Progressives to laggards? A comparison of policy-making in the British and New Zealand health systems, 1948 to 1993
Britain and New Zealand offer a promising case study for historical comparison of health systems. Both were regarded as progressive models within early health system typologies, which typically cited Britain’s NHS – the classic ‘Beveridge system’ – as distinctive for its public provision, universal cover and tax funding. Less well known was the fact that New Zealand had been the first nation to institute a NHS, in 1938. There were considerable differences between the two, both in their administrative structures, and in the earlier and growing latitude given to private medicine in New Zealand. Nonetheless both confronted similar challenges and pursued cognate policies in the postwar period, though mostly with varying outcomes. Their progressive reputations also gradually diminished, and by the 1990s scholars of social policy had come to classify both countries as laggards in comparison to states with more generous welfare regimes. What can comparison reveal of the factors that shaped policy directions and facilitated or impeded change?
This project will compare health system development in the two countries between the mid-century and the 1990s. It will seek to account for the changing agenda of health policy-making and its successes and failures.
The ‘family of nations’ approach is a recent development in the comparative analysis of welfare states. It emphasizes shared cultural attributes that may account for commonalities between clusters of nations, and has been applied for example in discussion of social policy in the English speaking nations since the 1980s. It contrasts with the more established welfare state typologies grounded in institutionalist analyses. These variously emphasize the internal social bases of welfare politics, particularly the role of labour, the nature of the state and policy processes, and the importance of path dependence. Comparative health systems histories have tended towards the latter, with particular attention paid towards generic features of medical politics, such as the operation of interest groups in pluralist polities. Both approaches may helpfully inform this project, which provides an ideal case study through which to test ‘families of nations’ in the health systems context.
Content 1. Phases and outcomes
Like all the advanced economies, Britain and New Zealand conducted their post- war health policies against a background of rising demand created by aging populations, escalating costs of medical technologies and heightened public expectations of care. Although the sequence of policy development in each country does not run exactly parallel to the other it is possible to identity broadly similar agendas emerging in time.
- 1950s Both countries reviewed their reformed health systems and affirmed government policies, with the private sector advantaged in New Zealand. Key events: 1953 Consultative Committee on Health Reform –
Barrowclough Committee (NZ); 1956 Guillebaud Committee (UK)
- 1960s/70s Both countries attempt to improve organization of primary
care, with health centres programmes hard to establish. Key events: 1966 Family Practitioner Contract (UK), 1971 Health Centres Advisory Committee (NZ), 1975 ‘A Health Service for New Zealand’.
- 1970s Both countries sought to rein back the scale of private medicine, and both failed. Key events: Barbara Castle’s attempt to end pay beds (UK), Labour’s 1975 proposals ‘A Health Service for New Zealand’.
- 1970s/80s Both countries attempted reform of administrative structures: Britain initially succeeded though elements were rolled back; New Zealand initially failed though elements were implemented. Key Events: 1973 NHS Reorganization Act (Eng & W); 1980 Health Services Act (Eng & W);1975 ‘A Health Service for New Zealand’; 1976 Special Advisory Committee on Health Service Organisation (NZ);1983 Area Health Boards Act (NZ).
- 1980s Both countries considered and sought to implement the tenets of new public management in their health services. Key events were: 1983 Griffiths Report (UK), 1988 State Sector Act (NZ), 1988 Gibbs Review (NZ).
- 1980s/90s Both countries sought to impose expenditure restraint in the face of fiscal crisis, and introduced market disciplines through a purchaser/provider split, though again with mixed results. Key events: 1989 Working for Patients (UK): 1991 Green and White Paper (NZ); 1990 National Health Service and Community Care Act (UK); 1993 Health Services and Disability Act (NZ).
Content 2. Policy drivers and outcomes
Through these episodes of health system politics it is possible to identify several recurrent and interlinked themes that run through policy discourse in the two countries. These provided the spur to reform initiatives, although the results rarely fulfilled the aims of policy-makers.
- The structure of primary care. Both countries sought to improve the means by which primary care was delivered to address issues of undersupply and quality. Both found the proposed solutions of health centres and group practice difficult to implement.
- The place of the private sector. Both countries faced the policy question of balancing the size and degree of regulation of the private sector to optimize health system performance. Both experienced poor results when efforts were made to assert greater state control.
- Spatial and sectoral allocation. As their welfare states matured it became apparent in both countries that some citizens were still disadvantaged by uneven resource flows according to place and to sector.
- Democracy and control. However controls over allocation also had ramifications for the degree of centralization of the system. There were vested interests in localism, and both countries oscillated between seeking to strengthen the centre and empower the periphery.
- System integration. In both countries the hospital sector became widely perceived as too dominant by the 1970s, and the importance of better integrating primary care and public health was asserted.
- Health system administration. However the question of integration was bound up with that of how to improve the administrative architecture. Passages to reform were difficult and unstable, with new organizational structures dislodged relatively quickly in further ‘big bang’ reforms.
Applying a health systems approach to comparative historical analysis of this sort will add to the literature in several ways. First, it will draw attention to the similar conditions and constraints which the early adoption of a NHS-model imposed, and the trajectories that followed; this will contribute to our understanding of system typologies and their features. Second, it will show the extent to which differences in political structures and interest group leverage in the two nations could determine outcomes of system reform efforts; this will add to the institutionalist analysis of health policy-making. Third, it will explore the role of language, culture and intellectual networks in health policy-making; this will illuminate the importance of diffusion in health system change, both in eras of growth, and the more recent period of retrenchment.
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