Health Care Analysis7: 79–90, 1999.© 1999Kluwer Academic Publishers. Printed in the Netherlands.

For Debate

Health Care in the 21st Century: What Could be theShape of Things to Come?

TOM MARSHALLDepartment of Public Health & Epidemiology, University of Birmingham, Edgbaston,Birmingham, B15 2TT, UK

Introduction

Health care systems across the world are in a state of change, services arecentralised, decentralised, planned, organised into competitive markets andthen reintegrated again. Despite this, much stays the same: health care isartificially separated from other aspects of welfare and is dominated bya single profession and a single professional paradigm. As a result manyof the central contradictions of health care remain unresolved. This paperattempts to address some of these by imagining a health care system whichmight evolve from a Beveridge style system at some point early in the newmillennium.

What Needs Would a Health Care System Meet?

The Needs of Individuals

Health is not an end in itself, but it is one of the requirements for individuals toachieve their own desired ends. The aim of the health service should thereforebe to help people achieve (and in some cases to identify) their own ends.Taken at face value this restatement of patients’ autonomy has a number ofpowerful implications.

Firstly, unless there is a specific reason to doubt someone’s competence– such as mental incapacity – individuals should rightly be the final arbitersof their own welfare. A primary objective should be to give them sufficientinformation to make decisions regarding their treatment.

Secondly, the patient’s rather than the professional’s perspective on theimportance of different outcomes should be given priority. This replaces

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biomedical conceptions of cure with the idea of restoring or preserving func-tion. It is an approach which would inform both individual practice and theresearch agenda. In other words, health care should be guided by empiricalknowledge about what is useful (effective) and worthwhile (cost-effective) interms relevant to the patient.

Thirdly, within the wider system of social welfare, health related needsshould not automatically be privileged over other needs. This means thathealth care should be part of a wider system for considering general welfareand not, as is usually the case, implicitly afforded higher priority. It alsomeans that it should be possible to divert resources towards the kind ofservices which had the greatest impact, whether health or social services,education or income supplementation. While achieving such a broad view ofwelfare may not be practical in the immediate future, the healthcare systemwhich is envisaged moves some way in this direction.

Societal Needs

In addition to meeting the needs of individuals, there are sometimes widersocietal needs, where the benefit to any one individual may be small.The most obvious examples are immunisation and the treatment of conta-gious diseases. More subtly, some kinds of services reduce burdens on thecommunity, such as family planning services to reduce unplanned pregnan-cies or rehabilitation to reduce physical dependency. Equally there are areasof health care where the wider interests may conflict with individuals’ needs,such as unrestricted access to antibiotics or habit-forming medications. Moregenerally, any form of medicalisation has a cost to individuals and to thecommunity in general. Aside from the opportunity cost, medicalisation tendsto reinforce symptomatology and encourage ‘somatic fixation’ (Huygen etal., 1992). It also leads to labelling of individuals as sick and undermines ourcapacity to care for ourselves (MacDonald, 1984; Illich, 1975). This meansthat healthcare interventions should generally be regarded under a presump-tion of guilt: as a necessary evil rather than intrinsically benign. To encourageprofessionals to be aware of the wider costs of health care, the system isdesigned to delegate responsibility for the resource implications of healthcarenear to the level where individual healthcare decisions are taken.

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Healthcare Finance and Expenditure

Main System of Finance and Coverage

The healthcare system would cover all residents and be financed out ofgeneral taxation. However, on the principle that institutions should bear thereal cost of their actions, insurers would be responsible for some of the costsof road accidents and the remainder would be claimed from the authoritiesresponsible for the roads.

Access to the health and social welfare system should be free at the pointof delivery. Out-of-pocket payments have the paradoxical effect of reducingaccess to the system by the most vulnerable groups and while increasing thetotal resources devoted to the system (Evans, 1997; Newhouse, 1993). Theytherefore tend to reduce both the efficiency and equity of health services.

Privately Financed Health Care

To ensure its widespread support, the service should aim to provide for therich as well as the poor. Privately financed health care would be unlikely todisappear, but would play a restricted role. Private health care would provideservices whose effectiveness was either doubted or was not yet known. Itcould also provide some excluded treatments and services where the cost ofprovision was excessive in comparison to the benefits.

Healthcare Benefits and Rationing

Following public consultation, the state would provide general guidance onthe objectives of health and social care. Patients would have an absoluteright to assessment and to information. If there was a possible remedy theywould be entitled to have their need for care considered. Where researchevidence suggested there was not an effective remedy, supportive care wouldbe offered. Regional health and social services boards would be expectedto have policies on the provision of care of unknown effectiveness and alocal procedure for deciding whether the effectiveness was justified by thecost. A higher priority would be afforded to those whose quality of life wasmost affected or most at risk and also to situations where there was a relatedsocietal need. This could, for example, allow regional boards to exclude infer-tility treatment as neither meeting a societal need nor addressing an inabilityto lead an independent life.

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The Healthcare Delivery System

Primary Health Care

The main emphasis of this health care system will be on the primary care. Thiswould have some similarities to existing primary health care systems, such asan emphasis on continuity in the relationship between the health professionaland patient, but there are also important differences.

Organisation of Primary Care

Primary care would be organised on the basis of independent multidisci-plinary teams consisting of family practitioners and a social care manager.These would be contracted jointly by local governments and regional healthand social services boards. The contract would specify objectives regardingpopulation coverage, accessibility and quality of services and provision ofinformation. Primary care teams would also be responsible for a budget, fromwhich they would finance the salaries of other primary care professionals andfinance any diagnosis, prescribing or referrals to secondary care. Part of thebudget would be allocated to the social care manager.

Family practitioners would generally be their first point of contact withthe system, but patients could consult other specialists if they needed. Theywould be able to refer to other members of the primary healthcare team, suchas health educators, physical therapists, clinical psychologists, dentists andso on. Public health units would also have certain responsibilities regardingpublic health – such as meeting immunisation targets and participation innational or regional health initiatives.

The internal organisation of the primary care could vary, some teamswould employ their own ancillary staff, others might contract with inde-pendent organisations. Some primary care teams would work in facilitiesowned by local government, others would own their own facilities. However,whatever the organisational structure, it would not be permissible to separateresponsibility for social care from health care.

Meeting Needs in Primary Healthcare – The First Contact Carer

The most basic need in times of illness is broadly spiritual: to acknowledgesuffering and to provide emotional support. The primary care system wouldaim to provide this within the context of a long-term relationship with afamily practitioner. Patients would choose and register with a primary careprofessional who would be their first point of contact with the service. Thefamily practitioner would be empowered to diagnose, prescribe and to refer

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to other carers, however they need not necessarily be a physician or even anurse. Indeed the key distinguishing features of different health professionalswould be deliberately eroded and patients could choose between family prac-titioners whose original professional culture was medicine, nursing, clinicalpsychology, physical therapy, naturopathy or even a non-western medicalsystem.

Meeting Needs in Primary Health Care – Support and Education

The next most important need is empowerment. Health problems are moreoften dealt with by the knowledge and skills of patients, friends and or familymembers rather than by health professionals (Dunnell and Cartwright, 1972;Banks et al., 1975). Even supposedly professionally led care is dependent toa large degree for its efficacy on the skills and knowledge of the patient. Anempowering approach to primary care is in keeping with the basic philosophyof this health system and may also, in a range of conditions, actually result inbetter health (Krishna et al., 1997; Turner, 1996; Di Fabio, 1995; Koes et al.,1994). A central role for formal carers would therefore be to inform, educateand train patients and their carers.

Meeting Needs in Primary Health Care – Support and Education

Primary care would be intended to be comprehensive, including basic medicalcare, dentistry, chiropody, rehabilitation, nursing care and psychologicalinterventions. While there would be an absolute right to information andassessment, the primary care team would not be obliged to carry out any inter-vention which could be demonstrated to be ineffective and would be entitledto refuse interventions which were not considered sufficiently cost-effective.

Meeting Social Care Needs

Social care, led by a budget-holding social care manager would be part of theprimary care team. The social care budget would not be formally separatedfrom the healthcare budget and resources could be moved from health tosocial care or vice versa. Out of this budget, social care managers would beexpected to meet legal obligations regarding the protection of children, resi-dential and domiciliary care and financial support for carers. Clients would beentitled to a choice of social worker and social workers would have access toa range of other agencies and voluntary assistance. The model for provisionof social care would be that of ‘assertive case management’, where attemptsare made to actively identify people in need.

The social care manager would be free to finance any service necessaryto allow the person to continue to live in their preferred place of residence.

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To encourage flexibility, clients or their social workers could request anyalternative arrangements to those proposed, providing they were not moreexpensive.

Paradoxically, some health- and social care systems are empowered to payfor professional care but can only provide limited assistance to those who giveup their time to care for family or friends themselves. To avoid this situation,a key role for the healthcare system would be to train, educate and supportinformal carers. Non-financial support would take the form of education andtraining, respite care, facilitation of self-help groups for carers and patients.Those undertaking long term care commitments would also be entitled to bepaid – a carer’s allowance – on a scale similar to that of a nursing assistant.

Secondary and Specialised Care

Where possible, health services would be provided on a domiciliary basisor as near to the patient’s home as possible. Nevertheless, secondary care islikely to play an important role in health care for the foreseeable future. Someout-patient secondary care could be provided by ‘chambers’ of specialists.These could function on a ‘group practice’ model (with physicians and relatedspecialists working as partners).

Secondary care specialists would have a particular responsibility toensure that patients were fully informed prior to major diagnostic or thera-peutic interventions such as elective surgery. This would be based on threeprerequisites. Firstly that the patient’s own preferences had been established.Secondly that the patient had been made aware of research evidence on theadvantages and disadvantages of the diagnostic or treatment alternatives inrelation to their own preferences. Thirdly, the patient should be made awareof the track record of the specialist or unit providing the service. If all threeprerequisites had not been met, the primary care team would not fund theintervention.

Most in-patient secondary care would be provided in district hospitals.Like the primary care teams, these could have a mixed ownership, someprivate, some local government owned and some state owned. State ownedhospitals would be accountable to a board consisting of representatives oflocal government, patients and employees. Internally, hospitals would beorganised into functional units led by a speciality director (a physician, nurseor other specialist) with managerial, budgetary and clinical responsibility. Theintention would be to minimise the separation of professional and managerialaccountability. The resident staff of hospitals would be a mixture of nurse-practitioners, physicians and other professions working together in the same

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departmental structure. In some cases this could mean that physicians (orsurgeons) were accountable to non-physicians.

Human Resources and Training

A key difference between present health services and the one which is envis-aged is in the nature of the health professions. Responsibility for meetingpatients’ different needs is often divided between different professionalgroups: a rheumatologist to prescribe, a physiotherapist to rehabilitate, anurse to administer medications and a general practitioner to certify inca-pacity to work. The sharp distinctions between the roles of doctors, nursesand other health professionals would be eroded. Members of any of thehealth professions could be trained and licensed to prescribe according toguidelines, undertake cognitive-behavioural therapy, certify illness and so on.Professional supervision and registration of all health professionals would bethe responsibility of a joint health professional council: an autonomous bodyincluding membership from all the main health professions.

Training

Training of doctors would follow a more problem-based curriculum, with anemphasis on lifelong learning. A considerable part would be based in primarycare institutions. Following graduation, doctors would undertake two year’sresidency, at least one year of which would take place in a primary careinstitution. After this they would be eligible to be registered as a qualifiedhealth professional and to enter specialist or primacy care training.

Training of nurses would take place in universities linked to healthcare institutions. Following graduation nurses could undertake additionalspecialist training. They could also undertake further training as nurse-practitioners, primary as healthcare professionals or to diagnose and prescribewithin their specialist field. Similar training would be available for a numberof other health professionals.

Research and Healthcare Technology Assessment

The central aim of this healthcare system would be to provide informationabout health and health services. This information would be generated fromresearch. A significant proportion of national healthcare resources would bedevoted to health services research. The research agenda would be deter-mined by an independent research council, which had significant patient

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group and public input. The main aim of research would be to amass evidenceto inform patients and those delivering care. This system would be allied to aparallel system for the assessment of new pharmaceuticals.

Information on Health

The day to day practice of health professionals at all levels within the healthservice would generally be informed by clinical guidelines. To make healthprofessionals’ decision making processes explicit, patients would have accessto these guidelines and an explanation of their general rationale. The devel-opment and updating of the research base to inform these guidelines wouldbe an important part of the role health services research. Dissemination ofthe information, to both the lay public and health professionals would bea responsibility of regional advice and information centres. In addition toproviding 24 hour public and professional access to research-based infor-mation on health and local health services. To ensure their integrity, thesewould be independent of the regional health and social services boards andaccountable only to the research council.

Organisational Structure and Management

Health would be the responsibility of the Ministry of Health and SocialWelfare. At a national level, the ministry would be obliged to comment on thehealth and social welfare implications of all major policy decisions. A publichealth and social policy department would establish targets for other minis-tries. These might include targets for the GDP20% (the per capita income ofthe poorest fifth of the population), nutrition targets and objectives of alcohol,tobacco and drug policy.

Organisational Structure of the Health Care System

There would be three main strands of accountability within the health caresystem. Local governments would be directly responsible for providingresources for health care and contracting with primary care teams. The broadframework of their responsibilities in health and social welfare would bedefined in national health and social welfare legislation. Hospitals would alsobe responsible to a degree to local governments.

Regional health and social services boards would be responsible for thesupervision of health and social services within their regions, for producing

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Figure 1. Organisational chart of the health care system.

public information on the services and for advising local governments withintheir areas on technical matters relating to health and social welfare.

The third accountability mechanism would be through the widespreadpublic dissemination of information on health and health care.

Planning, Regulation and Management

The health care system would be highly decentralised, with much respon-sibility at the level of local government. Where possible, the health caresystem would be driven by local concerns, with patients free to choosetheir primary care workers and local governments free to contract with theprimary care team of their choice. Patients would also be free to choosetheir secondary care provider within the constraints of local contracting. Theministry would oblige the regional health and social services board to specifyhealth and social welfare targets for each local government, but these wouldhave considerable latitude as to how the targets were achieved. These wouldessentially be measures of people’s health and wellbeing, derived from surveydata. The regional health and social services board would also be respon-sible for providing planning advice, for monitoring health service quality andproducing a range of indicators of the effectiveness of the health services.

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Financial Resource Allocation

Third Party Budget Setting and Resource Allocation

Health and social care resources would be allocated as a single budget toregional health and social services boards on the basis of a weighted capita-tion formula. The regional boards would then allocate resources on a similarbasis to local governments. These resources would be ring-fenced, but localgovernments could add to the health and social care budgets and would beresponsible for their deficits.

Local governments would contract with primary care teams, allocatingthem budgets also on the basis of weighted capitation. To reduce the risk offinancial insolvency, regions would have risk pooling arrangements. Thesecould vary from one region to another, but generally groups of primary careteams would pool a proportion of their budgets and these would be managedat the level of the regional health and social services boards. Patients whosehealth or social care cost more than an agreed annual figure would haveadditional costs financed from the pooled fund.

Payment of Hospitals and Other Providers

In general, hospitals and specialist chambers would be reimbursed retro-spectively on a cost per case basis. Where a group of patients requiredongoing medical care, an annual budget might be negotiated for the hospitalto provide this care. In some cases, secondary care providers might be dele-gated budgetary and gatekeeping responsibility for access to more specialisedservices.

Payment of Health Care Professionals

Healthcare workers in hospitals would be salaried, but specialists in chambersmight be paid on a fee for service basis. Both arrangements would exist inprimary care, with family practitioners and social workers paid largely on acapitation basis and other primary care employees salaried.

The Aims and Objectives of Reform

The aim of this health system would be to eradicate the notion of health asseparable from other aspects of life. Encouraging self-care would attempt

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Figure 2. Financing flow chart.

to stabilise the demands on the formal health- and social care system. Theemphasis on an informed public should make the system more responsive.It would also cause some current health care to collapse for lack of support.This could include preventive and screening programmes where the benefitswere doubtful or small, near futile interventions to prolong life and even asignificant amount of elective surgery.

The health system would continue to develop. As new research findingsbecame known about the provision of social or health care, the service wouldneed to be reconfigured. Local governments might be delegated increasingfinancial responsibility and allowed to transfer money from health and socialcare to education, transport and housing. New hybrid professions mightemerge. The state might experiment with creating a social and health fund tofinance future health cost. This could be built up from taxes on the causes ofill health and social problems (polluter taxes, alcohol, newly legalised drugsand tobacco).

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In the end this is a health care system which emphasises the centrality ofsubjective health and which champions the role played by informal systemsof care. Perhaps the most important objective of this system would be towrest the notion of health from health professionals and the formal health-care system. Health belongs in the public domain, a century of deference tobiomedical health is surely enough.

References

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Di Fabio R.P. (1995) Efficacy of Comprehensive Rehabilitation Programs and Back Schoolfor Patients with Low Back Pain: A Meta-Analysis.Physical Therapy75, 865–878.

Dunnell, K., Cartwright, A. (1972)Medicine Takers, Prescribers and Hoarders. London:Routledge & Kegan Paul.

Evans, R.G. (1997) Healthcare Reforms: Who’s Selling the Market, and Why?Journal ofPublic Health Medicine19, 45–49.

Huygen, F.J., Mokkink, H.G., Smits, A.J., van Son, J.A., Meyboom, W.A. and van Eyk, J.T.(1992) Relationship Betweeen the Working Styles of General Practitioners and the HealthStatus of Their Patients.British Journal of General Practice42, 141–144.

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Krishna, S., Balas, E.A., Spencer, D.C., Griffin, J.Z. and Boren, S.A. (1997) Clinical Trials ofInteractive Computerized Patient Education: Implications for Family Practice.Journal ofFamily Practice45, 25–33.

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Turner, T.A. (1996) Educational and Behavioral Interventions for Back Pain in Primary Care.Spine21, 2851–2857; discussion 288–289.