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4 Case Study – Caring for the Elderly in China
6 Institutions of Health Care
by Mao Zedong’s regime such as the life-long employment policy meant that older
people, at least those living in urban areas, could be financially independent (Sheng
and Settles 2006). With privatization in the 1980s this security was lost, making
older people more dependent on family support. China introduced a population control campaign in the 1980s, often described as the one-child policy, which led to a
rapid decline in the national birth rate (Sheng and Settles 2006). As a result of the
one-child policy the relationship between generations is strained, where a single
child may need to care for two parents as well as four grandparents without siblings
to share the responsibility (Chen et al. 2015). A further complication of this picture
is that life expectancy in China has increased. At the same time, there has also been
an increase in cancer rates in this older population with cancer, a disease that can be
protracted, now the main cause of death in China (Chen et al. 2015).
With few affordable resources to care for those suffering from diseases such as
cancer, families are required to provide social and financial support for elderly
Chinese people, as well as personal and nursing care. This caring role is fostered by
the Chinese tradition of filial piety (Chen et al. 2015). But the State has had to step
in to respond to situations where the older Chinese have not been cared for by their
families, and have enacted laws like the Law of Protection of Rights and Interests of
Older People, which requires the offspring of parents older than 60 to visit their
parents frequently and make sure their financial and spiritual needs are met (Chen
et al. 2015).
In the case of older Chinese with cancer and other terminal illnesses we can see
how cultural requirements to look after parents has been made increasingly difficult.
Policy efforts to control the population size and economic restructuring has created
intergenerational tension, with the State responding with new policies requiring
Chinese to meet their cultural and familial obligations, legislating the family’s role
in Chinese institutions of health care.
The Price and Cost of Health Services
Hospitals take up a substantial proportion of the spending on health care. In many
countries within the Organisation for Economic Co-operation and Development
(OECD) between 9 and 12 % of Gross Domestic Product (GDP) is spent on health
care, with the outliers being Singapore at less than 5 % and the United States at
nearly 17 % (Mossialos et al. 2015). Health systems, including hospitals, primary
care and public health, can be funded through a mix of private and public contributions, and provision of services is also often a mix of private and public provision.
The financing of public health provision can come from general tax revenue, as
is the case of the funding of the National Health Service in England, with a relatively small proportion of the population, around 11 %, paying for better access to
services such as elective services through private hospitals (Mossialos et al. 2015).
By contrast in Canada around two thirds of the population have private health insurance to cover services not publicly provided (Mossialos et al. 2015). In the United
The Price and Cost of Health Services
States health insurance is required to access most services, with a safety net of
public provision for hospitals and clinics for those uninsured. The federal government provides tax exemptions for employer-employee health insurance programmes. It also administers a Medicare programme for those over-65 and some
other groups, and administers Medicaid and the Children’s Health Insurance programme targeted at low income groups in partnership with State governments
(Mossialos et al. 2015). The Affordable Care Act, part of what is known as
‘Obamacare’, has further extended health insurance coverage.
In most OECD countries primary care provision is in private ownership.
Payments to providers vary mainly between fee-for-service payments (as in
Australia and Germany) or a mixture of fee-for-service and capitation payments
where payments are based on the number of patients enrolled with a service (as in
the Netherlands and Italy). One consequence of the latter has been that health professionals besides doctors, such as nurses, may take on more responsibilities as a
subsidy is not dependent on the patient seeing the doctor (Barnett et al. 1998). In
some countries income is also derived from meeting particular performance criteria
such as showing evidence of interventions in chronic conditions (as occurs in
Public hospitals tend to be publicly owned (as in Denmark and Norway) or
private-not-for-profit hospitals (as in Canada and the United States) (Mossialos
et al. 2015). They are generally funded through a combination of global budgets
where a maximum amount of money is provided to the hospital and the hospital has
to work within that budget, case-based payments, where payment is made for treated
cases at a set price, and fee-for-service (Mossialos et al. 2015).
Expenditure on health care has risen consistently in OECD countries over many
decades (Chernew and May 2011). The growth in expenditure is a result of aging
populations, new medical technologies and many other factors, including the expansion of disease categories discussed in Chap. 8 on medicalization, and the powerful
influence of pharmaceutical companies discussed in Chap. 9 about pharmaceuticals.
New technologies can lead to a rapid escalation in costs, so for example, the cost of
new diagnostic technologies for screening purposes is supplemented with extra cost
of treatments for the conditions detected by the technology (Chernew and May
2011). The cost of health care can increase with changes to practices around preventive care and defensive medicine. Preventive care targets, such as ensuring that all
patients over 50 have cholesterol tests, drive the cost of laboratory testing services
up. Defensive medicine, where doctors are concerned about possible patient complaints or scrutiny from practitioner organizations, may increase demand for more
diagnostic tests, and so it goes on.
Dominant discourses in contemporary health policy are those of priority setting
and rationing (Joyce 2001). Rationing has of course always occurred. For example,
nineteenth century hospitals rationed by such means as only admitting patients with
certain conditions (not incurable or syphilitics), only admitting those deemed worthy of receiving treatment and only admitting those for whom beds were available
(Rosenberg 1987). Local or state government involvement in the funding of health
services has always involved rationing. To ration out health services means criteria
6 Institutions of Health Care
are developed so that some people have access and some do not. The criteria we
choose varies over time, and are based on our values and also the organization and
politics of health service delivery.
Many governments have agencies that undertake cost effectiveness assessments
of technologies and pharmaceuticals, such as the National Institute for Health and
Care Excellence (NICE) in England and the Canadian Agency for Drugs and
Technologies in Health (CADTH) in Canada. Canada also has a Patented Medicine
Prices Review Board that regulates the prices of new patented drugs (Allin and
Rudoler 2015). Agencies such as these can make recommendations or provide
guidelines or can, as is the case of PHARMAC, the pharmaceutical management
agency in New Zealand, determine which pharmaceuticals will be subsidised by the
government. These agencies place pressure on pharmaceutical companies to price
their products to meet the cost effectiveness thresholds if they want their drugs
widely available to the public. Patient co-payments for pharmaceuticals are also
commonly used to contain costs, as in Australia.
Assessing the cost effectiveness of a service requires some means of assessing
the clinical effectiveness of a service. The development of evidence-based medicine
(EBM) has been a central element in the determination of clinical effectiveness.
Evidence-Based Medicine and Protocols
The rise of EBM can be seen as a consequence of a number of goals. One is to provide credibility to the medical profession by claiming that interventions are backed
up by the best science. Another is that evidence can lead to guidelines or recommendations being developed so that variation in clinical practice can be reduced. As
noted, evidence can also feed into calculations about what services are cost-effective
and so whether they should be provided in a public system or not.
EBM promotes a hierarchy of authority. EBM developed in an effort to orient
medicine towards what was perceived as the existing science and knowledge base.
It became increasingly important in the 1990s, although Lohr and colleagues (1998)
suggest that a landmark treatise was Archie Cochrane’s 1972 text Effectiveness and
Efficacy. At the top of the EBM hierarchy of evidence for interventions is the randomised controlled trial (RCT) while the bottom level is where guidelines are based
on the consensus of experts. Although advocates of EBM argue that decisions
should be based on the most appropriate evidence, therefore potentially extending
beyond RCTs in the context of interventions, RCTs still dominate systematic
reviews aimed at influencing treatment decision-making (Green 2000).
Linking EBM to forms of professional accountability restricts the art of medicine and the autonomy of the practitioner. Drawing on Weber, it has been argued
that evidence-based practice undermines traditional clinical expertise as clinicians
are increasingly required to point to an external evidentiary authority in order to
provide justification for their decisions as opposed to relying on their own experience (Lipman 2000). In what has been termed scientific-bureaucratic medicine,
bureaucracies oversee and control the implementation of evidence-based practice
further undermining the clinical autonomy of practitioners (Checkland et al. 2008;
Codes of conduct and professional standards, including guidelines, protocols and
practice policies, are some of the bureaucratic means of gaining conformity to
evidence-based findings. These bureaucratic means are “instructions telling medical
personnel to do a certain thing in a certain situation” (Berg 1997: 2). Medical practice can then be more standardized and defined as the logical and sequential application of science.
It should not be assumed that attempts to standardise medical practices through
such means as requiring the use of protocols will have the intended outcome. Indeed,
as has been demonstrated by detailed analysis of interactions between patients and
clinicians, there are a range of means by which clinicians can ignore, undermine or
utilize protocols and standardized procedures (Dew et al. 2005, 2010).
Debate over rationing brings to the fore a number of issues that point to some of the
tensions and contradictions within the institutions of health care. One is the claim
that medicine is based in science, and yet a great deal that is practised under the
aegis of medicine has had little scientific validation according to the precepts of
EBM. It is not easy to do a double blind controlled trial on surgery for example,
where neither the patient nor the person assessing the outcome know whether the
surgery has been performed or not. And as outlined in Chap. 9 on pharmaceuticals,
we cannot always be confident in the ‘evidence’ base of research trials.
Another issue is the tension between communal goals and individual goals. Who
should decide what services everyone should have access to? Should economists,
accountants, and managers make decisions based on explicit priorities, or should
individual practitioners make judgements on medical and ethical grounds (Tenbensel
2000)? Should decisions be made by consensus or by some particular representatives? One individual’s idea of an essential service may not coincide with the ideas
of the community. Should politicians, health professionals or patients define priorities? Is it better to spend the limited money we have on preventive measures that
may have a major impact in reducing mortality rates, such as campaigns against
smoking? Or should we make sure we have resources placed in areas such as neonatal units that are high cost but may help to save the lives of babies? Or should we
be focusing on the elderly?
In order to ration we need to have some measure of health outcomes, and there
are many of these. One commonly used measure is Quality-Adjusted Life Years
(QALYs). This is where you work out how many more ‘life years’ a particular
health care activity will produce, and the quality of life the intervention will give;
then this is set against the cost. Those activities that give the most life years at high
quality for the least cost will be prioritized (Tenbensel 2000).
6 Institutions of Health Care
Using QALYs or other measures to ration services poses a number of problems.
One is that the way you make a decision depends upon the value you assign to life.
If you price a human life as being worth $1 million then your decisions would be
very different from pricing it at $200 million (Simmons and Scott 1998). To illustrate just one difficulty, we can ask if a donated kidney infected with hepatitis C
should be used in renal transplantation. Using QALYs, it is better to use the infected
kidney than to discard it because your life years will increase. However, if you were
given an infected kidney you might not feel the same. This example illustrates how
such rational, economic decision-making can go against our own sense of ethics.
QALYs have also been criticised for failing to measure quality of life that is unrelated to health. For example, if we developed a system of rationing simply on the
basis of QALYs then people would not have access to services such as in vitro fertilization as these do not add QALYs to the individual (Devlin et al. 1999).
Another issue raised by rationing is the balance between efficiency (what works
for most people) and equity (how to ensure that the poorest have access to services).
There are always trade-offs that need to be made. An example can be drawn from
the treatment of older people and those with a disability. Older people and those
with a disability are less likely to get treatment if access to services is judged on the
number of years gained from having the treatment or the quality of those years
(Campbell 1999). Older people in general do not have as long to live as younger
people, and if you have a disability then your quality of life measured in this way is
by definition lower. A utilitarian approach, as with QALYs, prefers actions that
deliver the most happiness or pleasure and the least pain or unhappiness in society.
Utilitarian measures can mean that the lives of many are enhanced at the expense of
intolerable suffering for others.
Another way of ensuring accountability in the delivery of health services is through
gathering information about what services are delivered. New management tools
have meant that health professionals can be more easily tracked. For example, the
development of medical management information systems has meant that managers
have been able to look in more detail at how resources are being used, and so put
them in a better position to introduce guidelines and protocols (Barnett et al. 1998:
see also chapter 7).
Systems have also been put in place to track patients’ utilization of health services. This tracking of the population through the health system is an outcome of
state involvement in the provision of health services. This has been called the
administered society by Michel Foucault (1977). Wherever the state provides welfare there will be measures put in place to see that the provisions are appropriately
used. That is, welfare services should be used by those who need them, and used as
effectively as possible. These measures will involve a level of surveillance, which
means information collected about people and what people do. A possible
implication of this increasing surveillance is that we will be expected to conform to
rules laid down by the state.
In addition efforts have been made to control health practitioners to ensure quality and standards of care are met. It is not until the 1980s that we start to see efforts
being made to try to ensure that doctors remain competent to practice after receiving
their medical license (Chamberlain 2013). A number of atrocity stories related to
medical practice have facilitated this process, such as the Shipman case in the
United Kingdom. Dr Shipman was a general practitioner in the Greater Manchester
area. It was found that Shipman had murdered at least 215 elderly patients over a
period of about 25 years (Chamberlain 2013). The case is an extreme one but it supported calls for the introduction of systems of quality assurance and accountability,
such as the revalidation of practitioners to test their clinical competence on a regular
basis. As a result of the range of quality assurance programs that have been introduced, like revalidation, the professional autonomy of individual practitioners has
been limited. The development of quality assurance in medical practice does not
undermine the dominance of the medical profession in relation to other professions.
Through controlling the work of individual medical practitioners, quality assurance
preserves the power of the medical profession as a whole (Coburn et al. 1997).
How we organize the delivery of health services is based on our social values and
which values prevail have varied across countries and over time. In some countries
services may be made available to everyone at no cost to patients at the point of
contact and so taxpayers share the cost of providing those services. In other countries the state may provide services to the most needy only, and let others carry the
cost of their own health provision. For many countries there is a complex mixed
economy in the funding and provision of health services, which at various times has
swung between universal principles and targeted provision.
This chapter has only covered a fraction of the issues in the development of our
institutions of health care. Physiotherapists, nurses, dentists, pharmacists, alternative therapists, and many others have played roles in the shaping of health provision.
Powerful groupings within the health field have shaped the way services are delivered to protect their privileges. Attempts to re-organize services to ensure greater
efficiency or a more equitable distribution of services meet resistance. Attempts to
develop objective criteria on which to base the allocation of health resources are
overwhelmingly influenced by social values. New organizational forms appear in
the face of changes in the health system.
Although changes to the institutions of health care may not be a rational and
linear process, it can be seen as demonstrating the process of rationalisation in the
sociological sense. That is, increasing control is exerted over what practitioners can
do and how they do it, what the patients can receive, and what is known about them.
The rationalism of economics as applied to health services is one attempt to control
6 Institutions of Health Care
expenditure, and at the same time make more transparent the assumptions and reasons for the decisions we make. The other side of the coin is that there are quite
unethical aspects to this from a humanitarian perspective, and sometimes the consequences deeply offend our sense of moral justice.
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Health Care Work and Everyday Health Work
Abstract Health work takes place in multifaceted environments, with interactions
between a range of professions, people and technologies and a complex division of
labor. This chapter addresses the historical development and professionalization of
the medical profession. It then explores the gendered division in health work, particularly between doctors and nurses, while also noting the increased blurring of
professional jurisdictions in some contexts. The chapter draws on a case study of
maternity work to highlight the impact of attitudes towards gender on health care
work. The chapter concludes with a section on the everyday health work undertaken
by non-professionals in daily life.
Keywords Medical dominance • Professionalization • Gender and healthcare •
Diagnosis • Maternity care • Chile • Household healthcare
The delivery of health care and the work of health takes places in multifaceted environments, with interactions between a range of professions, people and technologies and a complex division of labour (Allen and Pilnick 2005). Early sociological
attention to health work focused on the health care professions dominated by medicine. However, the way in which health professionals work together blurs the distinction over who has control of, and responsibility for, health care work. Blurring
occurs on many fronts explored here with particular reference to nursing. This chapter outlines major sociological positions on health professional work and draws on
the case study of midwifery to examine the broader political and policy influences
on health work. Throughout the chapter it will be seen that health care practices
have a gendered nature, a consequence of broader social and cultural trends.
However, the way that gender influences the work of health care and its delivery
plays out differently over time and in different settings. Finally the chapter notes
that a great deal of health work is not undertaken by health professions at all, but is
an unexceptional aspect of everyday life.
© Springer International Publishing Switzerland 2016
K. Dew et al., Social, Political and Cultural Dimensions of Health,
Health Care Work and Everyday Health Work
Medical Dominance and Professionalization
As noted in Chap. 5, historically states have conferred great authority on the medical profession, establishing it as an autonomous profession with powers to selfregulate and to exert control over other health care occupations (Larkin 1983).
Sociological theorizing around professions and their work has gone through a number of phases. Early efforts influenced by functionalist orientations attempted to
understand the role of professions in society and what distinguished a profession
from other occupations. From this functionalist perspective professions played a
role in stabilizing society and supporting the status quo. The medical profession was
seen in altruistic terms, where medical practitioners were not motivated primarily
by financial gain but their patients’ needs came first (Chamberlain 2013). Traits that
could help define whether an occupational grouping was a profession or not included
a long period of training, a research culture, a high degree of autonomy over their
practice, and a code of ethics to be followed that is overseen by professional associations (Chamberlain 2013). Furthermore, professions are able to “set the very
terms of thinking about problems which fall in their domain” (Dingwall 2008: 4).
Theorizing about professions took a more critical turn when the question shifted
from what defines a profession to how its occupational control is achieved, with the
focus now on professionalizing strategies (Chamberlain 2013). Rather than basing
an analysis on the altruism of professions the idea of professional self-interest featured strongly. The medical profession was understood as an occupational grouping
that was able to secure a monopoly over its scope of practice and secure high status
through processes of political lobbying (Larkin 1983). This form of analysis drew
on the sociology of Max Weber. For Weber, legally recognized closure is one of the
most powerful means of exclusion exercised by an occupation. As noted in Chap. 5,
the medical profession gained the legal means to determine who could have the title
of medical doctor, the determination of which has been based on educational and
practice requirements. If someone did not have the appropriate medical degree then
they could not claim the title of doctor. Larkin, in his book Occupational Monopoly
and Modern Medicine (1983) uses the concept of occupational imperialism to illuminate the behavior of medical and para-medical occupations. By this Larkin is
referring to attempts by occupations to mould the division of labour to their own
advantage and the struggle to “establish ‘natural’ or ‘legitimate’ claims to segments
of the medical division of labour” (Larkin 1983: 15). This approach to professions
has been labelled the social closure model (Chamberlain 2013).
According to Willis (1983) medical dominance in the health division of labour is
sustained over three areas. One is dominance over its own work, therefore the medical profession is autonomous from other health professionals. Another is dominance
over the work of others, therefore it has authority over other health occupations and
their claims to legitimacy. Thirdly, the medical profession is dominant in the wider
health sphere, where doctors are institutionalized experts on matters relating to
health (Willis 1983: 2). Regarding dominance over its own work, Abbott (1988: 40)
argues jurisdictional claims over work content has three parts: claims to classify a
7.2 Medical Dominance and Professionalization
problem (diagnosis); claims to reason about it; claims to take action on it
Sociologists have argued that an important aspect of the jurisdiction over diagnosis and treatment is that this power does not simply lie in the application of medical
science but is also based firmly in clinical experience or acumen (Chamberlain
2013). Clinical experience involves aspects of the art of medicine, a view that can
be associated with the notion of indeterminate knowledge. Here indeterminate
knowledge refers to claims that there are aspects of medical practice that cannot be
codified or made technical (Jamous and Peloille 1970). This form of knowledge
may be a product of experience. Atkinson argues on the basis of his ethnographic
research on medical training that:
[T]he clinician who appeals to his [sic] personal knowledge does so not by reference to his
uncertainty, nor the uncertainty of his colleagues. Rather, he bases his actions and decisions
on what is taken as a bedrock – the certainty – of direct experience. (Atkinson 1997: 188)
Such a claim to clinical expertise can act as a form of resistance against external
efforts to control the work of medical practitioners as only those ‘in the club’ of
medicine can pass judgment about the competence or otherwise of club members
Chapter 5 notes a number of challenges to the autonomy of the medical professions. Challenges can be to the autonomy of the individual practitioners, such as
increasing requirements to align with evidence-based medicine, with the medical
profession itself having the authority to determine the adequacy of the practices of
the individual doctor. Other challenges can come from outside of the medical profession. An important challenge is the outcome of managerialism where new management tools are deployed to gather information on the delivery and outcomes of
health care interventions and require demonstrations of competency, quality and
efficiency. Deprofessionalization is a concept that has been used to describe this
challenge to medical autonomy that results in attempts to standardize medical practice (Chamberlain 2013). This process of standardization is compounded by other
developments such as the challenge to medical authority from an increasingly
informed patient population, the growth in self-help groups and the challenge to
medicine from unorthodox healing professions (explored in Chap. 2 on health consumers and the clinical encounter).
In this chapter we explore a range of phenomena that complicate a picture of the
medical profession as an autonomous health care occupation and the only domain
in which the health work of diagnosis, reasoning and treatment is legitimately conducted. The activities of the medical profession are far more widely dispersed. But
first we attend to another aspect of health work and occupations: the gendered
nature of health work.