Peggy Foster

Improving the Doctor/Patient Relationship: A Feminist Perspective *

Since the early 1970s British and American feminists have developed a comprehensive critique of the dominant doctor/patient relationship within mainstream health care services. In Britain, activists in the womens health movement have struggled to put into practice a model of health care delivery based on feminist principles, within which the doctor/patient relationship is radically redesigned. This paper will explore the principles and practice of this feminist health care model. It will then attempt to evaluate alternative strategies for strengthening and expanding feminist health care within the NHS. The paper will draw on data gathered by the author in 1987 through a series of unstructured interviews with feminist health care providers who were working within a variety of NHS settings in the North West of England.

Inequalities in health: what health systems can and cannot do.

Health promotion activities are actively encouraged in most countries, including the UK. Meanwhile many health care providers and health experts are becoming increasingly concerned about the growing evidence of significant health inequalities between social groups in the UK, and in particular the strong association between relative deprivation and poor health. In 1995, a report for the British government entitled ‘Variations in health: What can the Department of Health and the NHS do?’, identified the need for the Department of Health and the NHS to play a key role in coordinating and implementing public health programmes intended to reduce inequalities in health. Examination of existing evidence on the effectiveness of health promotion and prevention programmes designed to improve the health status of the most vulnerable groups in society reveals very little evidence to support current enthusiasm for adopting public health strategies in order to reduce variations in health status between the affluent and the poor. Alternative and potentially more effective health care responses to inequalities in health status need to be considered.

From compliance to concordance: a challenge for contraceptive prescribers.

In 1997 the Royal Pharmaceutical Society of Great Britain published a report entitledFrom Compliance to Concordance: Achieving Shared Goals in Medicine Taking. This article applies this new model—of doctors and patients working together towards a shared goal—to the prescribing of hormonal forms of contraception. It begins by critically evaluating the current dominant model of contraceptive prescribing. It claims that this model tends to stereotype all women, but particularly young, poor and black women, as unreliable and ill-informed contraceptors who need to be advised and even controlled by much more knowledgeable and socially responsible family planning experts. The article then suggests how a much more egalitarian model of contraceptive prescribing might be put into practice, whilst acknowledging the existence of many serious obstacles to such a radical shift within family planning services. In conclusion, the article suggests that until contraceptive prescribers begin to take women’s experiences of, and concerns about, hormonal contraceptives seriously they will fail to develop a potentially much more effective and liberating model of family planning.

The informal rationing of primary medical care.

All social services are rationed, yet the effects of such rationing on the client are rarely fully explored. This article reviews the evidence on the existence of informal rationing devices in general practice. It examines the effects on patients of a wide range of informal rationing devices now used by individual general practitioners. Various suggestions for reforming the present rationing of primary medical care are evaluated and the likelihood of any reform being carried out is assessed. Although this article concentrates solely on rationing in the primary care sector of the National Health Service, the issues discussed are relevant to most welfare agencies as they are presently organized.

Access to Public Housing

Whereas access to either the owner-occupied sector or the privately rented sector is primarily determined by ability to pay, council housing, at least in principle, is allocated according to need. In practice the objective of giving priority to those in greatest need usually conflicts with other objectives such as the protection of council property. Research has demonstrated that the criterion of need is by no means always placed first in the allocation process. In order to understand why local authorities sometimes fail to give priority to those in greatest need, we must attempt to unravel the process or rather processes by which applicants gain access to council accommodation. This chapter will be concerned not only with the question of how those in need gain access to council housing per se but also with the type of accommodation they are offered. In an advanced, reasonably affluent, society most people would probably agree that a public sector housing system should provide not just bare shelter but a decent standard of accommodation. Very few people in our society have no roof whatsoever over their heads. Many, on the other hand, live in accommodation which is officially recognised as unfit for habitation. The type of accommodation lived in and its location is crucial in determining a person’s overall welfare and living standards.

Charges and Means Tests

Universalists, such as Titmuss and Townsend, have consistently condemned the use of charges and means tests in the welfare sector. This may explain why so many students of social policy dismiss out of hand all arguments in favour of selective welfare provision and why little empirical research has been carried out into consumers’ reactions to the use of charges and means-testing. The consequences of their use have tended to be assumed rather than proved. Yet taken at face value much of the selectivists’ case in favour of charges and means tests makes good sense. It is difficult to deny, for example, the logic of concentrating scarce welfare resources on those otherwise unable to obtain help. Indeed universalists do not deny that the only way to ensure that the social services redistribute welfare to the poor is to positively discriminate in their favour. Supporters of the NHS and compulsory state education now accept that the relatively affluent have tended to get more out of them than the poor and deprived. According to Brian Abel-Smith, ‘The main effect of the post war development of the social services has been to provide free social services to the middle classes.’1 Universalists, however, reject consumer charges combined with means tests as the answer to this problem.

Client Demand and Welfare Rationing

The precise role which clients play in the process of welfare rationing has yet to be clearly delineated, but it is clear that clients’ initial demands on the social services do play some part in determining the final distribution of welfare benefits. We can identify three separate areas of debate over the impact of client initiated demand on the rationing of welfare. First, writers on welfare issues have attempted to assess the impact of client demand on overall levels of social expenditure. The significance of client initiated demand as opposed to other factors such as the demands of industry in relation to overall social expenditure is extremely difficult to calculate. Since we are mainly concerned with the allocation of welfare benefits to clients rather than with the process of resource allocation to the social services, the relationship between client demand and levels of social expenditure will not be explored in this book. A second, controversial, aspect of client demand is the question whether or not clients over use or abuse the statutory social services. A third important question is whether clients themselves play a part in perpetuating social class inequalities in the distribution of certain welfare goods and services. Before exploring these issues further we should note the difficulties involved in any attempt to isolate, measure or evaluate client initiated demand for social services.

Professional Rationing of Welfare Benefits

Professional welfare providers determine the allocation of welfare benefits in two distinct ways. First, they are able in varying degrees to determine the allocation of their own time and attention. Second, they exercise various forms of control over the allocation of material benefits such as prescribed drugs and medicines, NHS operations, school books and equipment and certain types of financial aid. The freedom of professionals to make their own decisions in response to their clients’ needs or demands, lies at the very heart of the concept of professionalism. This professional freedom and power is of key importance to those seeking welfare services. As Titmuss pointed out in 1968, ‘In the modern world the professions are increasingly becoming the arbiters of our welfare state: they are the key holders to equality of outcome: they help to determine the pattern of redistribution in social policy.’1

Strategies for Reform

Previous chapters examined the ways in which welfare providers control clients’ access to the social services. It is now time to take an overview of the existing system of welfare rationing. This will begin by identifying the key failures attributed to current rationing methods. It will then examine critically three distinct approaches to the reform of welfare rationing which will be labelled ‘administrative reformism’, ‘the market solution’ and ‘the Marxist alternative’.

The Objectives of Welfare Rationing

In order to understand the nature and outcome of welfare rationing in all its forms, we must first understand the aims and objectives of the institutions in which this rationing takes place. This chapter will attempt to explain why the state provides certain welfare benefits without recourse to the price mechanism. There will then be an examination of the conflicting nature of the key aims and objectives of the statutory social services. Finally, the various types of rationing used in the welfare sector will be briefly identified.