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In a series of cases over the last 10 years or so the Court of Justice of the European Union (EU) has begun to link health care with the principle of free movement of services. In this way health care, a traditional prerogative of the nation state, has become a focal point ofEU integration. One distinctive aspect of public national health care systems is that they are based on solidarity. Therefore any discussion of EU health care also needs to address the rather elusive concept of solidarity. A core question to be discussed in this context is whether it is accurate to assume that the nation state is the largest entity in which robust forms of solidarity are possible. The legal framework, in particular rights, whilst having an important role to play in this discussion can only provide a starting point in the analysis of this question. This thesis argues that the Court has applied consequentialism in its case law which made it easier for Member States to accept the supranational involvement in the sensitive area of health care. It will seek to tease out what might be regarded as Pareto and utilitarian influenced reasoning in the Court's case law which so far has been a crucial factor in developing EU health care law. A consequence of this approach is that it is primarily focused on national solidarity as the basis of EU health care. An alternative conceptual proposition would be deontology. The thesis discusses possible implications of such an approach; one being that supranational solidarity would become more prevalent in EU health care. Therefore it is necessary to study the relationship between the normatively desirable, and the factually possible ('ought' implies 'can'). In answering this question the thesis analyses whether we fmd different motivational factors between the national and the supranationallevel which may serve as an explanation for the fact that so far, the nation state seems to be the biggest entity in terms of robust solidarity.

Six Sigma is commonly applied and well established in the manufacturing sector, especially in the USA. Since the beginning of the 1990s several public administrations, particularly in the field of health care, have also been implementing Six Sigma. In Europe, public health care is very different from US health care in terms of organisation and its relationship with stakeholders. A specific Six Sigma model for European public health care is missing from the literature. In order to gain real advantages for such a health care system it is worth analysing, discussing and designing a possible dedicated model and comparing it with the manufacturing one. The idea of such a comparison has originated from the Italian public health care system. In fact the Italian health care sector has a mission and values, a culture, an organisation, strategies and processes that are often very different from the production sector. However, many of these differences can also be found in European public health care. As described in the first chapter, among the European systems there are fundamental common features that can justify a dedicated research. In order to achieve the aim, the thesis has been conducted in two stages. Although the thesis is primarily deductive, the first stage is typically inductive and the second one is deductive. A third minor stage based on qualitative-inductive methods helps to put the finishing touches to the proposed model by showing the differences from the manufacturing model and the features of the European system. The final model attempts to make new contributions to the literature by primarily bringing knowledge to the stakeholders in the academic field and secondarily to the practitioners. The main contribution is surely a roadmap for shaping a missing Six Sigma model for European public health care.

Health is a unique and intriguing sphere of European Union (EU) policy, not least of all because it has only been recognised as such for the last 15 years. From piecemeal origins in public health and occupational safety it underwent dramatic expansion as a result of exposure to free movement and internal market law in the 1990s. Now, in the aftermath of the economic crisis, it is entering another unprecedented era. As the focus of the European project has turned to fiscal sustainability and the strengthening of collective economic governance, health policy has been swept into frameworks designed for the oversight of macroeconomic policy and national expenditure. Crucially, these frameworks extend EU health influence into areas reserved in the founding treaties for exclusive national control. This thesis seeks to map the changing nature, scope and governance of EU health policy, contributing to the existing patchwork of literature and reviewing the prevailing narrative in light of the critical juncture now being faced. It draws on the theories of European integration, the Europeanisation framework and the more recent governance approaches to assess the continuing relevance of core themes – crisis politics, regulatory policy, the internal market, new modes of governance, and the role of the Court – in health policy development. Using six case studies and data from 41 interviews with experts, policy-makers and officials, it examines the catalysts, drivers and dynamics of health policy integration. It finds that as the actors and interests involved in health policy have proliferated, health issues have become increasingly politicised. Addressing the consequences of this trend, the thesis explores the growing dependence on, and progressive strengthening of, voluntarist governance, as well as the declining scope and influence of EU health policy. Finally, it reflects upon the future of health within a politicised European integration project.

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This Thesis is part of a wider programme of work being pursued by the Glasgow Centre for Population Health (GCPH) which is examining health outcomes in West Central Scotland and other post-industrial regions throughout Europe. Scotland‘s health has been improving since the industrial revolution but its position relative to improving trends within Europe has been deteriorating. This is recent, dating from the period since the Second World War and becoming more problematical over the past three decades. While deprivation is a fundamental determinant of health, in the case of Scotland (and particularly West Central Scotland (WCS)) it does not explain the entire extent of the higher levels of mortality. There is, of course, a well established link between deindustrialisation, deprivation and poor health. However, the unexplained additional mortality in Scotland and WCS (the Scottish Effect) compared to other similar post-industrial regions and the time scale of Scotland‘s worsening relative health status, require further investigation. Other research has examined this question using a range of well established public health principles and methods. This thesis adds to this understanding by providing a comparative analysis of the political and socioeconomic contexts for the observed mortality trends. Post-industrial change is discussed at three levels. These are (i) International regions – Eastern Europe and Western Europe (ii) Countries – Scotland within the UK is compared with two Eastern European (Poland and the Czech Republic) and two Western European (France and Germany) countries. (iii) Regions within countries that have been subject to deindustrialisation. Five post-industrial regions are investigated (West Central Scotland, The Ruhr, Germany, Nord Pas-de-Calais, France, Katowice, Poland and Northern Moravia, Czech Republic). These regions were selected because they are analogous in their experience of deindustrialisation but diverse in their political and socioeconomic histories. The main aim of the thesis is to determine what aspects of the political and socioeconomic context in WCS have diverged from comparable post-industrial regions of Europe and whether these might form the basis of potential explanations for the region‘s poor health record. Two methods were employed. First, a detailed narrative literature review was undertaken to examine political and socioeconomic change in the post-war period at the national level with a particular focus on policy responses to deindustrialisation. Second, case studies were conducted on the five regions listed above. These examined political and socioeconomic changes in each of the five regions in some detail using published data and a variety of literatures as source materials. In this way a rich but diverse picture of economic restructuring as a response to deindustrialisation emerged. Insights from the literature review and case studies were then brought together to formulate some conclusions about why health in WCS has suffered more adverse effects than in the other four regions. This thesis has shown that there was a broad correspondence between life expectancy and the socioeconomic/political success of states in Central East Europe and Western Europe during the 20th Century. When states prosper and their governments enjoy the confidence of the population, health improves. In all the countries covered in this analysis, deindustrialisation damaged health and slowed improvements in life expectancy (in some cases putting it into reverse). The institutional path dependencies and country-specific factors outlined in this thesis help to explain the divergence in policy responses and subsequent economic development that can be observed in each of the five regions and their parent countries. The five countries and regions have each taken a different approach to deindustrialisation, have varied in the levels of social protection provided and each manifests a very different context. In response to economic restructuring (and associated social costs), policy in WCS (and the UK) has focused primarily on narrow economic growth policies, emphasising employment and physical regeneration, but not social outcomes such as community cohesion and sustainability.

Background: Low socioeconomic position throughout the life course is associated with a number of adverse health outcomes in older people. However, whether life course socioeconomic position influences subjective outcomes in early old age, such as quality of life, is not well known. There is a lack of life course research that considers the wider structural determinants of health. In particular, it is not well understood if the association between life course socioeconomic position and quality of life is the same across European societies that have differing welfare state arrangements. This thesis addressed two key aims: (1) Investigate whether, and how, life course socioeconomic position influences the quality of life of Europeans in early old age. (2) Examine differences in this relationship by welfare regime. Methods: Two methodological approaches were taken to address the research objectives: (1) A systematic review of quantitative studies examining the influence of life course socioeconomic position on quality of life was conducted, with a narrative synthesis. (2) An empirical analysis was carried out examining the influence of life course socioeconomic position on the quality of life of individuals in early old age, as measured by CASP-12 and life satisfaction. This used secondary data from 13 European countries (representing Southern, Scandinavian, Post-communist, and Bismarckian welfare regimes) that were part of Wave 2 of the Survey of Health, Ageing, and Retirement in Europe (SHARE) and SHARELIFE, which collected retrospective life histories of respondents. Two statistical techniques were used to analyse the data: multilevel modelling and path analysis. Slope indices of inequality were calculated to enable measures of socioeconomic position to be compared. Results: The systematic review identified 12 relevant studies, which varied in terms of the outcomes examined, study quality, and populations. No studies were identified from Bismarckian or Post-communist welfare regimes, with most containing populations from the Scandinavian or Liberal regime types. Some supportive evidence was found for a latent effect of low childhood socioeconomic position on quality of life among women. Social mobility models were generally not supported. High quality studies addressing inter-generational mobility were lacking and few studies examined cumulative and pathway effects. Results from the analysis using SHARE suggested that the most proximal measures of socioeconomic position were the strongest predictors of quality of life. In most welfare regimes, inequalities in quality of life were largest by current wealth, but among women in the Southern and Post-communist regimes inequalities by education level were particularly large. In the Scandinavian regime there were very small differences in quality of life between the least and most educated. Generally, there was little difference in the magnitude of socioeconomic inequalities in quality of life between Scandinavian and Bismarckian regimes. Support for a latent effect on quality of life was lacking, using most measures of childhood socioeconomic position. The findings from both the multilevel models and path analysis supported the pathway theory whereby childhood socioeconomic position chiefly influenced quality of life through later socioeconomic experiences. However, the number of books in childhood exhibited a weak association with quality of life even when taking into account current measures of socioeconomic position, suggesting a small latent effect for this measure. When stratifying by welfare regime, the potential direct effect from the number of books in childhood was specific to particular welfare regimes and genders. A greater number of socioeconomically advantaged positions over the life course was associated with higher quality of life in early old age, but the results suggested this was mainly due to the influence of socioeconomic advantage during adulthood. The association between life course socioeconomic position (as measured by a cumulative socioeconomic advantage score) and quality of life was weaker in the Scandinavian regime and stronger in Southern and Post-communist regimes. Including a measure of current financial distress greatly attenuated these associations. There was generally a lack of supportive evidence for an effect of social mobility on quality of life. Conclusions: Socioeconomic inequalities in quality of life were apparent in all welfare regimes and were largest by more proximal measures of socioeconomic position. Overall, Scandinavian and Bismarckian welfare regimes exhibited both higher quality of life and narrower inequalities in quality of life, compared to Southern and Post-communist regimes. Interventions to reduce socioeconomic inequalities across the life course are needed, but those which buffer the effect of financial distress in early old age may be particularly beneficial for improving quality of life and producing a more equitable distribution.