The political economy of health care (Second Edition)
Where the NHS came from and where it could lead

Author/Editor(s):

Julian Tudor Hart

Format:

Paperback, 336 pages, 234 x 156 mm

ISBN

9781847427823

Published:

01 Sep 2010

Series:

Health and Society series

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North America customers can order this book here from the University of Chicago Press.

"...deeply practical...heart-warmingly optimistic."
Helen Roberts in Public Health Today

"This book is a masterpiece -- a unique combination of fascinating history, top-notch epidemiological science, sharp political analysis, and clinical insight. Scholar and practitioner, both, Julian Tudor Hart's understanding of how we can best pursue health in our communities is second to none."
Donald M. Berwick, MD

"This is a must-read for all who are interested in healthcare, and who are concerned to protect the fundamental values on which our healthcare system is based at the same time as maximising the potential of new developments."
Professor Dame June Clark, ex-President of the Royal College of Nursing, and member of the Wales Assembly Government Bevan Commission on the future of the NHS in Wales

"At a time when governments across the world seem ever more determined to expose health services to commercialisation and market forces, Julian Tudor Hart's analysis, insight and wisdom have never been more needed."
Dr Iona Heath, President, Royal College of General Practitioners

About This Book

With a foreword by Tony Benn. Drawing on clinical experience dating from the birth of the NHS in 1948, Julian Tudor Hart, a politically active GP in a Welsh coal mining community, charts the progress of the NHS from its 19th century origins in workers' mutual aid societies, to its current forced return to the market. His starting point is a detailed analysis of how clinical decisions are made. He explores the changing social relationships in the NHS as a gift economy, how these may be affected by reducing care to commodity status, and the new directions they might take if the NHS resumed progress independently from the market. This new edition of this bestselling book has been entirely rewritten with two new chapters, and includes new material on resistance to that world-wide process. The essential principle in the book is that patients need to develop as active citizens and co-producers of health gain in a humanising society and the author's aim is to promote it wherever people recognise that pursuit of profit may be a brake on rational progress.

Author Biography

Dr Julian Tudor Hart was born of medical parents in 1927. His teenage ambition was to become a general practitioner serving a coal mining community developing practical ideas for a future socialist society. After five years as a GP in North Kensington he worked under two famous epidemiologists, Richard Doll and Archie Cochrane. Returning to general practice in a South Wales valley community, he combined clinical work with epidemiological research led by his wife Mary and supported by the Medical Research Council. He has published four previous books and many papers in peer-reviewed journals, visited many countries as a lecturer or visiting professor, and served as an elected member of the Council of the Royal College of General Practitioners. He is an Honorary Fellow of four Universities, a former president of the UK Socialist Health Association, and now president of the SHA in Wales. 

Contents

Foreword by Tony Benn
Preface to the second edition
The NHS as wealth production
What does it produce?
How does it produce?
Generalists and specialists
Ownership: Justice and solidarity
A space in which to learn
Notes and references

ReviewsOwn it? Review it!

The political economy of health care (Second Edition)
At a time, in 2011, when a new government is embarking on perhaps the most radical surgery of the NHS since it's birth, this is a time for wise counsel and for those who know the system best to offer guidance. Whilst other scholars have pointed to the some of the problems that have occurred with the drive towards commercialisation in the NHS ( such as Allyson Pollock, in her fine book NHS plc - the privatisation of our health care), Julian Tudor Hart is uniquely qualified to offer the 'long view' of the this cherished organisation. In this book, the Octogenarian Tudor Hart ,who has witnessed the whole life time of the NHS and has spent much of that time working as a general practitioner and researching community health, distills decades of observation and practice into a treatise which is both passionate and scholarly.

In his widely read book the Gift, Lewis Hyde gives an account of the research he conducted whilst trying to understand his own struggle to survive, in a largely commercialised world, as an artist. He examines the many benefits of gift economies in a range of settings across wide spans of history and geography. It has become fashionable to criticise the sort of gift economy that has characterised the operation of the NHS. One of Tudor Hart's central themes relates to the benefits and efficiencies of this type of economy in health care systems. He provides a sound argument, together with a good deal of evidence, to support his thesis and a stern and thorough rebuttal to the usual criticisms.

The current government talks about unlocking the potential of clinical staff and reducing the dead hand of state bureaucracy. Yet this may be a sleight of hand since the very market reforms that they wish to continue to pursue within the NHS increase administration and there is precious little evidence that, in the long run they improve the motivation of staff. As Tudor Hart notes, where people are paid reasonably well, the values of solidarity and altruism may be far more efficient drivers for health care staff than extra monetary gain. With the coalition government accelerating the process, which started in Thatcher years, of converting the gift economy of the NHS into a market economy, I think that anyone would be hard pushed to find a more articulate and robust defence of that NHS system than appears between the covers of this book.

It would be easy to suggest that this defence of the NHS against commercial forces is simply an ideological one, based on the author's attachment to unfashionable socialist principles. However, those who suggest that the market is sovereign and that the application of it's rational efficiency to the NHS can only be beneficial, are to some extent hoist by their own petard. As the author shows convincingly, in purely economic terms, applying market principles to health care systems makes for a very inefficient method of delivering health care to a population. The huge US health industry provides many examples of such inefficiencies, which the author makes good use of to illustrate the point.

One of the major policy shifts in social care in recent years, which is now being tested in health care, is that of personal budgets. The drivers for this are something of a hybrid between grass roots activism and policy driven commercialisation. Advocates suggest that personal budgets can deliver a wide range of benefits, beyond the obvious ones of choice and control. Whilst it is true that many individuals might benefit in striking ways from this initiative in the short term, Tudor Hart reminds us that being truly patient focussed means also being population focussed and taking a collective and long term view of the production of health gain. As a community health practitioner who studied with some of the great epidemiologists, including Richard Doll, and who applied the lessons learned in daily general practice for several decades, we would be foolish to ignore the conclusions that this author reaches about caring for the health of populations and the different ways in which patients can be more involved in health care decision making.

It is striking that both Tudor Hart, and advocates of the creation of health and social care markets for consumers with personal budgets, talk about patients as co-producers of health. They have very different suggestions as to what this means in practice. Only time will tell who is right on this score.

The Political Economy of Health Care elegantly demonstrates how the NHS is one of the finest examples of collective action that Britain has produced. The public remain deeply aware and deeply committed to the nature and value of this institution. It in no surprise then that three quarters of those surveyed are against the reforms of the NHS which are being pushed through in 2011.

This a lucid, readable, rigorous and persuasive book that should be required reading for all who work in the NHS, and in private health care, and certainly for policy makers. Students of many disciplines will benefit from the wisdom within it's pages, and I would suggest that this is particularly true for those studying health economics.

References
Pollock A ( 2004) NHS Plc The Privatisation of our health care Verso
Hyde L (1983) The Gift Random House


Reviewed by Jim Rogers

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