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This is the second of six related articles, commencing with a 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.

The NHS Review: The need for a critical Sociological Analysis

Gareth Williams and Jonathan Gabe

Originally published in MSN Volume 14, Issue 3, August 1989

David Marsland (Medical Sociology News, April 1989) is right to say that medical sociologists need to develop a critical analysis of existing health care arrangements. In most other respects, however, his advice seems to us to be woefully wide off the mark. His assessment of the substance of the Government’s review of the NHS, Working for Patients, provides little more than an additional gloss upon a document that is glossy enough already and can perhaps be treated as just an exercise in apologetics. However, in passing, Marsland attempts to prescribe what a proper sociological analysis should do and to develop a characterization of recent developments in medical sociology. We would like to make a few comments about these matters before taking up some specific points he makes about the White Paper.

Marsland makes much of the need for dispassionate study and objective evaluation, viewing most criticism of the White Paper as little more than ‘an unthinking chorus of condemnation’. Yet his own commentary is replete with value judgements about ‘the Government’s modest and cautious proposals’, ‘the supremely pragmatic Minister’, ‘a large-scale “mutiny” among GPs’, and ‘our excellent doctors and nurses’ (the last two being illustrative, respectively, of just the ‘hysterical critique’ and ‘craven flattery’ for which he lambastes medical sociology!). how do such statements square with his commitment t value-freedom? Although it may be difficult for a long-time devotee of Talcott Parsons to grasp (Ramazanoglu, 1987), the value-laden language reflects the inescapable ethical and political underpinnings of any sociological and political underpinnings of any sociological analysis. Marsland should come clean and acknowledge his strong attachment to the neo-conservative ideology informing the Review.

Marsland’s criticisms of medical sociology are blunted by his somewhat eccentric reading of the history of the subject. What evidence is there, in the history of medical sociology, of ‘the persisting influence … of work such as Navarro’s? And on what basis can he argue that the discipline has ignored the interests of patients as consumers? It seems to us that both these claims are false. Indeed, Marsland’s claim can be inverted. What is striking about the history of medical sociology in Britain, in contract to the United States, is the absence of an avowedly Marxist perspective on health care and the popularity and influence of studies of patients’ views of different aspects of the health service – the studies of Stimson and Webb, Cartwright and her colleagues, and Jefferys and Sachs are just some of those that spring immediately to mind.

In relation to the White Paper itself, Marsland develops two main points first; that the Review should not be seen as a prelude to privatization (we have Kenneth Clarke’s assurances on this, after all); and secondly, that many of the proposals offer the possibility of real improvement in the quality of health care delivery to the mass of ordinary people. These points are then examined, or at least reiterated, in relation to the major initiatives proposed in the White Paper. Let us look at a few of them.

Marsland believes that under the new proposals that health authorities will become more professional and efficient and less political. This is a curious interpretation of a document which, in response to the perception that District Health Authorities are ‘neither truly representative nor management bodies’ (Working for Patients, p64), proposes to eliminate elected representatives altogether! How can a system in which the Secretary of State ultimately determines the composition of health authorities at both regional and district level be seen as a reduction of ‘political interference in health care management’? Moreover, it is hardly surprising that many GPs are sceptical of the Government’s claims to be working for patients when the proposals specify that the number of GP appointees to Family Practitioner Committees be reduced to just one, with no obligation to include among the five lay members representatives from the local community. As for the patients, it is unlikely that Community Health Councils (CHCs) will adequately reflect the needs of ‘consumers’ when they are given no place on decision-making bodies and, for all his expressions of concern for the consumer. Marsland seems to have ignored the criticism that consumers’ representatives themselves have produced in response to the Review (e.g Gaffin, 1989).

Looking at the opportunities presented by the proposals for hospitals to become self-governing, Marsland maintains that this is nothing to do with privatization and that local services will be protected – though he provides no arguments to support these contentions. By what mechanisms will the health care needs of local communities be assured? Surely once a hospital opts out of the control of the District Health Authority (albeit remaining within the ambit of the NHS, and begins to enter into contracts for the services it offers, the only way in which core services will be protected for the local population will be through the introduction of cumbersome regulation procedures (Paton 1989). It is unlikely that the new profitable trusts will be happy to do this and it therefore increases the probability of a move to full privatization, with any non-market obligation to the local community being abandoned altogether.

Marsland also claims that the cash limits proposed for GPs will have major benefits for patients in terms of improved quality of service, but he fails to ask, ‘for which patients’? It is likely that fixed budgets for larger practices, together with the proposal to increase the proportion of practice income derived from capitation, may act as an economic disincentive to the enrolment of those categories of patient (e.g the elderly) who have the greatest health care needs. Any attempt to identify in advance high risk categories of patient and adjust the capitation fee paid accordingly is fraught with difficulty, as Flemming (1988) has demonstrated with regard to the current capitation fee structure.

These points cast doubt upon Marsland’s grasp of the significance of key proposals in specific areas. But there is a more general intellectual lacuna. Marsland takes at face value concepts of efficiency, consumer preference and value for money, reflecting not at all upon either the complex meanings of the terms, or the structural realities which they purportedly describe. The fact is that the use of these terms signals a shift in the whole system to one geared to buying and selling, with cost reduction coming before the treatment of patients; and such a structural shift will act to destabilize the NHS (Robinson 1989). This will benefit the acute rather than the chronic sick, the wealthy rather than the poor and the hospital rather than the community; benefits which, on any ‘objective’ analysis of present and future health care requirements, is just what our society does not need. How, and for the benefit of whom, will an internal market resolve the problematical decisions of internal resource allocation? It will certainly not benefit, for example, the elderly person with arthritis (Haslock 1989).

Whatever the Secretary of State says, the reforms set in motion a process of change which will enable the NHS to be dismantled when the opportunity presents itself (Petchey 1989): a conclusion reinforced by the record of the present Government in other areas of economic and social policy. Marsland argues, with touching innocence, that serious reform always involves risks and costs. But who decides the level of risk and upon whom the risks are to be foisted? These are questions about political power which any critical sociological appraisal of the NGS Review has to ask. Marsland would have us assess the Government’s intentions for the NHS by taking their proposals item by item, on their merits. What kind of sociological analysis is that? It makes no sense to look at their proposals for the NHS out of relation to the wider strategy upon which Mrs Thatcher has been engaged – with some tactical variation – for almost a decade. This is not a form of ‘hysteria’, but an attempt to understand specific policies in the wider economic, political and ideological context. Such policies are part of a coherent attempt to move from a mixed to a market-orientated economy. This has involved an assault on the power of the professions such as medicine, along with a sophisticated attempt to reconstruct the ideological terrain so as to emphasise personal responsibility for health. Seeing the NHS Review in this context leads us to believe that Kenneth Clarke is involved in duplicity.

We do not castigate Marsland for holding his particular beliefs or values, but feel it is beholden on him to be more reflexive about the way in which they inform his writing. This sensitivity is a necessary component of a critical mode of sociological analysis. For our part, we have offered a perspective on the Review which draws on a different tradition within sociology – one which acknowledges the need for health policy to be examined within the wider context of economy, politics and ideology, confronts the reality of structured inequality and power relations and their consequences for health policy, and is wedded to the notion that health care provision should be equitable.

July 1989

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Fleming, D. 1988. The case for different capitation fees based on age in British general practice, British Medical Journal 297: 966-968.
Gaffin, J. 1989.
White Paper on the NHS – working for patients: the Arthritis Care response. London: Arthritis Care.
Haslock, I. 1989. Working for patients? (Editorial),
British Journal of Rheumatology 28: 185-186.
Paton, C. 1989. NHS White Paper (letter),
The Lancet, 1: 558-559.
Petchey, R. 1989. The politics of destabilization,
Critical Social Policy 25: 82-97.
Ramazanoglu, C. 1987. Reply to David Marsland,
Network 37: 5.
Robinson, R. 1989. Self-governing hospitals,
British Medical Journal 298: 819-823.

Next: 'Reform of Reaction in Health Care?' by Professor David Marsland