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This is the fourth of six related articles, commencing with a piece by Professor Marsland in MSN Volume 14, Issue 2 in April 1989, and concluding with his report in MSN Volume 19, Issue 1 in December 1993, which are published here, together, for the first time.

Research into Health Care

Professor David Marsland, MA, PhD, FRSH
West London Institute of Higher Education, UK

Originally published in MSN Volume 15, Issue 3, August 1990

Reactions to the White Paper “Working for Patients” and to the Government’s Bill now going through Parliament have demonstrated that there are very few academics, journalists or social policy researchers who are not substantially prejudiced in favour of the status quo in health care.

Apart from the Health Reform Group, the Institute of Economic Affairs and the Adam Smith Institute, Kenneth Clarke has been able to rely on precious little support in his brave efforts from intellectuals in Britain. Even these exceptional cases are outside public higher education, where the bulk of research funding is spent on health care. Indeed, even from the sadly few universities where there are important centres of innovative thinking in relation to health care, there seems to have been very little by way of public support for NHS reform since the Bill was published.

ESRC-funded research projects in the sphere of health care seemed likely, to judge by recent conference papers, to produce yet more critical material, rather than anything which could provide positive assistance in the implementation of NHS reform. Social scientists generally remain thoroughly sceptical about – not to say prejudiced against – any serious role for markets (external or internal) in the health sphere; about objective scrutiny of current health care costs; about strengthening the hand of devolved management; about genuine attention to consumer perceptions and dissatisfactions; or about allowing the proper emphasis on efficiency, which along with care, is essential in a modernized, dynamic NHS.

Even the sociology and social policy now routinely taught to doctors and nurses in training is largely, if we may judge from the textbooks typically used, impregnated with prejudices incompatible with genuine reform of health care.

Lack of support for health care reform from the academic community cannot simply be dismissed as a trivial, predictable nuisance. The agenda of debate in the media and the atmosphere of public discussion are shaped to a powerful degree by “merely” academic and intellectual influences. Unless something is done to encourage a more balanced and more objective approach in research and analysis, it seems unlikely that serious reform of health care in Britain will be successfully accomplished.

In private sector research, it would generally be considered foolish to commission studies from sources who were known to be opposed in principle to the service or commodity being researched. It would not be regarded as in any way prejudicial to place research with investigators who were believed likely to approach their task open-mindedly and in a spirit of honest practicality. Why should it be any different in the public sector?

It seems to me there are two distinct constituencies with a real interest in attempting to amend and improve the condition of research into health care:-

  • All those seriously concerned about current levels of costs and efficiency in the NHS, and anxious – for the sake of patients, staff and taxpayers – to see improvements.

  • All those with a broader interest in welfare reform as one fundamental aspect of the modernization of Britain. If reform is blocked or stalled in health care, moves in other spheres against bureaucracy, collectivism and inefficiency will be considerably weakened.

There are several important tasks which people who identify with either or both of these constituencies might usefully take on:-
  • Monitor academic publications, especially those used in teaching health care personnel and those which are taken up by the media, for the extent of their open-mindedness and objectivity in relation to NHS reform.

  • Systematically monitor the conclusions and public statements arising from research on health care funded from the public purse and publish the results.

  • Identify researchers in higher education who are other than prejudiced against health care reform.

  • Seek ways of strengthening funding for research undertaken by such people. Both public and private sources of funding will need to be tapped.

  • Develop networks of contact between, on the one hand, academics of good reputation who are sympathetic to reform, and the media on the other.

  • Establish a programme of invitation seminars over the next two years designed to examine the practical task of implementing health care reform. Key media people to be included as observers. Press releases to be attractive and professional.

Since 1945, and more particularly since the expansion of the social sciences during the nineteen sixties, there seems to have been a tendency for the research community to be more than somewhat partial in its ideological inclinations. Even among economists, but especially among social historians, sociologists and social policy analysts, the tendency has been:-
  • To underplay and even denigrate the potential positive role of markets, competition, enterprise and incentives.

  • To over-estimate the scope for effective central planning.

  • To lay greater emphasis on generalized principles of presumed social justice than on the particularities of individual consumers’ wants and satisfaction.

  • To underestimate costs and to downplay their significance in policy development.

  • To sympathize with the concerns of trades unions and professional associations at the cost of ignoring the requirements of efficient management.

  • To presume on some general trend of history towards increased state control and away from active participation by private, independent and voluntary producers and suppliers of commodities and services.

These tendencies have been apparent in most fields of social policy research, including housing, pensions, education, training, employment advice and placement, and not least health.

It seems to me unlikely that an intellectual context shaped by these tendencies can provide effective support for the radical reforms needed as much in the health sphere as in other sectors of social policy. Those who are seriously committed to reform ought, therefore, to be giving attention to measures designed to amend the one-sided inclinations of social research. This Working Paper is designed as a stimulus and encouragement to such efforts.