Health Education Research, Vol. 14, No. 6, 831-832,
December 1999
© 1999 Oxford University Press
Book Review |
Who Cares? The Great British Health Debate
Principal Lecturer, School of Applied Social Science, University of Brighton
Oliver Morgan is a journalist and states that his book is `intended to be read by anyone who reads a newspaper of whatever shape or size'. Not only is it addressed to an extensive lay readership but the author also hopes to provide a `readable and stimulating account for health professionals.'
The focus, as with a number of recent publications, is the 50th anniversary of the NHS, which is seen as an appropriate moment to take stock and look forward to the next 50 years. Oliver Morgan claims that the NHS is `trapped in the past', identifying a number of fundamental problems. These include the dominance of the medical model of health and of the medical profession, subordination of managers, deafness of the system to its users, lack of information and clarity, requirements to both ration and to hide rationing, and the inflexibility of health care provided through hospitals. The rest of the book then discusses these issues chapter by chapter coming to the conclusion that little advance has been made in the last decade and arguing for a shift in the mind set about what the public should expect from doctors.
One of the strengths of this book from the perspective of the lay reader is its robust and lucid style honed in the newspaper article rather than the academic text book. NHS managers' approach to waiting lists, for example, is summarized as `managers who wanted knighthood's got them down, those who didn't got the sack'. The debates on key issues are also enlivened by the use of `in boxes' quotes from leading academics and professionals such as Stephen Dorrell and Peter Griffiths on the NHS market and Sandy Macarra on medical accountability, and also from GPs and local NHS managers talking about the local implications of putting policies into practice.
In researching the book, Oliver Morgan has canvassed a range of opinion referring to market enthusiasts such as the Institute of Economic Affairs but also quoting from the Institute of Public Policy Research. A lively style does not imply a simplistic approach. Morgan recognizes the complexity of the headline issues he is discussing, e.g. he acknowledges that the notion of `infinite demand is controversial', that clinical input is necessary to `avoid the tyranny of evidence' and that `we must learn to reconcile the irreconcilable including duty to the individual and duty to the community'.
The issues tackled undoubtedly reflect the high profile controversial themes that have been the focus of media debates in the last few years, but is this really the Great NHS Debate? No one would deny the importance of medical dominance and the relationship between consultants and patients or that the NHS is hospital dominated but nine-tenths of doctor–patient encounters take place in primary care. There is comparatively little reference to primary care in this book other than to GP fundholding. In the initial chapter Morgan states that `unfortunately' he does not deal with the problems of mental illness or care in the community. He does not explain why, but given the title some explanation would seem appropriate. Does he believe that nobody cares about these issues or that it is only what the newspapers want to talk about that is important?
Fundamentally this book is about an `illness' not a `health' debate. Morgan acknowledges that the NHS developed as a National Medical Service but there is no reference to the emerging `New Public Health' agenda or the potential role of health promotion in the brave new world of the 21st century. Although Morgan is rightly critical of medically dominated hospital focused health care, he himself focuses exclusively on this aspect of the NHS. His book serves to perpetuate the notion that this is all the Great Health Debate is and even should be about.
In part the narrowness of vision in Morgan's book reflects a blinkered approach to his chosen themes. The author has researched specified key issues. Relying on secondary sources he has grasped the main debates, and reproduced them in a clear and lively fashion, but the reader has little sense of a broad understanding of the wider context. For example, although there are several references to relationships between the NHS and the private sector there is no mention of the Private Finance Initiative (PFI), while the discussions of medical dominance and potential conflict between medics and managers make no reference to the changing roles of other health care professionals such as nurses and new initiatives such as the nurse practitioner. The presentation of hard data is minimal, interview quotes largely substituting for charts and tables.
While there are memorable sound bites there are other places where journalistic gimmicks do not come off. The presentation in the introduction of a hypothetical daughter born in 1998 for whom Morgan postulates a high technology NHS 50 years on disappears from sight to be referred to only briefly on p. 183. Nowhere is there any real attempt to assess the likelihood that this initial vision of an automated NHS will come to pass so the point of constructing such a model tends to be lost.
It is the misfortune of all authors to find that the world has moved on by the time their book gets into print. The NHS more than most aspects of contemporary British life has been subject to a series of major reforms in recent years. While Morgan down plays Labour's reforms arguing that the `noise of reform is symptomatic of a lack of change', the short postscripts to a number of the chapters do not sufficiently address the potential impact of the `New' NHS. There are brief references to the National Institute for Clinical Excellence (NICE) and the Commission for Health Improvement (CHI) in the context of evidence-based medicine, for example, but there is no reference to the process of clinical governance which has considerable potential to shift the agenda. Likewise there is scant mention of Primary Care Groups (PCGs) set to become the hub of the new NHS and no mention of Health Improvement Programmes (HImPs). This dates the work and limits its future relevance.
Although the book has limitations, however, the fact that it is written from a lay perspective is its main strength. Acknowledging the exclusion of lay people from NHS debates in the past, it argues persuasively for `voice' as well as `choice ` and like the Citizens' Jury concept which it enthusiastically espouses has the potential to enhance informed debate but it is probably more likely to appeal to the reader of The Guardian or The Independent than The Sun!
Notes
Oliver Morgan, Radcliffe Medical Press, Abingdon, 1998, 240 pp. ISBN 1-85775-243-0
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