<i>The Politics of Healthcare in Britain</i> ‐ by Harrison, S. and McDonald, R

Harrison, S. and McDonald, R. The Politics of Healthcare in Britain . London : Sage 2008 ix+206pp ISBN 9780761941606 (pbk) Health policy is back in vogue if the number of new books on the subject is any guide. Perhaps the constant churn in health system reform, both in the UK and elsewhere, is responsible for the sudden rash of texts although the downside of such welcome interest is the difficulty facing academics and publishers of keeping up with the constant changes. The UK National Health Service has been undergoing major restructuring since the mid 1970s although over the past decade the pace of change has quickened and there have been more reorganisations than at any other time in its 60 year history. What makes this book more durable than many is its strong theoretical basis and historical perspective. The authors correctly observe that many excellent health policy texts are weak on theory and it is a deficit they set out to tackle through an eclectic approach which draws on concepts and theories from political science, sociology and economics. The authors are very clear that they are writing a textbook in which they hope to stimulate the reader and generate questions. They therefore avoid offering any conclusions or speculations about how they see health policy unfolding in future, although the final chapter does suggest that issues around consumerism and evidence-based medicine, the growing divergence in health policy across the UK, and choice and health inequalities are likely to dominate the discourse. It is a reasonable assumption. At the same time, many of the policy conflicts and confusions described in the book seem destined to remain features of health policy for some time to come. Indeed, they go to the heart of why health is so intensely political and will remain so. In the famous words of Rudolf Virchow, the 18th century pathologist turned anthropologist, and quoted by Harrison and McDonald, ‘medicine is a social science, and politics nothing else but medicine on a large scale’. The book is structured around a set of key themes, many of which the authors (particularly Harrison who is a seasoned and respected health services researcher and health policy analyst) have written about extensively in previous published work. The historical perspective evident in the accounts presented of each theme is a key feature of the book, especially when it sometimes seems as if history ended in 1997. The themes covered are: resources and rationing, health professionalism, clinical knowledge and evidence-based medicine, organisation and management, democracy and participation, and healthcare policy-making. A final chapter takes the form of three case studies whose purpose is to illustrate the interaction between themes. The substantive chapters, 1 to 6, are well worth close study and contain a considerable amount of useful information and important insights. A short review cannot do justice to them but a couple of chapters merit comment. The chapter on health professionalism examines the challenges to medical dominance that have been a particular feature of health policy and health systems reform over the past 20 years or so. As the authors note, initial outright resistance to management and regulation was replaced by ‘unenthusiastic compliance’ which, in turn, has given way to ‘more active compliance’ as a result in large part of new contracts that provide financial rewards for compliance. Yet, despite assaults on the medical profession's freedoms, the strong bias towards a biomedical model of health and illness remains intact and has not been subjected to any serious challenge. As govermment adviser, Derek Wanless, noted in both his influential reports in 2002 and 2004, the NHS remains unhealthily wedded to acute inpatient care and hospital beds. He favoured much greater emphasis on upstream interventions to keep people well and out of care. His call, though not a new one, has been embraced by government but the imbalance between health and health care remains. How far the ‘countervailing powers’ to tackle what are perceived to be the unacceptable excesses of medical dominance are likely to go before the pendulum starts to swing back as part of what Harrison and McDonald refer to as ‘the ebb and flow of politics’, or what might alternatively be termed path dependency, is a timely question to pose. The Darzi report on the future of the NHS appeared too late for inclusion in the authors’ analysis but it is seen by many as marking a turning point in medical-state politics. Darzi, a world-renowned surgeon, was invited by the then new prime minister, Gordon Brown, to enter government as a junior minister and put the clinical voice at the heart of future NHS reform. His prescription reasserts the importance of clinical leadership and endeavours to reconnect clinicians with the reform agenda. Another impressive chapter reviews the organisation and management landscape in the NHS and charts the arrival of the market under the Conservative government in the early 1990s, its subsequent partial and temporary retreat in the early years of New Labour, and then its re-emergence simultaneously with the injection of substantial new resources into the NHS. Nevertheless, the question remains why a Labour government should so boldly pursue policies that were opposed by its own supporters and of which its political opponents would have been proud. Three possible explanations are offered. The first suggests it was an example of New Labour's pragmatism and a demonstration of the ease with which it was able to jettison ideological baggage that had shackled previous Labour governments. The second takes up the New Public Management theme to which governments in many countries have been enthral since the 1990s. NPM entails the application of business-type practices and disciplines to public organisations. The third explanation is linked to the grip of globalisation and its particular neo-liberal bias. The authors conclude that it is not possible to determine which of these approaches has the greatest explanatory power. It may be that elements of all three apply and there are certainly overlaps between them. But of one thing Harrison and McDonald are convinced, namely, that the creation of a healthcare market may be difficult to reverse since those interests it spawns will become vociferous and influential advocates for its retention and further expansion. As the Canadian economist, Bob Evans, famously remarked about the inability to reform US healthcare, ‘once the genie is out of the bottle it is impossible to put it back in again’. Paradoxically, as the authors note, it was the parlous financial state of hospitals which led to their nationalisation in 1948. Sixty years later, it was the financial meltdown in the banking sector that has led to the virtual nationalisation of several major banks. One effect of the economic collapse might be a slowing down or reversal of the marketisation of the English NHS. The authors also pose a frequently asked question – why is the NHS forever being reorganised? They believe that political considerations play a part since reorganisation is immediate, visible and has high impact value. It also affords endless opportunities for ‘symbolic policy making’ or gesture politics which in a media driven age is not an insignificant consideration. If the book has a weakness it is the absence of an extended discussion of health, as distinct from ill-health. It puts in a brief appearance here and there but is not given the detailed or sustained treatment it deserves. Of course, as the authors acknowledge, it is not possible to cover every issue and other texts fill the gaps. However, if there is a key conundrum in contemporary health policy, and the politics of health more generally, it is the tension between keeping people well and out of health care services on the one hand while at the same time ensuring that the growing burden of disease is managed through effective health care services. Resolving this tension is possibly the major challenge facing policy-makers yet it receives scant attention here. Moreover, in acknowledging the omission, the authors are perhaps guilty of reinforcing the very biomedical model which they claim has received little serious challenge. Coincidentally, and quite unintended, an error in the book makes the point rather well. NICE is referred to throughout as the National Institute for Clinical Excellence but since 2005 it has been known as the National Institute for Health and Clinical Excellence in recognition of its expanded remit to include public health alongside clinical care. The casual observer could be forgiven for thinking little had changed especially when to all intents and purposes NICE remains NICE (with not merely a silent but also an invisible ‘H’). But they would be wrong. The change is potentially significant and has important implications for the way NICE conducts its business in future. It is now charged with reviewing the effectiveness of interventions that embrace the whole person and their journey from primary health prevention through to tertiary care. Indeed, NICE is attempting to do what the NHS itself has so far failed to achieve which is to bring together the domains of public health and health care to form an integrated whole system. But this flaw should not deter potential readers. The book is highly recommended, ably demonstrating the value and importance of a political analysis of health policy.

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