Books & Electronic Media
Interdisciplinary perspectives on health policy and practice competing interests or complementary interpretations?
Jane Robinson, Mark Avis, Joanna Latimer, & Michael Traynor.
Published by Churchill Livingstone, Edinburgh, 1999, 220 pages, £19.95, ISBN 0-443-05992-6.
After examining the effects of the reform of the National Health System (NHS) in the United Kingdom, Jane Robinson analyses the evolution of WHO and World Bank policies over the last half century. Those of WHO were founded on notions of social justice and equity, while those of the World Bank were utilitarian and guided by calculations of the relative efficiency of the different means of providing health care. She describes how the policies of the two organizations are today, in her view, converging.
Mark Avis then discusses the idea of need in relation to health. He opts for a determination of objective human needs by means of rational dialogue, and pleads for the broadest possible social consensus. He then cogently summarizes three notions of social justice and the right to care: the utilitarian, the egalitarian and the libertarian. In doing so he returns the discussion to the familiar ground of the ethics of fairness and resource allocation.
Michael Traynor carried out a series of interviews in the 1990s when the internal market system was being introduced into the NHS and general practitioners became fundholders. Analysing the discourse of those trying to make the new system work, he draws attention to the language of the new managerialism, and its preoccupation with measuring things. Making common cause with a growing band of dissidents, he draws attention to the pitfall of supposing that quantifiable data alone are important. In this connection, he notes the fallacious tendency to make meaningful synonymous with numbers. Traynor then goes on to examine the language of nursing during this period of NHS reform, showing how nurses constantly negotiate between the discourses of caring on the one hand and exploitation on the other.
Joanna Latimer describes the sets of interests that prevail in the health care system. She shows how the attitudes of doctors and nurses have changed in the course of the NHS reform, the major emphasis being now on throughput and pressure to discharge patients rapidly.
She regrets the loss of the communal dimension in relations between patients and health professionals. This is a real and important concern but there is a need for closer scrutiny of the respective roles of acute and long-term care and social services. Despite the desire for health services to be as comprehensive as possible, it is hard to see how to avoid specialization in practice. Acute care is necessarily more clinical (notwithstanding the need for it to be humane), whereas care that is mainly social has to consist more in assistance and accompaniment. Latimer sometimes tends to oversimplify this problem. In the following chapter she describes how nurses adopt judgemental and directive attitudes towards patients, and draws attention to the growing division of labour between hospital and primary care.
The themes of this book are highly relevant to current issues of health care systems, the more so now that various managed care experiments undertaken in the United States over the last 20 years are being closely examined and criticized. There is a growing concern that the financial interests of health professionals and shareholders may take precedence over the goal of delivering the best and most comprehensive care possible to patients. Overlooking the fact that the laws of the market apply imperfectly to health, the Americans have drifted towards practices that are wholly commercial. In the name of neoliberalism a quarter of the population is either without health insurance or only very inadequately covered. Where the United Kingdom is concerned, it has to be recognized that 20 years ago the NHS was inefficient and in need of a shake-up. The authors show how health professionals, especially nurses, made moral judgements about the managerial effort involved, claiming that their vocation was to serve patients, and that this was not reducible to quantified parameters. They describe how perceptions of the NHS changed from seeing it as a church to seeing it as a garage.
The importance of the civil and political context cannot be underestimated. The USA has gone too far down the path of commercialization and trade, seriously neglecting social equity in the name of an ideology that is unsuited to health care. In the United Kingdom, the values associated with the civil service, social justice and the availability of care regardless of social status (even if it involves queues and rationing) have made the NHS reform measures unpopular, however necessary they may have been. As always, the best (or least unsatisfactory) solution lies somewhere in the middle: scrupulous efforts to ensure access for all to quality care, balanced by effective and efficient health care services. The managerial claim to moral neutrality is groundless.
The outside observer is left with the impression that our British colleagues have too vigorously resisted some of the changes required by their health care system. But their resistance is inspired by ethical values to which too little consideration is given nowadays. The authors make an intelligent critique of their countrys health services which is well written, pleasant to read, and highly stimulating. As they would no doubt agree, their commitment to the values of the NHS entails a certain degree of partiality. It is easy to endorse the bulk of their concerns about the risk of excessive technicality and managerialism in health care, leading to a loss of empathy and an undermining of professional prerogatives. At the same time, however, health professionals are in no position to reject outright the demands placed upon them for efficiency, relevance and accountability.
Interdisciplinary perspectives deserves the attention of all health professionals, administrators and politicians who are concerned by the evolution of organizations and of professional attitudes. Although it deals mainly with the NHS, it provides a basis for valuable comparisons. All health systems in their different ways face the same central question, even in the richest parts of the world: how to reconcile limited resources with proliferating technological possibilities and virtually unlimited demand.
Jean Martin
Chief Cantonal Medical Officer
Public Health Service of the Canton of Vaud
1014 Lausanne
Switzerland