The retreat from equity: implications of the shift towards a primary care-led NHS

Older people as health service consumers: background to a study

User involvement in health care has received a high profile within the NHS Plan (Department of Health, 2000a), giving patients a greater say in their treatment and in the way that the NHS works. Older people, i.e. those over 65 years of age, as a group, are the highest users of hospital and community services (DH, 2001a). The national service framework (NSF) for older people (DH, 2001a) highlights the need to listen to older people, help them make informed choices and involve them in achieving a healthy lifestyle. While the NSF for older people rightly attempts to ensure fair and equitable access to health care services for older people, it is assumed that they want to be involved, and want to exercise their rights as users. This assumption needs to be tested. This study, presented as a series of four articles, sets out to explore if there is a consumerist ethic among older people in relation to health care. The first paper outlines some of the literature reviewed together with the methodology.

New Labour and the enabling state

The notion of the 'enabling state' gained currency in the UK during the 1990s as an alternative to the 'providing' or the welfare state. It reflected the process of contracting out in the NHS and compulsory competitive tendering (CCT) in local government during the 1980s, but was also associated with developments during the 1990s in health, social care and education in particular. The creation of an internal market in the NHS and the associated purchaser-provider split appeared to transfer 'ownership' of services increasingly to the providers - hospitals, General Practitioners (GPs) and schools. The mixed economy of care that was stimulated by the 1990 NHS and Community Care Act appeared to offer local authorities the opportunity to enable non state providers to offer care services in the community. The new service charters were part of the enablement process because they offered users more opportunity to influence provision. This article examines how far service providers were enabled and assesses the extent to which new Labour's policies enhance or reject the 'enabling state' in favour of more direct provision.

Health professionals' perspectives on service delivery in two Northern Ireland communities

This research builds on the findings of an ethnographic study of health inequalities in two small, rural communities in Northern Ireland. Through further analysis of existing data, this second study aimed to explore health professionals' perspectives on issues of service delivery relevant to government policy on primary care. Anthropological fieldwork was conducted for two consecutive 4-month periods during 1995 and 1996 in one predominantly Catholic and one predominantly Protestant town. To preserve confidentiality, the locations have been given the pseudonyms, respectively, of Ballymacross and Hunterstown. Research tools included fieldwork journals and a fieldwork diary, meetings with key informants, tape-recorded interviews, group discussions, participant observation and use of secondary material such as census data, local newspapers and community health profiles. Interviews with 15 health workers revealed that there was not a coherent approach to achieving health gain, little collaborative enterprise and minimal interaction between the different professional groups. The National Health Service (NHS)-employed primary care professionals, more than local community workers, appeared to be demoralized, exhausted and suspicious of the business-orientated health service. In this respect, the primary care-led NHS appeared not to be working. It is concluded that a shared health agenda should be developed by NHS-employed primary care professionals and local community workers to create a health-inducing environment at community level. This needs to be complemented by the establishment of formal mechanisms for inter-agency working at local, professional and government levels.