New Labour’s State of Health: Political Economy, Public Policy and the NHS

Book Reviews

New Labour’s State of Health: Political Economy, Public Policy and the NHS

Calum Paton

ISBN: 978-0-754645-13-9 2006 174 pages Ashgate Publishing

Angela Glasner

The National Health Service (NHS) in the UK has often been held up as a touchstone for publicly funded, free (at the point of delivery) healthcare for all citizens, based on need rather than ability to pay. Launched in July 1948 as a single organisation based around 14 regional hospital boards, it was originally split into three parts: hospital services; family doctors, dentists, opticians and pharmacists; and local authority health services, including community nursing and health visiting. Since 1948 there have been huge changes to both the organisational structure of the NHS and the way patient services are provided, and the last decade is acknowledged to have been one of unprecedented change. It is no longer a national service, with political devolution to the principalities of Wales, Scotland and Northern Ireland, making for very different experiences at the point of delivery. Even within England, the development of new regional structures makes delivery a differential experience. Calum Paton's latest monograph sets out to track the recent politics and policies that have given shape to a NHS which he describes as ‘in crisis'.

Paton is Professor of Health Policy and Director of the Centre for Health Planning and Management at Keele University in the UK, and was, from 2000-2006, chair of the University Hospital of North Staffordshire NHS Trust. He has, thus, both an academic interest in the health service and a practical, political experience as a part of the service itself. He has published extensively on health policy in general and the NHS in particular. This latest monograph is, as its subtitle suggests, an examination of the crisis of the NHS from the perspectives of political economy and public policy. His thesis is broadly that the crisis in the NHS - its state of ‘ill-health' - is a product of poor ‘new Labour' ideology and a post-modernist search for political radicalism. It is, unsurprisingly, a highly politicised account. As Paton indicates in the preface, the book has grown from theoretical work on political economy and health services into a synthesis of political economy (part 1), public policy (part 2), and New Labour's record in terms of the legitimacy and sustainability of its reforms and initiatives in the NHS (part 3).

The first part, ‘Political Economy', discusses economic and political regimes, predominantly in the UK, and examines the impact of post-fordism on the health services. Here Paton outlines his view that political economy is a major determining factor explaining health policy. The British context cannot be understood outside of global capitalism and reflects the balance between private sector and public sector. That the NHS is more efficient than private alternatives is, for Paton, not the issue. The key point is how the ‘three legs' upon which the NHS stool needs to balance - reducing health inequality, investing in and supporting the national economy, and pleasing health-wise and tax-wise middle England - can be kept in harmony. The paradox for the NHS is that is has to become so efficient by comparison with alternatives, including the private sector, that citizens prioritising lower taxes above welfare would still buy into it economically as well as culturally.

The second part, ‘Public Policy', has as its central focus the shape of UK public policy under the Labour governments of the last ten years, with a particular, but not exclusive emphasis, on health policy. Here Paton's deep opposition to the interventions of the Blair government into the NHS are apparent. He harnesses the ‘garbage can' metaphor used by Cohn et al (1972) to refer to a non-rational - if not arbitrary - decision-making process in organisations: when it is perceived that there is an opportunity for influencing or making decision ie, when a ‘decision point' is emerging for whatever reason, everyone with an interest in the process brings along their baggage, or ‘garbage'. The decision which emerges from the ‘can' is not ‘rational'. He identifies four major planks of health policy between 1997 and 2006, all pulling in different directions. Some, but not all, are capable of being reconciled. His discussion in this section aims to demonstrate how politics has affected the policies which have shaped the crisis in the NHS.

The final section, ‘The NHS', addresses the changes experienced under the Labour administration of Tony Blair. Here his aim is to present a ‘view from the bunker rather than from the bridge'. Paton does this by examining four ideas: the primary care bias (primary care is good and hospital care is bad); the pursuit of decentralisation; the pursuit of private management; and finally the biggest idea of them all, choice and markets, which gets a chapter of its own.

There are occasional international comparisons, with Europe and the United States predominantly, but the book neither sets out to, nor does it provide, an adequate comparative analysis. Its target audience is the post-graduate academic community, and it is likely of interest to those wanting to understand better the complexities of the English Health Service during the past fifteen or so years. The style presents as a very readable primer, reminiscent of a series of published lectures with the characteristic clear structure and repetition of points made, but this is misleading. In reality it has a complex conceptual framework and a substantial grounding, often not spelt out, in a body of previous literature and previous debates. It is highly topical and easy reading for health policy, health management and policy analysts in general, and provides a provocative analysis of government policy, shaped implicitly, if not explicitly, by Paton's own experiences as chair of a Trust which experienced severe financial and management challenges. Paton continues to hold the view that health policy in England is primarily led by ideological factors and the challenge for the future is the reconciliation of political ideology with that of the medical profession and the public.

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