Chapter 11 – Policy Influences upon Health

Lecturer PowerPoint
Lecturer Lesson Plan
Additional Case Study
3 Papers
3 Websites
3 Media Articles
Learning Tasks Discussion
Issues you may have considered in relation to the Learning Tasks in the book…

Learning Task 1: The UK media and policy influence

What results did you discover from your internet searching? A good starting point for exploring any issue is to find some academic discussion about it. For example, there is a detailed discussion of the ethics associated with this case in a book chapter that you can access. You can compare this discussion to the media reporting to explore the way in which this issue was framed by some reporters. Did you consider the ways in which media reporters framed the issue (who did they favour, if anyone – the medics, the courts, the parents?). The law in this instance was used to determine the outcome of the case, so what does this tell you about power?

The Charlie Guard case and the issue of the right to die are very emotive examples of health issues. Why might policymakers in the UK be concerned with enacting new legislation to support the right to die (think about values, ideology, risk and vulnerability)? Given that this book is about the social determinants of health, you should also consider the ways in which policy decisions are likely to affect people in different social groups in a range of ways. For example, those with more money, resources and social support may well be able to attain their ‘right to die’ wish by travelling overseas. See the Independent news report called ‘The True Cost. How the UK Outsources Death to Dignitas’.

Learning Task 2: Making health policy work

Carrots: Carrots are a form of incentive or reward and they might work to reduce gambling consumption in a number of ways. For example, people could be financially rewarded (e.g. with payments or with vouchers) for reducing their gambling levels by a number of hours each week. This is likely to encourage people to reduce gambling whilst they are being rewarded. However, there are questions about the long-term effects of such programmes – what happens once the rewards are no longer provided? This media article discusses the idea of paying people to stop smoking in a similar approach using carrots.

Sticks: Sticks are punishments often in the form of regulation and so there are many examples of these in the policy sector already. For example, it is illegal to gamble in the UK if you are under 18 years of age, but this does not stop all young people from getting access to gambling websites. One proposed stick that is often discussed in policy and social science debates as a way to reduce gambling is to increase the costs associated with engaging in this activity. However, does this mean that people would not engage as they may opt to spend less money in other areas of their lives?

Sermons: Sermons usually consist of advice and guidance. These can be in many forms, for example advice in classrooms, education programmes for adults and broad-based media and health promotion campaigns. For example, TV adverts show the negative effects of gambling and websites provide information and guidance. However, there are debates about how the messages given in such sermons work in practice. Does everyone want to hear the messages? Do people change their behaviour after they have seen them or read about the problems associated with gambling? The Gambling Commission suggests that a combination of more regulation (sticks) and advice (sermons) is needed in the UK.

An academic article published in the British Medical Journal (May 2019) discusses the need for policy action in relation to gambling: ‘Gambling and public health: we need policy action to prevent harm’.

Learning Task 3: Ideological beliefs

In thinking about which of these statements you agree with, you will be able to understand where your own ideological beliefs are positioned. It may be the case that you are not clearly within a single ideological ‘camp’, because our values and opinions are usually complex.

People are responsible for their own health behaviour and should be resilient in the face of challenges. This belief is tied to notions about individual responsibility for health and is therefore associated with more right-wing ideological positions, which hold that individual control over health is very important, and the state should have less influence and intervention.

People who need to be hospitalized after binge drinking and other self-inflicted conditions should pay for their treatment. This belief is again tied to notions about individual responsibility for health and is therefore associated with more right-wing ideological positions, which hold that individual control over health is very important, and the state should have less influence and intervention.

People who can afford to pay for private healthcare should not have to contribute to the funding of public health care. This belief is usually associated with right-wing perspectives too, where those who want to ‘opt’ out of paying for state-/publicly funded healthcare are allowed to do so and instead use private provision. In practice, payment for health is often more complex than this, e.g. in the UK you can use private health providers if you are in a financial position to do so but will still pay general taxation and therefore contribute to the publicly funded system, too.

Health is a commodity rather than a basic human right and therefore can and should be bought and sold in a competitive free market system. This belief is usually associated with a more right-wing ideological position in which the free market is believed to be about the provision of choice, with competition being an effective way to provide goods and services. Marxist theorists are critical of such viewpoints, arguing that choice is not real, competition is not real and not all can afford to buy health.

All healthcare systems should be in public control because provision should not be market led, rather It should respond to needs. This belief is usually associated with a left-wing ideological viewpoint. The term public control means that healthcare provision is provided by the state, i.e. the government who have ultimate responsibility. The UK NHS is a publicly controlled health care system. This viewpoint is usually associated with the belief that healthcare needs to be understood as a public good because it benefits everyone in the community.

The state should intervene, for example, by using legislation to influence moral choices such as the termination of pregnancies. This belief is usually associated with numerous ideological positions. Often left-wing commentators view state involvement in policy as potentially beneficial for health, e.g. the role of healthy public policy such as the introduction of seatbelts and smoking bans is usually supported by those with left wing-viewpoints. However, not all state intervention is necessarily positive in terms of health, especially where moral decisions become enshrined in policy, and not all policy is ideologically driven. As chapter 11 shows, there is a range of complex factors that influence policymaking, especially when it is dealing with moral decisions. For example, abortion is illegal in some countries because of strong religious influences.

Healthcare should be free for all consumers at the point of consumption, irrespective of whether they have contributed to paying for the care in any way, because health is a basic human right. This belief is usually associated with left-wing perspectives. The UK NHS was established based upon such a principle that has been described as left wing. Chapter 11 says “The British NHS, established in 1948, is based upon the principle of healthcare as a right for every citizen, including the provision of care as comprehensive, universal and free to all at the point of consumption. The policy literature refers to this as institutionalism, an ideological position associated with left liberals and Fabians.”

If you adopt unhealthy lifestyle choices such as smoking, eating sugary foods and not exercising, then you should pay for the healthcare you require as a result of your behaviour. This belief is usually associated with more right-wing ideological positions which, as previously illustrated, suggest that health is the responsibility of the individual. Critics of these beliefs argue that they fail to take into account the range of determinants that influences people’s individual health choices. As this book shows, the determinants of health are complex and important.

Learning Task 4: Policy sectors and health implications

You will have discovered that there are many government departments and if you view health holistically then many of these will impact upon health. The following two examples are by no means exhaustive; they simply give you an idea of how different departments and associated policies may influence health in a variety of ways.

Department for Transport
This department has a remit for all matters relating to transport, including road safety which has a large health-related impact. What about the Department’s approach to building new roads: what does this mean for air pollution and health? Is the Department also focusing upon more environmentally friendly modes of transport too? Might these be better for public health in the longer term?

Department for Education
Is the governments drive to increase skills a positive policy approach for public health (e.g. more skills, better jobs and therefore improved health)? Are there any issues with this approach: for example, are there always jobs available? Did you explore the section on the website that explains about eligibility for free childcare? This is a targeted policy approach aimed at those who experience more disadvantage – is this positive for health in your view?

Multiple Choice Quiz

1. Policymaking has been characterized in a number of ways. All but one of the following are models used to describe the policymaking process. Select the answer which is NOT a policymaking model.
a. Rationalist
b. Incrementalist
c. Pluralist
d. Feminist

ANSWER

The correct answer is d. Feminism is a theory rather than a policymaking model. The Rationalist model is one in which policymakers are seen as having a good understanding of the problems and therefore able to make clear, rational decisions. The Incrementalist model view policymakers as not starting with a blank sheet, but responding to issues and making small and incremental changes. The Pluralist model understands policy as emerging from the interaction of different parties at all stages of development and implementation.

2. All but one of the following are current policy issues related to health. Select the answer which is NOT a current health policy issue.
a. Collateral damage
b. Funding challenges
c. Long-term conditions and chronic illnesses
d. Demographic changes such as an ageing population

ANSWER

The correct answer is a. Collateral damage is a term that is often used to refer to the consequences of war, e.g. unintended casualties, and so can be a consequence of policy, but is not a current health policy issue.

3. The British Welfare State was established after the publication of the Beveridge Report in 1942, to tackle 5 giants threatening the UK. Which of the following is NOT one of the giants?
a. Want
b. Family problems
c. Disease
d. Idleness

ANSWER

The correct answer is b. The additional two not listed as options for this answer are squalor and ignorance.

4. Many ideological schools of thought influence beliefs about the provision of and payment for healthcare. Which one of the following is NOT an ideological school of thought?
a. Conservatism
b. Environmentalism
c. Fordism
d. Socialism

ANSWER

The correct answer is c. Fordism is a term that refers to a social and economic system based upon mass production. rather than an ideological school of thought.

5. Policy can affect health positively. Which one of the following policy examples is NOT included in this description?
a. Fiscal policy that attempts to tackle health inequalities
b. Policy to ensure the safety of the working environment
c. The removal of tax upon high-fat food products
d. Policy to ensure that health care services are curative

ANSWER

The correct answer is c. Removing tax on high-fat food products would make them more affordable and potentially increase sales, which would not be beneficial to health.

6. ‘Health in all policies’ can be defined as policies that:
a. are an established approach to try and improve health and tackle inequalities via all policy sectors, recognizing that cross-sector action on the wider determinants of health is needed because of the social, environmental, economic and commercial conditions in which people live.
b. use a downstream approach to deal with health problems
c. attempt to improve healthcare services
d. ensure health services manage and control the symptoms of chronic conditions

ANSWER

The correct answer is a. A downstream approach to health problems is reactive rather than preventative. Healthy public policy focuses upon a much broader range of policy sectors and influences rather than just healthcare services and the associated management of chronic conditions.

7. Examples of ‘health in all policies’ include all but one of the following. Select the answer which is NOT illustrating a health in all policies approach.
a. The introduction of legislation to enact bans on smoking in public places
b. Policy which attempts to reduce health inequalities via a variety of mechanisms
c. Policy that supports the use of fossil fuels
d. Policy to reduce greenhouse gas emissions

ANSWER

The correct answer is c. The effects of such approaches are not positive in relation to health outcomes.

8. Some academics argue that the biggest health outcome gains have resulted from public health measures that are not related to medical interventions, such as all but one of the following.
a. Improving water quality
b. Improving nutrition
c. Introducing seatbelts as a legal requirement for all those travelling in cars
d. Improving the quality of health care provision

ANSWER

The correct answer is d. Healthcare provision is medically driven – it is a medical intervention rather than a general public health measure.

9. Fiscal policy is important in relation to health according to Wilkinson and Pickett (2009) because it:
a. can act as a mechanism to improve the well-being of entire nations via the redistribution of income and reduction of inequalities
b. can improve overall education levels within populations
c. can encourage globalization and therefore enhance the ‘trickle down’ effect that results from economic growth
d. can develop service improvement by increasing efficiency through the introduction of competition

ANSWER

The correct answer is a. Education levels are related to health outcomes, but this is not the central argument made by Wilkinson and Pickett (2009). Wilkinson and Pickett (2009) do not espouse the view that economic growth results in a ‘trickle down’ effect, nor do they write about efficiency and competition as part of service provision.

10. Austerity has historically had which of the following impacts upon the health of the public?
a. Reducing poverty rates
b. Increased hunger, food poverty and the use of food banks
c. Increasing life expectancy
d. The introduction of increased public services

ANSWER

The correct answer is b. Austerity usually results in increased poverty rates especially for those who are the most vulnerable, such as the disabled, and has resulted in the stalling of life expectancy gains in the UK and reduced funding for public services, such as libraries and public transport.

Additional Case Study: Political economy and population health

In reading chapter 11, you will have realized that politics, economics and public policy are all important in determining population health. Evidence (McCartney et al 2019) suggests that countries with social democratic welfare systems, that spend more on health and have lower levels of health inequalities have healthier populations. Socially democratic welfare systems are those that use policy to try to curb inequality, support underprivileged groups and reduce poverty. Examples of such policy approaches include universally accessible public services like care for the elderly, childcare, education and healthcare. The UK has some elements of these policies: for example, the NHS is free at the point of consumption for residents, and education is universally available at no direct cost for families until the age of 18. However, social care for the elderly is largely privatized and recent welfare system changes have been described as neo-liberal by many commentators.

Countries that have pursued neo-liberal approaches to economic policy have worse health inequalities and higher mortality rates, according to the evidence base. Neo-liberal policies tend to use market-based approaches and the privatization of both goods and services, such as education and healthcare. Neo-liberal restructuring (such as the use of austerity) increases health inequalities and leads to worse health outcomes in a range of areas.

This evidence clearly illustrates that greater public spending is better for overall population health and that reductions in provision lead to worse health outcomes.

McCartney et al (2019) ‘Impact of Political Economy on Population Health: A Systematic Review of Reviews’ American Journal of Public Health 109, 6, 305001.

3 Papers

Mantoura, P. and Morrison, V. (2016) Policy approaches to reducing health inequalities. Canada, National Collaborating Centre for Healthy Public Policy. LINK
This article discusses policy as a tool to reduce health inequalities in a range of ways. It is the basis for the case study in chapter 11 but warrants further attention because of the detail that is in it.

Thomson, K., Hillier-Brown, F. Todd, A., McNamara, C., Huijts, T. and Bambra, C. (2018) ‘The effects of public health policies on health inequalities in high-income countries: an umbrella review’ BMC Public Health 8: 869. LINK
This article presents the results of a systematic review that looks at the evidence of effectiveness of policy approaches in tackling health inequalities. It is an extension of the case study material discussed in chapter 11 and provides further evidence about the potential of policy to address health inequalities.

Stuckler, D., Reeves, A., Loopstra, R., Karanikolos, M. and McKee, M. (2017) ‘Austerity and health: the impact in the UK and Europe’ European Journal of Public Health 27, Supplement 4, pp. 18–21. LINK
This short review looks at the ways in which austerity measures impact upon health. The authors describe two clear impacts including a social risk effect and a healthcare effect, drawing upon data from both the UK and Europe to point out the impacts of such policy approaches upon the most vulnerable.

3 Websites

1. The King’s Fund
This website offers a range of reports linked to recent health and social care analyses about healthcare (The NHS), social care, what the public thinks about policy, as well as comment on changing trends.

2. The History of the NHS in charts
This BBC article outlines the early years of the NHS to the present day through the use of charts and figures, comparing 1948 to 2018, which saw the NHS celebrate its 70th birthday.

3. The Welfare State – Never-ending reform
A website with content discussing the history of the British welfare state, including sections about Beveridge, Thatcher and the mixed economy of care. A brief but interesting read.

3 Media Articles

1. Can you turn around the health of an entire town?
This report discusses a community-based approach to improve health by encouraging local people to take control of their own health. The article discusses the early outcomes and some of the wider social determinants affecting people’s health in the community under discussion.

2. Where not to live if you want a good care home
This article highlights a postcode lottery of care quality for older people, naming the areas which have the highest concentration of poor social care in the UK, and discussing the government’s plans to reform the system.

3. Austerity kills: this week’s figures show its devastating toll
This Guardian newspaper report outlines the impact of austerity on health, outlining its impact on life expectancy and its ideological basis.