Healthcare reform is one of the debatable questions in the American politics. Critics and medical professionals admit that effective markets require that consumers are able to assess and compare the value of the goods and services supplied, and to alter their purchasing behavior accordingly. Such comparisons and assessments are often impossible in the health service. It is true that, at an intuitive level, patients are now more able to choose between alternatives: public and private healthcare. Current healthcare practices are designed to meet needs and expectations of rich patients and private healthcare organizations depriving low income and poor people a chance to receive a quality medical care. Thesis A need for healthcare reform is explained by social inequalities permitted by current healthcare system and inadequate healthcare provisions delivered to poor.
A Need for Change
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Critics admit that to make matters more complicated it is difficult to measure the extent to which a modern health service can be responsible for improved levels of health. Proxy measures of quality have been used but none are free from ambiguity, and the evidence which they present is equivocal. For example, a number of indices show how our standards of health have increased. Infant mortality has declined steadily and morbidity and mortality statistics demonstrate that we are in general living longer and healthier lives than ever before. But the extent to which these improvements may be attributed to the health service is difficult to assess because other factors have significant effects (Porter and Teisberg, 2005). Modern state leaders need to recognize that many of the main improvements in the health of the nation have come about not from advances in medical treatment, or the existence of the healthcare, but from public health measures, better nutrition, and improvements in the economic, social, and natural environments. A separate difficulty concerns the extent to which a market for health is consistent with the development of clear strategy in the healthcare. Before the implementation of the reforms, Healthcare resources are distributed from the top downwards from the Secretary of State, through the regions, to the districts. In principle, national policy could be imposed at local level. With the introduction of fund-holders and healthcare Trusts, however, decision-making power has shifted towards private and public hospitals (Kotlikoff, 2007).
Those practices which leave patients feeling that they have received a good service are more likely to attract custom than others. Objective data on the rates of success and failure of hospitals, which would assist in promoting high achievers, is largely unavailable. Statistics which simply record the numbers of patients treated in hospital are clearly inadequate, in that they fail to assess the quality of the care provided, e.g. whether the treatment was successful. Indeed, if a patient has to be readmitted after discharge because the initial treatment is unsuccessful, this would appear in such statistics as being counted more than once. Clinicians are not routinely monitored for the purposes of comparison, nor is information available to patients as to the hospitals with the least attractive records of surgical success. Thus, both patients and doctors are often wholly ignorant of the relative advantages and disadvantages of the service-providers available. There has been some interest in making patients more critical of the standards achieved, and consequently more selective in their choice of doctor, by giving them more information about the outcome of treatments in hospital (Porter and Teisberg, 2005).
Ineffectiveness of the Healthcare System
Equally, with regard to operational matters within hospitals, the market may be too slow or ineffective to deal with lapses in standards of treatment. For example, there are wide variations between the standards of care achieved by different hospitals which are difficult to explain. The audit has noted that there are major differences in mortality rates between hospitals. Standardized mortality rates for chronic rheumatic heart disease ranged from nil to approximately six times the 'expected' rate in different districts. Given the difficulty of obtaining information of this nature, market principles are not always helpful to patients and it is proper for the state to intervene with measures to improve the levels of care made available to patients, say, by concentrating expertise in fewer hospitals (Porter and Teisberg, 2005). In addition, the market may operate too quickly and threaten the smooth running of hospitals in a particular area. Contrary to market trends, it may be necessary for the Department of Health to insist that the centers of excellence continue to provide long-term care for patients, and not be tempted to close expensive units on the ground that the facilities could generate more revenue by being put to other uses. 'Managed' competition, therefore, is about balance. Health authorities are not entirely free to merge with one another, or engage in collusive behavior because such activity would weaken the benefits that competition may bring. Precisely this question has arisen with respect to waiting lists (Kotlikoff, 2007). Fund-holding practices can use their bargaining power aggressively on behalf of their patients, and some have demanded that their patients be given hospital appointments ahead of the patients of non-fund holding practices. This has led to allegations that fund-holding has created a 'two-tier' health service. Of course, there is nothing new about a two-tier system; private care has always offered patients greater flexibility as to the timing and location of their treatment than under the healthcare provisions. Indeed, even within the healthcare there may be unintended variations in the standards of care provided in different parts of the country owing to the complicated formulas by which regions are funded. On the other hand, before the introduction of the internal market for health the system did not encourage distinctions between rich and poor patients. What is new in fund-holding is the idea that doctors should be more enterprising in promoting their patients' interests. Thus, fund-holders may decide to pay consultants to provide a specialist out-patient clinic for their patients at the practice surgery, instead of putting them on hospital waiting lists. Also, some hospitals appear to offer preferential treatment to the patients of fund-holding practices (Raffel and Barsikiewicz, 2001).
Waiting times may be systematically shorter for patients of fund-holders, hospitals may agree to provide separate out-patient clinics for fund-holders' patients, 'hotel' care may be more comfortable and, toward the end of the financial year, hospitals may only accept for non-urgent care referrals from fund-holders (Porter and Teisberg, 2005). Arguably, if one accepts the advantages to be gained from competition, one must also accept that some will inevitably do less well than others. This will encourage an improvement in standards. In a national health service, this must be right. Say an operation for which a patient has been waiting is cancelled in order to make way for a non-urgent patient of a fund-holder. The cancellation causes the patient to suffer additional complications. Such a patient would have legitimate cause for complaint. The common law would also insist that, unless there were compelling reasons to the contrary, a system of management which attached more weight to the status of the referring doctor than the urgency of clinical needs would be arbitrary and unreasonable. Fund-holders enjoy a freedom to use financial savings made during the year for other purposes, such as physiotherapy sessions, or out-patient appointments with a consultant at the surgery. No comparable freedom exists for non-fund holders who have no funds with which to transfer savings (Kotlikoff, 2007).
Purchasing power in the system is to be increased and refined so private healthcare organizations are given their own health service resources to manage because they, rather than a remote health authority, are able to make the arrangements with hospitals which best suit the practice and its patients (Raffel and Barsikiewicz, 2001). This has been made possible by the introduction of fund-holding. Inevitably, fund-holding gives public healthcare a much more explicit role in the management of resources. For the moment, no precise formula exists by which the allotment can be made and the process allows for reference to past referral patterns, mortality and morbidity statistics, and a good deal of hard bargaining. Parties may have to make compromises between competing objectives. Perhaps the quantity of a particular service ought to be reduced to expand facilities elsewhere; or prices ought to be reduced to attract more custom. Similarly, there is the need to balance administrative and transaction costs (the costs of setting up, operating, and monitoring the service) with the money devoted to the services themselves (Kotlikoff, 2007).
The present concern is whether the courts are competent to hear evidence as to why a particular patient has been refused care, i.e the 'micro' issue. It is entirely possible for health authorities to present evidence on which individual decisions have been based. For the court to review the reasons for such a decision does not require it to substitute its own decision. A requirement to adduce such evidence is necessary to enable the court to ascertain whether a decision was taken in the light of relevant considerations, and excluded irrelevant ones. Naturally, given the limitations of its expertise in the area, a fairly low threshold of satisfaction will tend to be required. Indeed, few such cases will have realistic prospects of success. The very fact that such clinical evidence were required would focus minds on ensuring that these unenviable decisions are reasonable and defensible, and would help to satisfy patients and the public that the question has been properly addressed (Raffel and Barsikiewicz, 2001).
Reductions in Standards
A need for reform is caused by reductions in standards of care disadvantageous in that they would compromise the care which patients are currently entitled to expect. However, their advantage is that they could make available treatment which would otherwise have been denied altogether because of fear of litigation by the minority for whom the procedures were unsuccessful (Raffel and Barsikiewicz, 2001). Ultimately, the choice is between treating limited numbers of patients with optimum standards of care, or maximum numbers with limited care. There is much concern about this matter and a number of incentives have been developed aimed at reducing the rate of increase in spending on drugs. None, however, have suggested that patients ought to be given less effective medicines; indeed, that may be inefficient and more expensive. If the risks attached to the use of the inexpensive product mean that some will not be assisted by treatment and will have to be admitted to hospital (which is vastly more expensive), it may be counter-productive to insist on the saving. The question has arisen with respect to the medicines recommended by hospital consultants (Kotlikoff, 2007).
Current regime of treatment and care is expensive. This is primarily a matter for clinical discretion which is not affected by the availability of resources, except to this extent. The way in which funds are distributed between health and social services departments may differ from place to place. Some may have invested more heavily in the provision of health services in the community (Raffel and Barsikiewicz, 2001). In such an area discharge from hospital may be more appropriate because adequate health care is available from health visitors. By contrast, those areas which have less sophisticated facilities in the community may find that adequate care of the type required by the guidelines can only be provided in hospital. This suggests that closer co-operation between health and social services authorities will be required, with respect to both providing care in the present and its purchase for the future. Those who are discharged from hospital against their wishes will continue to be entitled to receive primary care services in the same way as before, without the need to pay for them. This is the case whether the care is provided at home, or in a nursing or residential home. Included amongst these services will be specialist nursing advice such as continence and diabetic advice, stoma and catheter care, physiotherapy, speech therapy, and chiropody. However, it would not include meals on wheels or assistance with bathing, dressing, and mobility. They could be provided by the social services authority which may levy a charge for providing them (Morris et al, 2007). Health service economists will understandably reply that they propose only that we use our resources more effectively and in this sense the system is every bit as comprehensive under the quality principle. Indeed, if it provides more efficient use of resources, it could be said to be more comprehensive. In principle, the parties are entirely free to enter or leave the doctor-patient relationship. The procedure for doing so is simple and neither is obliged to tolerate the other against his or her wishes (Raffel and Barsikiewicz, 2001). The mechanism for applying to a doctor to be accepted onto his or her list is straightforward. Managers exercised only limited control because many of the activities of hospitals were determined centrally, or by senior clinicians acting in isolation. In addition, the absence of precise information on how and where money was spent in the service made the process of effecting change very difficult (Morris et al, 2007).
Critics recommend a management structure for the healthcare in which the creation of policy at national level would clearly be distinguished from the responsibility for its implementation and operation; and that, at each level of operation, managers should be set specific responsibilities and targets and be held accountable for them (Raffel and Barsikiewicz, 2001). A necessary component of clinical directorates is resource management initiative, which evaluates the success with which clinicians have carried out their responsibilities and measures the various elements of cost involved in medical decision making (Morris et al, 2007). The idea is to encourage hospital managers and clinicians to agree on objectives and priorities and to devolve responsibility for their accomplishment to tiers of authority further down the hierarchy (Naidoo and Wills, 1997).
A need for change in healthcare is caused by inequalities in healthcare delivery for rich and poor. Still, no specific formula has been set down, no generally accepted means of measuring whether improvements in patient care have been achieved, and there are no objective standards by which goals can be put in order of priority. The idea behind the system is to improve patient care by giving doctors and nurses a greater role in the management of resources and devolving responsibility for budgets to clinical teams within hospitals, enabling managers to negotiate workload agreements with these clinical teams, and improving information systems to provide staff with better data about their services. There is obvious merit in including doctors in the management of health care resources, but this involvement significantly affects the traditional concept of the doctor-patient relationship. Clinicians now should have managerial obligations to hospital managers as well as to patients, so that the director's own clinical practices, and those of the colleagues for whom he is responsible, may be modified. This is surely a matter driven solely by clinical considerations which provide the basis of the relationship of trust between doctor and patient.
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