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This is the first of six related articles, commencing with this piece by Professor Marsland in MSN Volume 14, Issue 2 in April 1989, and concluding with his report in MSN Volume 19, Issue 1 in December 1993, which are published here, together, for the first time.

Progress in Health Care: A Sociological Appreciation of The NHS Review and its potential benefits

Professor David Marsland

Department of Health and Paramedical Studies
West London Institute of Higher Education, UK

Originally published in MSN Volume 14, Issue 2, April 1989

Reactions to the NHS Review seem so far to be wearisomely predictable. The opposition parties in Parliament‚ their media allies‚ the left en bloc‚ the health unions from the BMA downwards‚ and orthodox opinion in the social sciences have condemned it in its entirety. One might be forgiven for thinking that the Review were recommending an equivalent to Dean Swift's ironically intended final solution to the Irish problem - eating babies. One might imagine to judge from the self-righteous hysteria provoked in the health establishment by the Government’s modest and cautious proposals that the NHS were beyond improvement‚ and as unimpeachably sanctified by history and tradition and Magna Carta.

Challenges to this chorus of negativism have so far been few and far between. One interesting and important exception‚ however‚ was provided by Chris Ham of the King's Fund Institute, writing - where else - in “Marxism Today" (March, 1989). Headlined "
Kenneth Clarke: far reaching and imaginative proposals", he rejects opposition allegations that the Review is a prelude to privatization‚ and suggests that introduction of incentives for doctors and hospitals will produce services which are more responsive to patients. "In tandem"‚ he says‚ 'competition between providers will be used to stimulate greater efficiency in the use of resources". He counsels a "discriminating response" by "those on the left"‚ and argues that “outright rejection of the White Paper would be both wrong and a missed opportunity". While advising of possible dangers‚ he provides what is unambiguously a positive evaluation of the Review overall‚ admitting weaknesses in the NHS which have for too long been irresponsibly denied‚ and urging solutions to these problems along the broad lines recommended in the Review. Thus:

"The NHS clearly has a number of weaknesses that need to be tackled, including a lack of responsiveness to patients‚ the wasteful use of resources‚ and the lack of accountability of doctors. Where the Government’s proposals offer the prospect of addressing these problems, they should be welcomed“.

I would broadly agree with this analysis‚ which finds further support in a new study of consumer preferences by Peter Saunders and Colin Harris ("Popular Attitudes to State Welfare Services", Social Affairs Unit, 1989). I would seriously advise colleagues involved in research and policy analysis in the health sphere to reflect carefully on the deficiencies in existing health care arrangements and the scope provided by the Review for real improvements in the quality of service offered to the mass of ordinary people before they join the unthinking chorus of condemnation. It goes without saying that serious reform - any serious reform - always involves risks‚ always imposes costs‚ and usually leads to at least some major mistakes which will need correcting. But without serious reform we face in health‚ as in every other sphere, stagnation and decay.

Reviewing the Review

There seems to be eight major topics in the reforms proposed by the Review. I shall briefly comment on each of these separately‚ indicating the major lines of criticism and the counter-arguments. In this I shall limit myself to practical and policy considerations.
In each case I shall add some further specifically sociological observations designed to open up technical debate among readers of this journal. In this aspect of my analysis I am drawing in part on the critique of orthodox modern British sociology which I have presented in my book “Seeds of Bankruptcy' (Claridge Press‚ 1988) and elsewhere.
For Medical Sociology seems to me at least as much prone as other sub-fields of the discipline to fundamental errors in theory and methodology. In the sphere of health‚ sociological errors and confusions have produced a contradictory mixture of hysterical critique and craven flattery of existing health care institutions. Perhaps the Review will provide the opportunity for Medical Sociology to review itself and thus to amend and strengthen its analysis.

Self-governing hospitals

The Review proposes the establishment of NHS Hospitals Trusts which will allow major hospitals to become self-governing. Criticisms are of three kinds. First the danger of self-government becoming privatised independence; secondly the risk that local provision of essential services may be threatened; and thirdly the challenge posed to supposedly essential large-scale planning. On the first‚ the Review and the Government are clear and firm: no privatisation is intended. Similarly the Review unambiguously guarantees that essential local services will be protected. The third criticism goes to the heart of this first proposal. The basic assumption underlying it - which I find entirely persuasive - is that bureaucratic planning has failed‚ and proved itself thoroughly counter-productive. Major hospitals need the freedom and flexibility which only self-government can offer if they are to serve the complex‚ changing needs of patients well.

The sociological issues posed by this first proposal - how to optimise effectiveness in complex organisations‚ how to provide coherent services while avoiding bureaucracy‚ how to provide for planning without impeding initiative are all standard themes in general sociology‚ but somehow curiously neglected in recent medical sociology.

Re-structured health authorities

The role of the health authorities will be substantially changed by the Review‘s proposals concerning self-government, funding‚ management‚ and family doctors. There was in any case much dissatisfaction‚ internal and external‚ with their operation even before the Review was contemplated. It seems a little curious therefore to find critics rushing to the defence of the RHAs.

The proposed changes are intended to make them more professional and more efficient‚ and to reduce politicisation. All of these are surely proper and sensible objectives‚ likely to be resisted only by those with a vested interest in political interference in health care management.
For sociologists extremely interesting and important issues are raised about the relations in a democracy between the central state, the local state, organised labour (particular professional labour)‚ and specialised institutions and their senior managements. Querulous one-sided complaints about centralization hardly seem a plausible approach to investigating such complex issues with the dispassionate care they call for.

Flexible funding

RAWP and its associated elaborate formulae and procedures are to be replaced by simpler methods of resource allocation and an internal market. This seems to me potentially one of the most radical proposals in the Review. Critics object mainly in terms of "thin end of the wedge” argument about markets‚ and out of what looks to me very simple prejudice against any serious use of monetary criteria in welfare services.

On the issues involved sociologists
ought to be capable of providing useful guidance. In any large-scale organization - and the NHS in as big us any - internal resource allocation decisions are inherently problematic. The choice - which commonly turns into arbitrary oscillation between de-centralised competitive procedures and authoritarian centralised systems regularly turns out to be a "Devil and the deep blue sea" scenario. An internal market‚ recognising real cost‚ profit, and efficiency centres, perhaps offers a way through this deep-seated dilemma.

Modern management

The Review heavily emphasises the need for improved management capable of providing value for money and handling the more complex tasks posed by the other proposed reforms efficiently. The over-bureaucratised structure currently in place in to be streamlined to allow local management "to get on with the task of managing".

In the main‚ criticisms have focused on the supposed threats to union pay negotiating strength. Of course these anxieties must be attended to, but in principle there seems to be no reason why more localized authority‚ including even pay flexibility should not be advantageous to the majority of health service personnel. And in broad terms - in which for once sociologists might concur with the man and woman in the street - it is surely desirable to make a serious effort at reducing bureaucratic over-management and giving managers at all levels the discretion they need to do their essential job well?

More consultants

At least one proposal in the Review which should escape criticism in for a significant increase in the number of consultants. This should at the same time reduce waiting lists and improve career prospects for junior doctors. However‚ alongside this increase in resources‚ the Review promises a new and more effective form of medical audit‚ confidential and peer-controlled, but nevertheless seriously equipped with teeth.

This whole package‚ which also includes reform of merit awards‚ seems to me sensible and overdue. It acknowledges consultants’ crucial importance and indispensable value‚ while at the same time seeking to limit any possible abuse of their considerable power.

Medical sociology has tended by and large simply to treat senior doctors an villain-chieftains of the so-called "medical model“. Perhaps we may now hope to see more careful attention to the real complexities of the work and careers of specialist senior medics?

Healthcare at the front line

As I write‚ a large-scale "mutiny' among GPs in the face of the Review’s proposals is brewing. This is predictable and understandable. At first blush the main thrust of the Review is to set cash limits and require GPS to pay more attention to their costs than has been usual.

However‚ it seems to me a short-sighted reaction. The Review acknowledges generously the key role of family doctors in health care which is likely to increase still further as the emphasis shifts from treatment to prevention and health promotion. Larger practices are to have their own budgets and the capacity to spend it on the patient’s behalf wherever they can get the best deal in terms of quality and price. Savings can be ploughed back into improvements in the practice.

This redresses the balance between doctors and hospitals significantly. At the same time these proposals are likely to reduce drug prescribing - a change which nearly everyone concerned about health care has been pressing for.

No doubt some doctors will be anxious about their capacity to handle their new freedom and responsibility‚ and critics have argued that attention to budgets will distract doctors from quality care. There
may be need for some adjustments to this segment of the Review’s reform proposals. But this has been anticipated from the start by the - supremely pragmatic - Minister, and in seems to me equally likely that the pay-off to patients in terms of improved quality of service will be higher from this part of the reform proposals than from any other.

Hopefully sociologists will be joining actively in careful‚ objective evaluation of the consequences for patients.

Patients first

The whole Review is focused on improving the quality of care and service for patients. It is a health consumers' charter. More specifically the Review calls - not before time – for appointments systems, improved waiting rooms and family facilities‚ information about facilities and services, better complaints procedures‚ etcetera.

All this seems to me absolutely commendable. One of the gravest weaknesses of the NHS has been the tendency for patients' interests as consumers to be ignored. Even a state monopoly is after all a monopoly. I find it surprising and disappointing that in general sociologists have done so little by way of acknowledgement and exploration of this serious deficiency.

Towards the future

The eighth and last aspect of the Review I shall deal with concerns the private sector. Here the left were anticipating a dreadful lurch away from basic NHS principles‚ while the right were sullenly resigned to their demands for a serious reconsideration of 1940s thinking being ignored altogether.

As it turns out‚ the Review Charts a moderate path which seems to have perplexed left and right alike. Tax relief on private insurance has been offered to the over-sixties‚ and various suggestions for collaborative partnership between the independent sector and the NHS have been proposed.

Of tax relief the Nursing Times (Vol. 85 No 6 February 1989) says plausibly enough that it "will generate enormous ideological debate‚ but in short and medium terms at least its direct effects are likely to be very limited". For sociologists the Review’s considered allegiance to the status quo in this ideological debate - that is to say a positive partnership between public and private, with the former substantially predominant - should provide an opportunity for more dispassionate and open-minded analysis of private sector provision than has been typical hitherto.

Even the most careful studies‚ such as Joan Higgins' "The Business of Health Care“ (Macmillan‚ 1986), have tended simply to presume that the private sector’s contribution to health care is unnecessary, regrettable‚ and overdue for termination. We might now show ourselves at least as pragmatic and open-minded as the Review‚ and assess the public/private balance on its merits.

Saunders and Harris conclude their analysis of popular attitudes to state welfare services as follows:

“If this analysis in correct‚ then the choice for those concerned with public policy is clear. They can attempt to suppress the growing demand for the right to exit from the state System, or they can start to restructure the system of state support so as to enable consumers to express their preferences effectively. State monopoly provision in kind is being rejected by increasing numbers of people‚ but the state still has an important role to play as a facilitator rather than a provider. Policy-makers would best be advised to work with the change that is coming by enabling people to purchase the services they want, rather than attempt to stand out against the tide”.

This tide in not to any substantial extent reflected in the White Paper, which largely concerns itself with improving the capacity of a better organised and more effectively managed NHS to provide good quality‚ value for money‚ care for patients. Not, however‚ does it exclude movement in a more liberal‚ less monopolistic‚ direction in the future‚ supposing popular demand were to shift as Saunders and Harris predict.

Perhaps sociologists will manage - despite the persisting influence in medical sociology of such work as Navarro's, and our tendency to treat the NHS as an index of welfarist virility rather than as a practical instrument for delivering certain important services effectively to achieve at least the White Paper’s level of honest pragmatism. What matters most‚ surely‚ is that our excellent doctors and nurses should have the administrative systems‚ management structures‚ and resources available to them which will allow them to give their patients the best of care.