paradigm
change. In other words both the epidemiological transition and the
accompanying social transitions have entailed and seeded what can be
seen as a more fundamental ‘philosophical transition’ in health policy.
This philosophical transition involves a reorientation of the
relationship between the ‘clinic’ and the ‘social world’, including a shift
in emphasis from the former to the latter as the locus of health-related
activity. Here – roughly speaking – the ‘clinic’ refers to the activities
associated with dedicated health settings or health professionals, and the
‘social world’ refers to all of the other private and public spaces in which
individuals and publics pursue their lives. This reorientation produces a
‘fuzzier’ story about the healthcare division of labour, a social diffusion
of health-related concerns, technologies and data, and the recognition
of broader, more plural, conceptions of expertise and legitimacy. Partly
this involves the increasing dissolution of the ‘boundedness’ of clinical
activities and concerns, such that they can reach into every space of
personal and social life. Partly it entails an extended ‘re-socialisation’
of the clinic – with increased expectations that professionals will find
themselves in dialogue with, and be receptive to, other voices and be
alive to the personal and social contexts in which people experience
illness, health and health services. This process involves, in essence, a
renegotiation of the relationship between medicine and society.
This transition has very many policy-related and practical dimensions
but it also makes sense to think of it as a ‘philosophical’ matter. Indeed
I will be arguing in what follows that it is philosophical in two senses.
First, it involves changes in the mix of ideas that shape healthcare, in
particular in key ideas about the nature of healthcare – that is, what
healthcare is and is for. Second, once we confront questions about
whether and how new ideas can be incorporated into health systems
– and how new emphases can coexist with old emphases – we discover
that this involves difficult philosophical problems. In other words we
discover that there are no obvious ways of answering these questions,
and that empirical or technical methods are certainly insufficient for
addressing them. This means, in a nutshell, that policy and practice
uncertainties and dilemmas can no longer be seen as marginal
complications but become part of the core business of healthcare. In
other words, for everyone entangled in health policy – in whatever
capacity – this transition entails new ways of seeing and new ways of

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 Building blocks

thinking. That, at least, is what I will be suggesting and exploring in

the rest of the book.
In the remainder of this chapter I will develop the notion that ideas
are the ‘building blocks’ of health policy, and begin to explore the
implications of recognising that key ideas in healthcare – not least our
conceptions of healthcare itself – are not only in flux but also often in
tension with one another. In particular – at the close of the chapter
– I want to suggest that it is useful to think of healthcare planning
and priority setting as less about picking from a menu of competing
interventions and more about the enlargement and balancing of
competing conceptions and visions of healthcare.

Health-related ideas: shaping the practices and climates

of health systems
Thus far I have used the ideas of cure and care to indicate what I mean by
key ideas and goods in healthcare. Although these are very general, and
thus relatively vague, ideas they are also fundamentally important ones
that can be used to summarise the nature and aims of healthcare – we
might call them ‘organising ideas’ or ‘foundational ideas’ in healthcare.
They are also strongly connected to some of the other general, but
absolutely central, ideas that orient the ways we think about healthcare,
such as disease and well-being, or medicine and persons. In later chapters I
will discuss, and in some cases analyse, these and other such ideas, some
of which have only just started to emerge in Freida’s story: ideas such
as choice, participation, partnership, holism, community, responsiveness and
personalisation. As I have said, I am treating these kinds of ideas as the
‘building blocks’ of health policy and systems. This use is metaphorical
only in part – the notion is that healthcare is, in very important ways,
constituted by these ideas, because of the ways they can be used to
frame, reframe or extend the organising principles of healthcare.
Obviously, ideas like ‘cure’ and ‘care’ do not have very simple
denotations – like ‘bricks’ and ‘mortar’. They point to general notions
that can be further specified and qualified in a range of ways. But they
do indicate the underlying rationale of a broad range of practices. In
this sense they are more like clusters of ideas – they convey frameworks
of thinking, including assumptions about underlying purposes and
processes. If I am ‘curing’ I am trying to achieve certain kinds of ends
in certain kinds of ways; that is, the broad purposes and assumptions
in play will be different than if I am ‘caring’. In brief, to talk of
‘curing’ is generally to have in mind some more or less direct physical
or biological intervention into the body to counteract the effects of

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 Healthcare in transition

disease; whereas ‘caring’, by contrast, is a more diffuse idea that can

embrace ‘cure-type’ responses but extends much more widely to,
and emphasises, such things as physical and emotional comfort, and
psychological support and responsiveness. To spell all of this out is in
many ways odd, because we just ‘know’ this, as it were unthinkingly,
when we use the language.
In this context sociologists tend to talk about ‘discourses’ – these are
ways of talking and thinking, containing constellations of related ideas,
but are also embodied in our habits, practices and social institutions.
Social reality is, in this sense, made from ideas. For example – within
health services and elsewhere – discourses of ‘audit’ and ‘performance’
have grown in influence. At one level these discourses can be seen
as ‘just’ a collection of ideas – sets of linked ideas about evidence,
accountability and the importance of measurability – but they have also
come to shape many people’s environments, practices and experiences.
They are not just ‘thought’ but they are ‘done’ and ‘felt’ and they
substantially determine what matters and what is ‘real’.
The approach I am taking to health policy centres on these kinds
of building blocks – organising ideas and the discourses that surround
them – and asks how policy is shaped by them and how they can and
might be combined together. The underlying notion is that the new
directions health systems are taking reflect the ways we interpret,
combine and apply key ideas about health-related goods, and that these
goods are not always and everywhere compatible with one another but
can generate tensions that need to be acknowledged and addressed.
Of course health systems are not wholly built out of ideas. There is
also the question of how ideas are practically and materially realised.
We can explore this by sticking, for now, with the contrast between
‘cure’ and ‘care’. If we talk, in broad terms, about ‘curing environments’
and ‘caring environments’ (leaving aside for a moment the issue of
how far these can and should be thought about separately), then such
environments are created from multiple kinds of things. These include
physical structures and objects, specialist and general equipment,
guidance, information and protocols on forms and software, working
schedules and templates, staff and patient norms and relationships,
professional routines, individual habits, attitudes and activity. Ideas –
like ‘curing’ and/or ‘caring’ – can be embodied in and reproduced by
all of these things.
We can imagine environments that correspond fairly closely to
archetypes of cure and care (such as an acute medical unit and a long-
term nursing home). These would be made up of rather different
versions of the same kinds of things: the physical ‘stuff’, the protocols

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 Building blocks

and the individual routines would reflect and realise the underlying
purposes (or emphases) of the units. Of course these archetypes are
crude. It will often be better not to talk of ‘cure’ but of ‘treatment’
aimed not to eliminate disease but to reduce its length, severity and
impact. Furthermore, in practice there is no tidy distinction between
cure and care – they need not occur in separate spaces or stages. This
separation can be implied in the way, for example, that the move from
‘unsuccessful’ cancer treatment to ‘palliative care’ is sometimes spoken
about. But, of course, the boundaries here are both unclear and variable.
Palliative care can be combined with treatments and, indeed, forms of
clinical treatment are used for palliative purposes. Nonetheless, there
are sometimes well-recognised problems in this area when it comes
to combining cure and care together – either in achieving the best
mix of the two or in smoothly shifting the emphasis between the two.
For example, there can be an unwarranted reluctance on the part of
some professionals to accept the failure of curative therapy. There can
also be cases of poor coordination between professionals or services
with different emphases, or even just poor understanding by some
of what is demanded by palliative care, including inadequate insight
into the situation or experience of the person being treated (Kaur and
Mohanti, 2011).
Thus these very broad-brush ideas of cure and care can be used,
albeit somewhat crudely, to indicate some of the possible divergences
between ‘healthcare worlds’. The recognition that these different ideas
will tend to produce different environments and norms is useful: (a)
for showing how ideas, and the goods they represent, are central to
the production of health systems; (b) for showing that different ideas
cannot always, or easily, be seamlessly combined together. Ideas like
cure and care – and the other ones we will be considering – need to
be translated into real-world environments and actions, and generally
speaking environments and actions will tend to embody some ideas
(and related approaches and purposes) better than others.
I do not see this focus on ideas or discourses as a replacement
for the various other ways in which health policy can be analysed,
nor as sufficient unto itself – it needs to be consolidated with other
approaches. Policy analysis typically considers health systems and
their architectures – for example, the composition, configuration and
structure of services, or of forms of funding. My emphasis is more on
the architecture of our thinking about healthcare. This is another way
of talking about what I earlier called the ‘rationale’ or ‘frameworks of
assumptions’ conveyed by ideas. The point is to underline the way in
which frameworks of thought and assumptions shape and structure

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activities just as design blueprints shape and structure the artefacts that
are built by reference to them; or – to use an even more materialist
comparison – in ways that are analogous to the shaping and structuring
of biological organisms by underlying genetic codes. Authors use
a number of terms to draw attention to underlying frameworks or
rationales. I will draw on two of these most frequently: ‘models’ (for
example, in relation to biomedical models or person-centred models
of healthcare), and the language of ‘logics’ (for example, the logic of
professionalism, the logic of choice, and service logic, all of which will
be discussed in the following chapters).
The architectures of health ideas and of health services are overlapping
determinants of practice. For example, some health policy work centres
on the ideological contests between different modes of funding and
organising healthcare. Other work looks at the challenges of identifying
and delivering both efficient and equitable approaches to healthcare
resource allocation. These currents of work on the properties and
priorities of ‘real world’ systems are very important and I will not be
ignoring them completely, but just de-emphasising them, in what
follows.
I am suggesting that one approach to understanding health systems
and services is to pay attention to ‘organising ideas’ – the underlying mix
of ideas about the nature of healthcare that help to shape and structure
them – and to ask how these ideas are, and should be, evolving. A
particular health service unit might, for example, have to undergo a
transition so as to better incorporate palliative care within and alongside
its curative work. In the book as a whole I am arguing that health
systems are undergoing an analogous, but more fundamental and
wholesale, philosophical transition. When I come back to discussing
this transition in later chapters I will largely drop the language of ‘cure’
and ‘care’. This distinction is only one very approximate indication of
another very broad-brush distinction that I have already mentioned
and will consider at much greater length – the distinction between
the clinical and the social dimensions of health and, more specifically,
between ‘biomedical’ and more ‘person-centred’ models of healthcare.

Trends, reforms and ‘trade-offs’

Social commentators make reference to broad policy trends, and these
can be presented as more or less inexorable. In relation to health policy,
for example, these would include, in addition to the struggle over
the rising costs of care, the ever-expanding role of technology. A full
account of major trends in ‘developed’ health economies would take

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