Home and Community Care Digest

Home and Community Care Digest February 2004 : 0-0

Has the 'medicalization' of care led to the social exclusion of chronic care users?


In recent years, governments have grappled with the increasing demands placed on health care systems by shifting care from institutions to the community, particularly for patients with chronic conditions. The author argues that this process of rationing results in the social exclusion of chronic care users. She also finds that this rationing is one aspect of a larger trend towards understanding need in exclusively medical -- as opposed to broader social -- terms. This trend is a result of the pre-eminent position given to the medical profession in both the determination of need and the funding of care based on clical rather than social needs. Government's emphasis on universality of care, as defined by medical need, risks exacerbating the exclusion of those with social care needs.
Background: Since the 1990 reform of the National Health Service (NHS) Act, Britain has undergone a process of redefining national health care priorities similar to that underway in Canada. Each of the Canadian and British reform efforts responds to the same demographic and economic pressures, as well as to funding structures that advantage acute care and the medical profession, over chronic care and caring professions. The author examines the division between chronic and acute care, focusing on the elderly. She argues that shifting chronic care from institutions to the community results in the social exclusion of chronic care users.

Methods: A sociological approach is used to examine the chronic care landscape in Britain. The evolution of legislation defining publicly funded care is reviewed in the context of changing definitions of clinical need, and the implications for chronic care. The author also highlights literature that addresses the professional division of labour in chronic care, as well as the growing trend toward emphasizing the medical and scientific aspects of care over its social ones.

Findings: The shift from 'moral' to 'medical' definitions of need over the last century has created a class of chronic care users that has been subject to exclusion from the social, economic, and political spheres which determine social integration. Through the early 20th century, chronic care was provided under the Elizabethan Poor Laws to those whose need was determined to meet health, economic, or social criteria. The advent of the NHS and National Assistance Acts changed this determination of need by empowering the medical profession to define need as purely clinical, excluding social factors. Yet the NHS Act, similar to the Canada Health Act, emphasizes universality and stipulates that access to care be determined by 'clinical need alone', rather than 'ability to pay'. Those with economic or social need for chronic care can thus be excluded under the justification of universality.

The social exclusion of the chronic care class is reflected in the subordination of caregivers under a professional hierarchy that places specialist physicians at the top and social caregivers at the bottom. Doctors and nurses prefer working in acute hospital wards over chronic ones because of greater perceived professional status and dramatic results associated with treating acute patients. Geriatric medicine has been unable to obtain specialty status, and patients are managed by subordinate 'geriatric teams'. The trend towards 'medicalization' of care presents two faces to the elderly: an expansionist face, where more acute procedures, such as joint replacements and cataract surgeries, are available; and an exclusive face, where non-medical determinants of need are no longer considered in allocation of care.

Conclusions: The rationing of health care that has favoured acute, medical care over chronic, social care has led to the social exclusion of a class of chronic care users, dominated by the elderly. Legislative changes and the hierarchy of caregiving professions have contributed to a shift in society's understanding of the moral needs of the aged. Government's emphasis on universality, where need is narrowly defined in clinical terms, does not protect against age discrimination, and may lead to its exacerbation.

Reference: Simms M. "Opening the Black Box of Rationing Care in Later Life: The Case of 'Community Care' in Britain". Journal of Aging and Health, 2003; 15 (4), 713-737.


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