The future of health futures

Health futures represents the application of various futures tools to the arenas of health and health care. This special issue of Futures reflects the significant growth of health futures. Health and health-care systems can be far better by the early 21st century, or they could be worse. Health futures enables individuals, organizations and communities to understand better the threats and opportunities facing their health, both of which are profound. The International Health Futures Network is an indicator of the growth of this subfield of futures. The future of health futures will be shaped by the ability of futures techniques and those who use them to provide value to organizations and individuals. Better networking among health futurists, expert systems, and the ability to measure and communicate quality will be essential.     

What future for health futures in Latin America and the Caribbean?

The Pan American Health Organization (PAHO), Regional Office of the World Health Organization, is a United Nations agency specializing in providing technical cooperation in health to the countries of Latin America and the Caribbean. A futures approach has much to offer in this endeavour, and PAHO is making health futures tools available to its Member States through a variety of activities. The purpose of promoting futures thinking and the application of futures tools is to improve health-policy planning and public health action within the framework of the ‘Health for All’ vision and PAHO's current Strategic and Programmatic Orientations.     

WHO''s health futures consultation

The World Health Organization's 1993 consultation on health futures examined the field from perspectives of the macro-environment, health status, health resources, emerging health technology, alternative care systems, and tools for health futures research. The consultation produced numerous suggestions about how WHO could promote and support health futures work. Among the ideas now being implemented are new efforts in global surveillance of infectious diseases, the publication of health futures articles, the establishment of an electronic health futures bulletin board, and preparation of a handbook for health futures studies.     

“Every today was a tomorrow”: An integral method for indexing the social mediation of preferred futures

The visions we hold of the future, whether they are of utopias or dystopias, are not simply a matter of personal imagination. Our conceptions of the future are mediated to us as much as they are privately created by us. To this point, futures studies have not developed an integrative and broad-based framework for considering the social mediation of futures. Understanding how social mediation impacts on our futures visioning requires an interpretive framework that can cope with the multilayered nature of futures visions, the worldviews that are associated with them and a theory of mediation that can be applied within such a context of ‘depth’. Using theory-building methodology, the current paper attempts this task by describing a theory of social mediation that builds on the integral futures framework. An application of the framework explores the relationship between various scenarios of health care futures, their associated worldviews and the mediational factors that influence our visions of future health care systems.     

Beyond medicine : Health challenges and strategies in the 21st century

The future of health involves much more than the future of medical care since the major factors affecting health are environmental, social and economic ones. Health has generally improved in the past century, but the continuation of this trend is threatened by population growth, urbanization environmental change, poverty, inequity, war, existing communicable and chronic diseases, and possible new ones. New policies and strategies emerging to deal with these challenges include the formulation of healthy public policy, investing in health, and the development of new structures and processes of governance. Integrated national studies focused on human well-being and environmental health are one means through which the futures field could contribute to the improvement of health in 21st century. Visioning workshops and other participatory futures activities are equally important, since they enable people and communities to take part in the definition and achievement of their preferred health futures.     

Public sector borrowing requirement: A plain man's guide

With the implementation of an internal market in the UK National Health Service (NHS), interest in marketing NHS services is growing. Yet marketing practice in other sectors of the economy, and the experience of other markets in health care, raise doubts and objections as to whether marketing should be introduced in the NHS at all. Some of these objections have force, and there are important structural differences between the NHS internal market and conventional markets. Simply copying conventional marketing methods is therefore unlikely to be an effective, or even a desirable, approach to marketing in the NHS. Specific forms of marketing are required for the NHS and these forms differ for purchasing organizations, for commercialized health care providers (including NHS trusts), and for directly‐managed NHS services. Differences between these variants can be illustrated by considering the different ways in which a generic model of marketing would have to be amended for each case. The differences also suggest some policy and managerial parameters for the future development of NHS marketing.     

The NHS Plan: Accounting for investment and reform in twenty acute hospital trusts in England (1998–2003)

The National Health Service (NHS) Plan published in 2000 summarised Labour's commitment to modernising the NHS in England. The NHS would receive substantial additional funding bringing expenditure on health, as a share in national income, to levels comparable with a European average. The promise of secure financing from government promised to reduce uncertainty and facilitate medium term resource planning in the NHS. Extra funding, as outlined in the NHS Plan, would also be tied into capital and labour process reform(s) to ensure that investment translated into the much needed additional capacity to treat patients. During the period 1998–2003 funding for an average acute hospital has increased 50% in cash terms satisfying expectations set out in the NHS Plan. It is now an appropriate time to review progress. Using information collected for 20 acute hospitals, selected on the basis that they had started and completed PFI projects in the period 1998–2003. This paper constructs a physical and financial audit which is then used to reveal the degree to which acute hospital finances are now secure and the extent to which physical capacity to treat patients has been robustly transformed.     

Health scenarios and policy making Lessons from the Netherlands

A decade ago the Dutch government established the Steering Committee on Futures Health Scenarios (STG) to organize and facilitate research and debate on alternative futures in public health. The STG has since carried out dozens of scenario projects on specific health topics, and the resulting reports have played an important role in the decision-making process within the health sector. The researchers, policy makers, and administrators who have been involved with STG activities have also learned a great deal about which methodologies, processes and organizational arrangements are best for this kind of enterprise. Those lessons are shared here for the benefit of other health agencies interested in carrying out similar programmes.     

What have we learnt about joint working between health and social care?

Joint working between local authorities and the National Health Service (NHS) has been an integral part of health and social care policy in the United Kingdom for many years. Using evidence from two literature reviews this paper argues that there is little indication that joint working delivers the outcomes envisaged in policy. While recent reforms may be beginning to influence improvements, they are undermined by constant reform and professional scepticism.     

The International Health Futures Network (IHFN)

The International Health Futures Network (IHFN) provides an opportunity for those oriented towards health futures research, leadership and strategic policy-making to discuss the future of health and health care, share new ideas and visions and deepen their understanding of international health-care issues. IHFN members are committed to an ambitious vision of “improving health status worldwide by applying and advancing health futures”.     

Facts & figures: Value‐for‐money auditing in local government; Access to information

Although there have been restrictions on access to health care since the inception of the National Health Service (NHS), there has been increasing debate on rationing and priority-setting following the changes introduced from 1991. Much of this debate has been fuelled by the fact that local Health Authorities (HAs), working with limited budgets to purchase health care services for their local population, must set priorities in order to remain within their budget. Some commentators go further and argue that health care rationing is both necessary and inevitable. Others suggest that acceptance of the necessity of rationing may be self-defeating, and question the underlying assumptions. This article reviews some of the arguments and asks whether health care rationing is really necessary.     

Is it Necessary to Ration Health Care?

Although there have been restrictions on access to health care since the inception of the National Health Service (NHS), there has been increasing debate on rationing and priority-setting following the changes introduced from 1991. Much of this debate has been fuelled by the fact that local Health Authorities (HAs), working with limited budgets to purchase health care services for their local population, must set priorities in order to remain within their budget. Some commentators go further and argue that health care rationing is both necessary and inevitable. Others suggest that acceptance of the necessity of rationing may be self-defeating, and question the underlying assumptions. This article reviews some of the arguments and asks whether health care rationing is really necessary.     

Things are different today: the challenge of global systemic risks

While most OECD countries have been rather successful in reducing risks to human lives, health, and the quality of the environment, the record for new global risks such as climate change, pandemics, financial breakdowns, and social inequality is much less convincing. This is the challenge of systemic risks. Since the global financial crisis, it has received rapidly growing attention. However, considerable conceptual confusion mars research on and practical responses to this challenge. We undertake an effort of conceptual clarification, starting with the paradigmatic example of the financial crisis. This leads to a view of global systems as involving an interplay between micro- and macrodynamics internal to the system, with the system simultaneously interacting with its environment. Such dynamics typically show periods of stability, punctuated by situations opening up several possible futures. Alternative global futures, like other prospects, constitute risks for an agent if she considers some of these futures as less desirable than others. Agents may have lexicographic preferences over futures they would like to avoid, so as to consider some futures as just undesirable, but others as catastrophic. If an agent expects some of the relevant futures at a bifurcation point of a global system to be catastrophic in this sense, they are faced with a systemic risk.     

Ethical dilemmas: Teaching futures in schools

Educational policy is implicitly futures oriented, yet in most instances fails to engage learners with explicit futures tools and concepts at a school level. Futures studies in education, or futures education has the potential to reposition learning as purposeful and mobilizes the lives of participants by connecting the curriculum of schools with the multifaceted futures of learners. This is a complex task within the tensions often existing between: the cultural role of a school, the expectations of a society, the expertise of teachers, and the increasingly diverse needs of learners (Bateman, 2012). It is between the tensions of these things that the ‘ethical’ issues of what is taught, or omitted as content in a classroom and the consequences of these choices are evident.This paper highlights ethical and moral dilemmas, as they were apparent in two futures education projects. In the first study, the teachers discuss the inherent limitations of offering a broader and more futures oriented curriculum. In the second study, teachers reflect upon their students’ anxiety with regards to futures images as they are interrogated within a curriculum study. Each of these studies highlights the ethical challenges that arise, when possible, preferable and probable futures are developed as part of learning in school settings, which are culturally and demographically diverse.Tirri and Husu (2002) highlight the ethical dilemmas, which emerge in classrooms around the world, based on conflicts in values and competing intentions between key stakeholders. In the studies which contribute to this discussion, there is evidence to suggest that futures thinking causes conflict within an individual's perception of how the world should be, or their worldview as a result of futures imagining which goes beyond what is taken for granted, or is an assumed future eventuality. In the same way, Carrington, Deppeler, and Moss (2010) argue that all curriculum choices about what is taught (or not taught) in a classroom reflect an ethical decision made by a teacher, with regards to what is foregrounded for learning and what is omitted.It is crucial to re-examine the role of a school in educating students for their futures, as opposed to educating students with an aim of furthering governmental agendas. More significantly, however, as this paper highlights, it is exploring the boundaries of what is acceptable or unacceptable, appropriate or inappropriate to teach in a classroom, given the changing diversities of schools and education systems throughout the world.     

Health trend assessment in Indonesia Futures studies at the provincial level

Health trend assessment studies have been carried out in Indonesia at the national and provincial levels, to provide input into long-term national development plans and to build up the capacity for local health planning in anticipation of decentralization. Provincial health trend assessment studies have been done in five provinces by teams from local health and planning authorities and the local school of public health. These provincial teams have all used background documents and standard procedures developed by a national team and have gone through the same methodological training. Out of the experience have come specific ideas about how trend assessment and similar activities can be strengthened. Among the recommendations are the establishment of national research centres for trend analysis, efforts to improve availability and reliability of relevant data, the training of a cadre of health professionals familiar with futures methods, and continued promotion by WHO and other agencies of long-term health planning and health futures.     

The future of health futures : Another perspective

A good ‘market’ for health futures and easy access to relevant information are among the reasons that health futures is currently centred in the wealthy nations. Interest in health futures is growing in the less developed countries, however, in part because of efforts by WHO and its regional office. Many benefits can be expected if the field becomes more international, including an influx of fresh ideas about health futures study designs and about innovative approaches to health care. A shift to a more global orientation is also imperative simply because health futures deals with the well-being of human beings, and most human beings live in the less developed countries of the world.     

Change and Decision-Making in the NHS: The Case of the Care Programme Approach

Using the Care Programme Approach (CPA) as an example, this article examines the difficulties of implementing change within the National Health Service (NHS). A framework is suggested which aims to clarify the nature of change by distinguishing where, when and how decisions are made. It is argued that structural change in the NHS and the related emergence of new institutions, systems, relationships and operational principles, have generated new uncertainties and ambiguities. A fuller appreciation of how the decision-making process operates is necessary to an understanding of how different policy objectives are pursued.     

WHICH INTERNAL MARKET? THE NHS WHITE PAPER AND INTERNAL MARKETS

Much of the discussion surrounding the publication of the NHS White Paper 'Working for Patients' has centred on proposals for an 'Internal Market'. However, the term 'Internal Market' embraces two quite distinct concepts, both of which are found within the White Paper. These two types of Internal Market have very different implications for cost, equity, priorities and the planning and delivery of health care. The pattern of health and health care will be strongly influenced by the relative strengths of the two types of Internal Market in the future NHS.     

Managing activity and expenditure in the new NHS market

The English National Health Service is introducing ‘Payment by Results’ so that hospitals are paid according to the activity they undertake. This should encourage hospitals to increase activity but perhaps to unaffordable levels. Drawing on interviews with NHS staff and documentary evidence, the authors examine local strategies to manage activity and NHS expenditure. These alone cannot be relied upon to control expenditure, and payments themselves should be modified.     

A vision for Nicaragua : Health services in the new century

Nicaragua is facing a crisis in health and health care, and a health futures programme has been initiated to focus concern and mobilize key actors. Two national scenario workshops have been held at which participants constructed several scenarios describing alternative health futures for the country, with particular emphasis on the organization of health services. One or these, a scenario of profound change, was selected by the participants as their vision of the preferred future. It involves more emphasis on health promotion, decentralization of health-care services, broader participation in health matters, improved training for health professionals, and a stronger role for universities and other educational and research centres. Implications of the selected scenario regarding health policies and actions have been identified, among them being the adoption and implementation of the Ottawa Charter on Health Promotion, the organization of local health service networks, and the more active involvement of health professionals in the designing of health systems.