Rethinking the Welfare State: The prospects for ... - e-Library

Health care 103
A second limitation on patient autonomy in the Canadian system is the prohibition on
opting out of the system. Many provinces make it illegal to sell private insurance
covering medically necessary physician and hospital services and all provinces require
physicians to be in or out of medicare—that is they cannot operate in both the public and
private spheres. The only available alternative is to seek care in another country but for
most citizens this alternative is prohibitively expensive.
Purchaser/provider split
Prior to the introduction of major reforms in 1989, the British government employed a
“command-and-control” approach to health care. 31 That is, the state was responsible not
only for the financing of health care services but for the management of the delivery of
those services as well. 32 At the top of the governing hierarchy was the Secretary of State
for Health. The Secretary appointed Regional Health Authorities (RHAs) which in turn
delegated duties to District Health Authorities (DHAs) and Family Practitioner
Committees (FPCs). The DHAs were responsible for supplying their respective districts
with public hospital services. Each of the approximately 145 DHAs directly managed
hospitals that provided care to the district’s population, which, on average, amounted to
about 250,000 people. 33 In turn, the FPCs were responsible for provision of general
medical, dental, ophthalmic, and pharmaceutical services. Every individual in the UK
was enrolled with a general practitioner (GP) whom they were free to select from the
National Health Service (NHS) list. These GPs acted as gatekeepers, limiting patient
access to more expensive entry-points in the health care system such as hospital or
specialist services. 34 Although publicly financed, GPs were treated as independent private
contractors who were compensated through a mixture of three methods: (i) salary, (ii)
capitation payment per registered patient, and (iii) specific fee-for-service payments for
particular preventative services. 35
While it might appear that the pre-reform UK system had strong state control over the
NHS, in fact a hybrid model of governance existed. 36 While it is true that the state
administered the NHS through the hierarchical tiers of administrative bodies outlined
above, the organized medical profession, primarily the British Medical Association
(BMA), played a key role in the corporatist regulation of the health care system. The
BMA negotiated health policy with the Department of Health and the profession
administered the health services in conjunction with health authorities. This left
individual physicians with a significant degree of autonomy and power.
The driving force for change in the NHS arose out of heightened public perceptions
that the service was on the brink of collapse. The basis for the intense and pervasive
sense of crisis incorporated three inter-related factors: (i) budget constraints, (ii)
increased demand for health care services, and (iii) pressure on providers to increase
efficiency. 37 As a result of the troubled state of the British economy in the 1980s the
government was committed to keeping health care expenditures in check, choosing to
focus on increasing efficiency rather than dedicating an increasing proportion of its
budget to the NHS. At the same time, however, demand for health care services was
growing; the NHS’s notorious waiting lists grew from 700,000 to nearly 1,000,000 and
the number of individuals opting for private health insurance rose from 3.5 million at the
beginning of the decade to almost 6 million at the end. 38 Recognizing the impact that