European health policy : Contemporary dilemmas &

challenges

The Stockholm Manifesto

Steve Iliffe

14th IAHPE conference

Thessalonika May 25-28th 2005

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What is the problem?

• Counter-reformation across European health care systems

• Regressive modernisation, through markets

• But what is progressive modernisation?

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Counter-reformation

• Systems of social solidarity emerged and developed in Europe

• Challenged powerfully by market mechanisms• Pro-market views now have political advantage in

the European Union

Philip Berman & Petra Wilson (European Health Management Association) Facing (uncomfortable) facts: the European dimensions of health services European Health Policy 2004;10(3&4):3-5

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Regressive modernisation

• Socialised care is unresponsive to citizens (tailoring versus one size fits all)

• Socialised care is resistant to change (vested interests of professionals)

• Market mechanisms increase responsiveness and overcome resistance to change

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What is progressive modernisation?

Solving problems and retaining social solidarity?

We need mechanisms for:

• Increasing responsiveness to individuals & communities

• Promoting innovation, smarter working, efficiency, re-engineering

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Stockholm Manifesto 1

• IAHPE conference in Stockholm, 2003

• Collective knowledge (The many are smarter than the few)

• Expert group, diverse experience

• Nominal group methodology

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Stockholm Manifesto 2

Steve Iliffe, Medicine, UK

Alexis Benos, Public Health, Greece

Rolf Gustaffson, Social policy, Sweden

Jane Lethbridge, Health Policy, UK

Jens Niehoff , Health Insurance, Germany

Jill Manthorpe, Social policy, UK

Dieter Borges, Medicine, Germany

Jochen Zenker, Public Health, Germany

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Stockholm Manifesto 3

• Validation process (Labour reform group conference, London, September 2003, IAHP conference South Africa 2004, Perugia February 2005)

• Open Delphi method – failed

• Version 5

• IAHPE conference in Thessalonika 2005

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Stockholm Manifesto 4

• Larger and more diverse expert group

• Analyses of local experiences

• Testing the Manifesto themes

• Produce a philosophy for everyday action in European health services

• Version 6

• Consultation after the conference

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Stockholm Manifesto 5

The three themes:

• Complexity & system approaches

• Work processes & managerialism

• Public involvement

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1.ComplexityAll analyses at all levels depend upon knowing:• ‘Instruments’: scientific knowledge & technologies• ‘Rules’: financial basis, management, codes of

conduct• ‘Community’: the influence of outside interests• ‘Division of labour’: who does what• ‘Professionals’: those providing services• ‘Users’: those using servicesEngström’s Activity theory

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Complexity

INSTRUMENTS: SCIENCE, TECHNOLOGY & SERVICES

HEALTH CARE PROFESSIONAL

USERS & CARERS

OUTCOME

RULES: ETHICAL,

FINANCIAL

COMMUNITY DIVISION OF LABOUR:

After Engström

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2.Work processes, managerialism

Fordist industrialisation of health care

• Cost effectiveness

• Standardisation of knowledge & practice

• Flexibility & teamworking

• Soft bureaucracy: centralisation through decentralisation, corporatism.

• Governance

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Governance

All health service management depends on a combination of:

• Command: hierarchical control & rules• Communion: shared values, professional

leadership• Contract: exchange of contributions

The balance depends on political forces & cultures.Stephen Harrison Governing Medicine: theory and practice, Oxford University

Press, 2004

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3.Public Involvement

• Democratic and multi-disciplinary norm-setting• Needs defined & prioritised in transparent process• Norm-setting identifies priorities that will

determine investment needs • People who can think for themselves, functioning

independently in a decentralised way, will make better decisions and judgements than experts, if they have a mechanism for aggregating different opinions (i.e. voting)

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Progressive modernisation

• Whole systems (no simple solutions)

• Stable systems, evolving slowly

• Not-for-profit economics

• Post-Fordist work processes: decentralisation, low hierarchies, limited standardisation

• Democratic norm-setting