This is likely to be a controversial and much discussed book. It will be very unpopular in the corridors of power, which alone should ensure a wide readership. Having last worked in the NHS in 1986 and suffered under the New Zealand health reforms of the 1990s, I shouldn't perhaps have been surprised by this book. I was, however, not just surprised but appalled at the facts and figures, which Professor Pollock has assembled to support her account of the disastrous privatisation of the NHS in recent decades. She describes in detail the ideological obsession of successive governments with the belief that the market will solve the problems created by decades of underfunding a system that once was the envy of the world. Her recurring thesis is that the involvement of private business in the private funding initiatives (PFIs) led inevitably to expensive, yet smaller, hospitals offering less comprehensive services. These reductions were exacerbated by the hospital trusts having to service the new, and massively increased, debt from their operating budgets. The efficiencies needed to achieve the necessary savings resulted in a cascade of more restricted services; an army of managers and accountants needed to track expenditure. Savings were made by casualising the nursing workforce, outsourcing ancillary services, and higher transaction costs led to further cuts … and so on.
The evidence presented seems almost too persuasive, so I was grateful for the opportunity to run the arguments past a senior Labour politician. The (somewhat defensive) response was that outcomes are what is important and the waiting time for a hip replacement in England is a quarter that for the same operation in Wales (which, apparently, has not embraced involvement with the private finance sector in the same way). Why is it that waiting times for elective surgery seem in the minds of politicians to be the only arbiter of quality and effectiveness? Something about grumpy constituents perhaps?
The professional bodies — in particular the British Medical Association — do not emerge with much credit in this sad story. Indeed, many in senior positions within the profession seem to have been complicit, or at least asleep, to the implications of what was going on. Professor Pollock pulls no punches in naming names and the huge salaries paid to those who have benefited most from the backdoor privatisation of the health service. The tactics employed by government to discredit the author and her unit bring little credit to the former and would, I am sure, merit greater publicity.
The section on the evolution and reform of general practice/primary care in recent decades is interesting, if too brief. The effect of the new contract is only superficially discussed, however the local improvement finance trust (LIFT) scheme rates a mention and is portrayed as the thin edge of the same privatisation wedge. Erstwhile, primary care fundholding enthusiasts should definitely read this account; perhaps they will have a different perspective on the last two decades?
This book is very readable, unsettling, and particularly persuasive. I would recommend it to all those with an interest in the future organisation and delivery of primary and secondary care in the UK, as well as those in countries that consistently follow UK policies, irrespective of the evidence. The reforms of recent times have been profound and, clearly, the way in which we have traditionally practised will never be the same again. Will the changes ultimately be better for the patients as end users and for the health professionals working in the system? Time will tell if the ‘efficiencies’ gained will outweigh the transaction and opportunity costs, and the fundamental shift from a professional to an accounting paradigm of medicine and of health care in general.
It is a great shame that policy makers insist on repeating, rather than learning from, the mistakes of others. Ideologically driven blind faith in the omnipotence of market principles remains the greatest threat to health systems worldwide — the more so in the UK as this heavy-handed, misguided evangelism seems to have infected both sides of the political divide.
All in all, definitely worth a read, but not late at night — it is too troubling.
- © British Journal of General Practice, 2004.