Who Cares? The Great British Health Debate

Citation

Goodwin, N. (1999), "Who Cares? The Great British Health Debate", Journal of Management in Medicine, Vol. 13 No. 2, pp. 219-220. https://doi.org/10.1108/jmm.1999.13.2.219.1

This is another book whose publication is timed to coincide with the NHS′s 50th anniversary. However, this book is different because it is written not by an academic or a former government insider but by an author and journalist. This has the advantage, as you might expect from someone whose profession is the use of words, of being very readable. Do not assume however that there has been little preparatory research because it is much in evidence; however the book is also differentiated by vignettes describing a number of issues and which are based on interviews with health service professionals.

The book is not a celebration of the NHS but a clearly written and thought provoking presentation about its future. As Morgan himself points out the book is not all embracing, for example it does not include issues around mental illness and care in the community. The book instead focuses on the main area of NHS activities, namely the primary and secondary sectors, management and politics and of course, consumers. Before launching into an analysis of the organisational and service ills of the NHS, which most commentators seem to link to the changes of the last two decades, there is a useful summary of the last 500 years of healthcare in the UK that Morgan calls “the five ages of healthcare”. As he rightly says it remains to be seen if consumers empowered with information and knowledge can challenge the self‐importance, mystery and mystique of the medical profession and whether they feel it is right for them to do so.

The chapter on the internal market tells us what we already know, namely that in reality there never was a market for health and healthcare and it was introduced by government to deflect attention away from unattractive economic reality. As Morgan says the market itself had to be managed, it was not allowed to develop significantly for the first two years and adjusting it ‐‐ via the emphases and predilections of successive ministers ‐‐ sent confusing signals to the service, which was endeavouring to make it work. There is an excellent four‐page critique of the 1997 Labour government′s policy for healthcare pointing out the contradictions between Labour′s public statements and the reality of its policy having quite a lot in common with that of the previous government. A pertinent point is that both the Labour and previous Conservative governments avoid directly addressing the level of funding issue. The chapter about doctors and their accountability is excellent, covering many of the questions we like to ask but are afraid the answers may be too confusing: consultants, their contracts and private practice; general management, managers and the control of doctors; and general practitioners and primary care. It is appropriately followed by discussion of issues around politics, the public and accountability to consumers.

The big issue of course to which most commentators return when discussing the UK NHS is funding, which in turn means addressing the demand for services. This also means discussing the issue that both excites health service professionals and generates fear in politicians, namely rationing. Morgan devotes almost half his book to these issues in a well presented and analytical way. Barriers to change are discussed including the medical profession itself, the use ‐‐ or non‐use of clinical audit and workforce inflexibility. Rationing is well covered but as Morgan says, “Just as there is increasing pressure to bring rationing out into the open, opposition to doing so is a strong as ever”. But this seems to sum up the approach to the NHS as a whole. There is the need to be clear about how decisions are taken and who is taking them; and there is the need for a sensible discussion about how future demands for health services are to be met. As the UK NHS embarks on yet another largely structural approach to addressing its operational and financial problems it is doing so, as Morgan points out, without a clear course and without a clear mandate from the public. The time for a fundamental debate on the future of the NHS has come but as Morgan intimates this is not for the first time.

The book will not find its way on to the shelves of serious health service policy academics but it was not written with that intention. It does fill however a very useful niche in that it should have wide appeal to those within health services who would like an appreciation and understanding of the last 50 years. It is also useful to those who would like to dip in to specific issues, possibly to gain an initial understanding before delving more deeply; and to those outside the UK who would like a short and readable historical perspective on the UK NHS.