1.2 Market vs welfare health care systems

This learning object, ‘Market vs welfare health care systems’ develops the idea that different models of health care system will lead to differences in the spatial organization of care. In reality, the global context provides many diverse examples for health care delivery systems yet a helpful distinction is between systems that are fundamentally market-driven and those that are essentially welfare-oriented systems. It is not uncommon to find both of these types of system operating side-by-side in the same country but serving different population groups. It is now unusual to find health care systems which are entirely centrally planned and the complex arrangements for funding and provision of care lead to mixed models of locational decision making and catchment area definition, for example. The general principles in evidence here apply at many levels within health care systems.

 

The UK’s largely welfare-oriented National Health Service (NHS) includes general practitioners and dentists who are self-employed professionals with contracts from local Clinical Commissioning Groups (CCGs) to provide a range of health services to registered patients. CCGs replaced Primary Care Trusts on 1 April, 2013 as a result of the 2012 Health & Social Care Act. Access to primary health care through this system is universally available and free at the point of use, hence there is very little genuinely private general practice. GPs most commonly work in small partnerships of 3-4 GPs and will generally own their own practice premises and employ their own staff, although grants and other support services may be provided by the CCG. These partnerships will make some business decisions which are similar to those of private businesses while other aspects of their business will operate essentially as local branches of a state service. Outside a core package of services for registered populations provided by contracted GPs, CCGs will additionally contract for out-of-hours and other services with a range of providers, including private agencies and consortia of GPs. CCGs have powers to set certain features of the local health care ‘market’, for example to approve practice area boundaries, or to declare an area ‘closed’ to further GPs if provision reaches a threshold above national norms. Similarly, PCTs may directly employ salaried GPs within their own premises to assist in filling local gaps in provision. In the less-closely managed area of dentistry provision, the state system is unable to attract sufficient dentists to ensure NHS services in all areas and a more strongly business-oriented model applies.

Hospital services are purchased by CCGs on behalf of local populations from a range of providers, of which the majority are publicly-funded NHS Trusts. These trusts will similarly make some decisions (e.g. with regard to It is thus possible to find evidence of some market-oriented activities even within essentially state-funded systems. GIS analysis for health care planning will thus always sit within the context of a specific health care delivery model which sets the scope of geographical decision-making by the different agencies involved.


Activity

Consider the health care provision which is available to you and identify the different agencies which provide different types of care (local health workers, general practitioners, dentists, hospitals, specialists). Consider each in turn and try to identify whether it is working to essentially welfare or market-oriented models: does it receive central funding as part of a state-organized system or direct payments from patients or health care insurers? Now consider the spatial organization of care evident in your locality. Are you able to identify the type of decision-making which led to the location of services as they are currently configured? Your answers are likely to vary widely according to your national and regional context but at the broadest level, it should be possible to apply these same considerations to any health care system. It is likely to become apparent that the motivation for using spatial data and GIS will be different for each major agency in the health care system. Record your observations in your reflective diary.


References (Essential reading for this learning object indicated by *)

Moorin, R. E. and Holman, C. D. J. (2005) Development of a health care policy characterisation model based on use of private health insurance Australia and New Zealand Health Policy 2, 27 http://www.anzhealthpolicy.com/content/2/1/27

Howell, B. (2005) Restructuring Primary Health Care Markets in New Zealand: from Welfare Benefits to Insurance Markets Australia and New Zealand Health Policy 2, 20 http://www.anzhealthpolicy.com/content/2/1/20

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