Shaping the future

This concluding chapter asks how health policy needs to change character in the light of the transitions and tensions reviewed in the book. The emphasis in health policy has to move more decisively from a delivery model to a deliberative model of healthcare; or, in other words, from an assumed model of ‘top-down’ service provision towards a more diffused and democratic model. Moreover, the philosophical transition explored in the book should, in part, be seen as a transition towards philosophy, because philosophical questions are now manifestly at the centre of healthcare debate and activity. The chapter then presents some substantive conclusions about the key balancing acts that need to be struck in shaping the future of healthcare, including the balance between the responsibilities of policy makers and professionals, on the one hand, and the collective responsibility of patients and publics, on the other.

Choosing care

This chapter focuses on some of the mainstream and circumscribed examples of rethinking agency. Once one starts seeing and treating people as healthcare actors—as having something to contribute to their own care and to health systems and environments—many possibilities emerge. Some of these are already absorbed into mainstream thinking and others are more challenging or radical. The former includes the expectation that patients should play an active role in clinical decision making that affects them. The latter extend much more widely—questioning why ‘lay people’ are often allowed to be influential only in circumscribed instances, when their agency and perspectives could be equally influential in agenda setting and design decisions in all aspects of service planning, care provision, research, resource allocation and so on. This question highlights the potential to move beyond an individualist or consumerist conception of agency and towards more civic, social and democratic conceptions of social action.

Especially for you

This chapter discusses one of the most important ideas shaping health-policy reform and debate: personalisation. It should be said that there is nothing new about individualising or tailoring healthcare. Clinical healthcare, unlike some aspects of population or public health, is always already ‘targeted’ healthcare. However, both technological and cultural changes mean that possibilities and expectations of the degree of ‘tailoring’—to people's bodies, on the one hand, or to people's values and/or life circumstances, on the other—have substantially expanded and intensified. Depending upon how it is interpreted, personalisation can be presented as contributing to both medicalising and de-medicalising currents of healthcare change. It can be used to refer to closer attention and responsiveness to individual biology. It can also be used to refer to closer attention and responsiveness to individual biography. The chapter then presents a very rough distinction between ‘personalised medicine’ and ‘personalised care’.

The challenge of integration

This chapter analyses the increasingly influential idea that healthcare systems, or health and social care systems more broadly, need to be better integrated—that both services and the experiences of individuals need to be less ‘fractured’ and that this depends upon attending to the overall architecture of systems. In order to approach the integration agenda, it is worth acknowledging the ‘problem’ that gives rise to it. The agenda is closely bound up with divisions and boundaries that are both necessary and a source of difficulties. The way in which health systems seek to provide diverse goods is through a division of labour that structures both services and roles. Yet the necessary division of labour inevitably and notoriously creates problems. Perhaps the central device through which health policy addresses and manages this tension—between differentiated provision and consolidated needs—is by supporting both specialism and generalism.

Taking less medicine

This chapter examines the premise that health policy is ‘out of kilter’ and needs reform. It suggests that much of the debate about reform can be seen, in crude terms, as a debate between ‘more medicine’ and ‘less medicine’ or, more precisely, between continuing processes of medicalisation and forces of ‘de-medicalisation’, where the latter refers to the erosion of—or a diminished role for—a narrow focus on bodies rather than on persons. Framing health services around a biomedical model produces problems but it also has some serious advantages. Meanwhile, a healthcare system that is responsive to persons—in their individual complexity, social constitution and relatedness—is one that has to think and act much more expansively.

Building blocks

This introductory chapter presents the notion of a philosophical transition as part of a discussion about ideas being the building blocks of health policy. Using the examples of ‘cure’ and ‘care’, it illustrates the ways in which ideas are embedded in healthcare settings and practices and begins to indicate the many broader questions that surround the relationships between medicine and persons. In brief, to talk of ‘curing’ is generally to have in mind some more or less direct physical or biological intervention into the body to counteract the effects of disease; whereas ‘caring’, by contrast, is a more diffuse idea that can embrace ‘cure-type’ responses but extends much more widely to, and emphasises, such things as physical and emotional comfort, and psychological support and responsiveness.

Systems and lives

This chapter explores some of the things that are entailed by calls for anti-reductionism or ‘holism’ in health policy. In particular, it considers what is sometimes called the ‘social context’ of health. Many reforming currents in health policy are informed by, and draw attention to, the importance of seeing health—including clinical medicine and individual well-being—in social terms. It has, for example, become a truism in health services quality-improvement work that a realistic prospect of change depends upon ‘systems thinking’—analysing and addressing the broad range of factors that shape the practices one is hoping to improve. Systems thinking has strong resonances and overlaps with traditions in public health and health promotion which also, of course, look at health in social terms, including as something that needs addressing at a population level.