Health reform and the politics of nursing practice

The phrase ‘health sector reform’ is a relative newcomer to the lexicon of health-care. Its meaning can stretch from macroeconomic changes in governance and funding to micromovements within the service delivery system. Its use may also depend upon the actor and audience. Politicians, for instance, are fond of using the term rhetorically to enlist support for changes they seek to promote. But this elasticity proves a challenge for the researcher. The structures, processes and outcomes of reform need to be clearly defined. Moreover, a distinction needs to be drawn between structural reforms and incremental changes that occur naturally within the system. Reform therefore represents a process involving sustained, planned institutional and structural change, led by a government geared towards the attainment of explicit policy goals (Saltman and Figueras 1997). The drivers of reform include not only the values that underpin the health system, and the state of the national economy, but also the capacity to implement reform. Humanity, equity, effectiveness and efficiency, for example, may all impinge on the reform process. Rising inequalities, inadequate allocative and technical efficiency, quality and accountability may all be important triggers. But macroeconomic realities often predominate. Health reform is a common response to escalating health budgets and a strategy for cost-containment. In Western Europe, for example, many member states of the EU have been cutting back public spending in order to reduce budget deficits to targets set by the Maastricht Treaty as a condition of European monetary union. Economic pressures have also brought new players into the international policy arena. Institutions such as the World Bank have linked economic restructuring with health reform and often made one a precondition of the other. Socio-demographic, technological, epidemiological and political pressures may prevail. Countries in the former Soviet Union, for instance, have been undergoing market-oriented economic and health reform. The break up of the Soviet Union and the formation of the Commonwealth of Independent States in the early 1990s removed the 40% subsidies from Moscow. The outbreak of armed and civil war conflict in a number of areas produced rapid economic decline, with the exodus of many healthcare workers and the consequent intensification of shortages. Nurses in particular are in scarce supply. Yet although nursing is critical to the successful implementation of health reform, it is often an afterthought in the minds of planners. Rarely are nurses involved in the design of reform proposals. Typically, it is at the point of downstream delivery or human resources planning that nursing enters the equation. This reflects both the paucity of nurses within policy élites as well as the political weakness of organised nursing within specific countries. As a child of the 1980s, health reform reflects the contemporary fascination with management. At the time this involved some degree of antiprofessionalism. The shiny ‘new public management’ applied techniques and strategies developed within the private sector to public sector problems. Decentralisation and process re-engineering became the stock-in-trade of macho managers, redrawing the profiles and boundaries of the clinical professions. The role of the state in the provision of health-care also changed. An enhanced role for the private sector in some cases accompanied the move towards the market. Faith in managerial and technocratic solutions has been so strong it has given rise in some cases to what might be called ‘the managerial state’. The managerial state’s apparatus of accountability and performance regimes has tried to clamp down on the clinical power of doctors. In the UK the most recent wave of New Labour reforms in the National Plan have spawned some 15 new bodies to ‘modernise’ standards through powers of inspection and review (Department of Health 2000). A series of medical scandals have provided the pretext for the government to push through radical reforms to reconstruct professional self-regulation. Tony Blair’s crusade thus far has focused on quality. In keeping with New Labour’s pro-European position and faltering move towards a single currency, European indicators of health are the benchmarks of achievement for the future. But, like its Clinton counterpart of the mid-1990s, the English health reform plan (now with devolved powers and separate jurisdictions for Scotland and Wales), shifts the emphasis from secondary to primary care. New ways of delivering services are being developed often through enhanced roles for nurses and midwives. Health reform can impact positively upon the politics of nursing practice. But we cannot assume a sudden and unbridled enthusiasm on the part of the government for nursing. Nurse-led services may have changed the pace and pattern of access through new technologies and techniques of service delivery. It currently suits the government to promote nursing while it is putting the pressure on medicine to comply with its performance agenda. But medicine will not give up its power base easily. Every reform campaign has its discourse of denigration. During Clinton’s health reform campaign (1994–95), the Texan Medical Association created a visual pun of a duck with a stethoscope and a caption on nursing below. The attack on nursing as quackery could be considered a comment on the relative political strength of nursing at that time. The healthcare reform campaign for nursing in the USA stands out as a successful episode in which nurses exercised unprecedented political influence in advancing a nursing agenda. In many ways it reflected an increasing level of political sophistication on the part of organised nursing, as well as the fortuitous convergence of circumstances that brought nursing and the Clinton administration together. First, nursing’s agenda and healthcare reform as sponsored by the national leadership converged. Second, the Clintons’ own experience from Arkansas of rural and underserved populations was crucial. Third, nursing organisations under the leadership of the American Nursing Association (ANA) had unprecedented access to the White House. Virginia Trotter-Betts, then President of ANA had been a legislative aid to Al Gore (as a Robert Wood Johnson Fellow). Gore was identified as an important point of access for a number of people who became involved early on in health-care reform and as a supporter of non-physician providers as key to reducing health costs. Nursing’s unusual degree of influence then lay in the particulars of the relationship that emerged between the leadership of the Democratic Party and the ANA. The fit between the national health-care and nursing agendas was close. Advanced practice nurses provided a potent solution to the triple problems of cost, quality and access in American health-care. Although we can see some similarities in the promotion of an advanced practice agenda in health reform across a number of Western countries (Australia, USA, UK), the evidence base for many reforms can be weak at best. Hospital workforce redesign, for example, has become the target of widespread and strikingly ssimilar organisational restructuring activities undertaken by hospitals in a number of Western economies, North America and Europe included. Such activity however, appears to be economically and ideologically driven in the absence of empirical evidence to support such interventions. The impact of workforce changes on patient outcomes, in particular, is largely unknown. A cross-national study is currently underway to investigate the natural experiment afforded by hospital restructuring in the US, UK, Germany and Canada (Sochalski et al. 1997). The study aims to enhance understanding of how variation in the organisation and staffing of hospitals affects patient outcomes, and the implications that this might have for decision-making regarding how scarce resources can be best allocated to achieve positive patient outcomes. As we can see, the research agenda associated with health reform is enormous. Much more research is required on workforce patterns of all staff and their relationships to clinical outcomes, and the mechanisms by which staffing and healthcare organisation influence outcomes. International comparisons provide the advantage of examining the consequences of different stages of restructuring at a single point in time. This is all the more important when cross-national borrowing of reform strategies occurs. But there is a global problem of research capacity, not only in economics but in outcomes research and in the evidence base needed to underpin nursing as part of the wider solution to healthcare problems. The reform of research is also required if nursing is to feature as more than a footnote and to act as a major player in health reform and the politics of practice.

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