- Email: [email protected]
A national health service? The restructuring of health care in Britain since 1979
based texts, they are of some interest to health geographers. In this instance, Ovretveit’s work is arguably more relevant, as the influence of geography is recognised. Moreover, the presentation of the book warrants praise-particularly the reiteration of the key points at the end of the chapter. In contrast, Ray Robinson’s largely superficial explanation of markets in health care seems to sit uneasily in a text that essentially details the mechanisms of the privatisation process. Although this edited book will be highly valued by economics and management students-the text traces the privatisation process from the drawing board to the policy, its value to health geographers is limited. Lee Redpath University of Portsmouth
Reference Moon, G. (1990), ‘Conceptions of Space and Community in British Health Poli‘, Social Science and Medicine, ?oMJ, No.1, pp. 165-171.
Society and Health: An Introduction to Social Science for Health Professionals G Moon and R Gillespie (eds) Routledge, London (1995) xiv + 265pp, indexes ISBN 0 415 11021 1 f3.5 hardback ISBN 0 415 11022X f9.99 paperback
It is now some years since the radical changes to pre-registration nursing and paramedical training, which brought the education of health care professionals, such as physiotheraptherapists and ists, occupational radiographers firmly within higher education. It is within that context that the publication of Society and Health is most timely. Whilst the past five years have seen the publication of a series of textbooks related to specific disciplines, such as sociology, Moon and Gillespie’s textbook covers a range of social science frameworks. Rather than cover each social science perspective separately, the different in68
sights are presented in an applied fashion. This can be a strength (in-so-far as health professionals find some academic subjects inaccessible if they fail to assist the practitioner in relating to his/her own practice). But it can also be a weakness, when students might flounder without recourse to the theoretical work underpinning the social science disciplines. However, in their textbook, Moon and Gillespie’s emphasis is upon the sociology of health care, with some attention to demography, history and geography, but very little overt recognition of psychology, philosophy and ethics, all of which have contributed to the debates within health care professional education during the past decade. The separation of the book into three parts was most appropriate; the Setting of Health and Health Care, highlights some of the social science components, but in a review for an environmental journal, it is worth noting that the spatial considerations are implicit, rather than explicit. However, for two target groups of practitioners-on common foundation programmes and those on shared learning courses for students in year one of professional study-this introductory text provides background material suitable for further development. But, for students wishing to identify issues at the interface of environment and health, the book is more problematic. Demography and epidemiology are given some attention, but it would have been valuable for some of the material on health inequalities (Chapter 12) to have followed Chapter 1. The second part of the textbook, Care in Actions will be much valued by trainee professionals. Behaviours within a caring context are identified at a variety of different levels. The material is both accessible and applied to areas of student interest. It would have been useful to integrate some areas of nursing research into this section. Any textbook that examines health policy in a current context must fall foul of the fast-changing world within which it is written-
there is little attention to GPs, fundholders, the internal market and, until the very last chapter, social service departments. Whilst in one sense this is excusable within a general textbook, any text seeking to integrate geographical perspectives, should identify potential spatial consequences of these recent changes to the health service. Students will benefit from the easy reading and succinct chapters. The use of shaded ‘concept boxes’ gives a brief resume of some major concepts and areas of attention by the authors. In conclusion, whilst geographical perspectives permeate parts of the text, they are given less attention than those of other social sciences. The student with a human geography background should be able to identify and apply the spatial perspectives. As a final anecdote, it may be no coincidence that many applied human geographers have found successful careers within both the health service and higher education for the caring professions. It is fitting, therefore, that social scientists, including a human geographer, have published this introductory text. Robin Talbot University College of St Martin, UK
A National Health Service? The Restructuring of Health Care in Britain since 1979
J. Mohan St. Martin’s Press New York; Macmillan, London (1995) xx + 287pp, indexes ISBN 0 333 57831 7 hardback ISBN 0 333 57832 5 paperback
This is an earnest book that documents the downsizing of the NHS under the Thatcher and Major governments during these past 17 years. It is bound to offend die hard conservatives as well as those on the Left wishing to explain restructuring as responses to post-Fordism, disorganised capital, or a Schumpeterian workfare state. The hollowing out of the welfare state would likely leave both Hayek and Marx dissatisfied. That is why Mohan argues that
Book reviews
the solutions for the NHS are not so simple, reflecting instead the complexities of British politics, local and national tensions, and the fickle nature of Britain’s ‘new’ health-care market. Nine substantive chapters and a thoughtful conclusion with the author’s alternative proposals constitute this book. A useful Appendix that chronicles the major developments in health and health care policy since 1979 serves as roadmarker both for readers who know the NHS saga well (but wish to see how Mohan structures his argument) and the novice. The book begins with an overview of provision and finance activity and key policy changes. It then presents a readable account of the changing nature of public services in Britain. Chapter 3 offers an assessment of Thatcherite political strategies for health care. With this background, Chapter 4 ‘grounds’ the discussion by reviewing the political geography of resource allocation by the NHS; terrain that Mohan knows well. This reviewer found Mohan at his best discussing the role and meaning of imagined and imaginary ‘communities’ (Chapter 5). US readers will not fail to see the parallels in the current decentralization and ‘states’ rights’ frenzy that leave state capitals with lots more power, but with far fewer dollars for ‘caring’ than in the past. Chapter 6 offers insights that could not have been made a few years ago about how incentives for the ‘new’ managers in the NHS are markedly different from before 1979. As the commercial health sector expands, the state adjusts to new consumerist forces (Chapter 7). Here and in Chapter 8 we can reflect on the new roles of charitable organisations in
the British sense of what George Bush termed the ‘thousand points of light’. To be sure, the boundaries between the NHS and private nonprofits are not always clear. Although the NHS has become more ‘flexible’ in delivering care, the reality of commercializing the NHS is driven home when Mohan concludes that: ‘increased commercial and charitable involvement in the NHS has not increased local control: those who have raised funds for hospitals have not been in the happy position of influencing health policy decisions, and hospital closures have been implemented despite the often considerable efforts of communities to keep them open. Active citizenship takes place on the state’s terms. . .’ (p. 193). Chapter 9 further explores this point. The author makes the case that decentralisation has had the unintended and contradictory outcome of having the government impose its authority on regional and local tiers of public administration. Whose national health service is it? The rhetorical and perhaps Orwellian response is that it belongs to everyone, though more to some than others. This reviewer would have liked to have seen more discussion of comparative social policy in other nations undergoing similar transformations. Instead, comparative Mohan’s framework draws on the works of Gough, Lash and Urry, and others whose examples are less grounded in health-policy outcomes and more contoured by the normative behavior of the welfare state. Mohan shows that conservatism is not monolithic; Thatcher’s penchant for cost cutting differs somewhat from Major’s concern over quality. Together, though, the NHS has pro-
duced a geography of uneven services and outcomes. Boundary disputes and market failures consume planning and policy deliberations in ways that those championing the dismantling of the welfare state probably had not envisioned. The NHS devotes more time to remedying the failures of the ‘invisible hand’ than anticipated. Hence, the NHS eases out of service provision only to slip into a new regulatory mode. It shuts down costly inner-city hospitals and then seeks out a more supportive rural and suburban electorate. Mohan garners ample evidence that a deregulated health-care labour market is incompatible with a truly national service. Privatizers now realize that subcontracting to private providers means retaining a compliant, full-time core of personnel that ultimately rely on an underpaid, part-time periphery. The patient must somehow remain afloat between these two shorelines. The alternative, Mohan tells us, is that inevitable outcomes of privatization mean that preventive health measures must be shouldered up in the community; a recommendation echoed by socialists and liberals in the USA (Turshen, 1988). The NHS can only place a limited number of proposals in the leaky policy dike before the rising inequality of care and outcomes flood the debate over the future of the NHS. Joseph L. Scarpaci Virginia Tech
Reference Turshen, M. (1988) The Politics ofPublic Health. Rutgers University Press, New Brunswick,
NJ.
69
Reference Moon, G. (1990), ‘Conceptions of Space and Community in British Health Poli‘, Social Science and Medicine, ?oMJ, No.1, pp. 165-171.
Society and Health: An Introduction to Social Science for Health Professionals G Moon and R Gillespie (eds) Routledge, London (1995) xiv + 265pp, indexes ISBN 0 415 11021 1 f3.5 hardback ISBN 0 415 11022X f9.99 paperback
It is now some years since the radical changes to pre-registration nursing and paramedical training, which brought the education of health care professionals, such as physiotheraptherapists and ists, occupational radiographers firmly within higher education. It is within that context that the publication of Society and Health is most timely. Whilst the past five years have seen the publication of a series of textbooks related to specific disciplines, such as sociology, Moon and Gillespie’s textbook covers a range of social science frameworks. Rather than cover each social science perspective separately, the different in68
sights are presented in an applied fashion. This can be a strength (in-so-far as health professionals find some academic subjects inaccessible if they fail to assist the practitioner in relating to his/her own practice). But it can also be a weakness, when students might flounder without recourse to the theoretical work underpinning the social science disciplines. However, in their textbook, Moon and Gillespie’s emphasis is upon the sociology of health care, with some attention to demography, history and geography, but very little overt recognition of psychology, philosophy and ethics, all of which have contributed to the debates within health care professional education during the past decade. The separation of the book into three parts was most appropriate; the Setting of Health and Health Care, highlights some of the social science components, but in a review for an environmental journal, it is worth noting that the spatial considerations are implicit, rather than explicit. However, for two target groups of practitioners-on common foundation programmes and those on shared learning courses for students in year one of professional study-this introductory text provides background material suitable for further development. But, for students wishing to identify issues at the interface of environment and health, the book is more problematic. Demography and epidemiology are given some attention, but it would have been valuable for some of the material on health inequalities (Chapter 12) to have followed Chapter 1. The second part of the textbook, Care in Actions will be much valued by trainee professionals. Behaviours within a caring context are identified at a variety of different levels. The material is both accessible and applied to areas of student interest. It would have been useful to integrate some areas of nursing research into this section. Any textbook that examines health policy in a current context must fall foul of the fast-changing world within which it is written-
there is little attention to GPs, fundholders, the internal market and, until the very last chapter, social service departments. Whilst in one sense this is excusable within a general textbook, any text seeking to integrate geographical perspectives, should identify potential spatial consequences of these recent changes to the health service. Students will benefit from the easy reading and succinct chapters. The use of shaded ‘concept boxes’ gives a brief resume of some major concepts and areas of attention by the authors. In conclusion, whilst geographical perspectives permeate parts of the text, they are given less attention than those of other social sciences. The student with a human geography background should be able to identify and apply the spatial perspectives. As a final anecdote, it may be no coincidence that many applied human geographers have found successful careers within both the health service and higher education for the caring professions. It is fitting, therefore, that social scientists, including a human geographer, have published this introductory text. Robin Talbot University College of St Martin, UK
A National Health Service? The Restructuring of Health Care in Britain since 1979
J. Mohan St. Martin’s Press New York; Macmillan, London (1995) xx + 287pp, indexes ISBN 0 333 57831 7 hardback ISBN 0 333 57832 5 paperback
This is an earnest book that documents the downsizing of the NHS under the Thatcher and Major governments during these past 17 years. It is bound to offend die hard conservatives as well as those on the Left wishing to explain restructuring as responses to post-Fordism, disorganised capital, or a Schumpeterian workfare state. The hollowing out of the welfare state would likely leave both Hayek and Marx dissatisfied. That is why Mohan argues that
Book reviews
the solutions for the NHS are not so simple, reflecting instead the complexities of British politics, local and national tensions, and the fickle nature of Britain’s ‘new’ health-care market. Nine substantive chapters and a thoughtful conclusion with the author’s alternative proposals constitute this book. A useful Appendix that chronicles the major developments in health and health care policy since 1979 serves as roadmarker both for readers who know the NHS saga well (but wish to see how Mohan structures his argument) and the novice. The book begins with an overview of provision and finance activity and key policy changes. It then presents a readable account of the changing nature of public services in Britain. Chapter 3 offers an assessment of Thatcherite political strategies for health care. With this background, Chapter 4 ‘grounds’ the discussion by reviewing the political geography of resource allocation by the NHS; terrain that Mohan knows well. This reviewer found Mohan at his best discussing the role and meaning of imagined and imaginary ‘communities’ (Chapter 5). US readers will not fail to see the parallels in the current decentralization and ‘states’ rights’ frenzy that leave state capitals with lots more power, but with far fewer dollars for ‘caring’ than in the past. Chapter 6 offers insights that could not have been made a few years ago about how incentives for the ‘new’ managers in the NHS are markedly different from before 1979. As the commercial health sector expands, the state adjusts to new consumerist forces (Chapter 7). Here and in Chapter 8 we can reflect on the new roles of charitable organisations in
the British sense of what George Bush termed the ‘thousand points of light’. To be sure, the boundaries between the NHS and private nonprofits are not always clear. Although the NHS has become more ‘flexible’ in delivering care, the reality of commercializing the NHS is driven home when Mohan concludes that: ‘increased commercial and charitable involvement in the NHS has not increased local control: those who have raised funds for hospitals have not been in the happy position of influencing health policy decisions, and hospital closures have been implemented despite the often considerable efforts of communities to keep them open. Active citizenship takes place on the state’s terms. . .’ (p. 193). Chapter 9 further explores this point. The author makes the case that decentralisation has had the unintended and contradictory outcome of having the government impose its authority on regional and local tiers of public administration. Whose national health service is it? The rhetorical and perhaps Orwellian response is that it belongs to everyone, though more to some than others. This reviewer would have liked to have seen more discussion of comparative social policy in other nations undergoing similar transformations. Instead, comparative Mohan’s framework draws on the works of Gough, Lash and Urry, and others whose examples are less grounded in health-policy outcomes and more contoured by the normative behavior of the welfare state. Mohan shows that conservatism is not monolithic; Thatcher’s penchant for cost cutting differs somewhat from Major’s concern over quality. Together, though, the NHS has pro-
duced a geography of uneven services and outcomes. Boundary disputes and market failures consume planning and policy deliberations in ways that those championing the dismantling of the welfare state probably had not envisioned. The NHS devotes more time to remedying the failures of the ‘invisible hand’ than anticipated. Hence, the NHS eases out of service provision only to slip into a new regulatory mode. It shuts down costly inner-city hospitals and then seeks out a more supportive rural and suburban electorate. Mohan garners ample evidence that a deregulated health-care labour market is incompatible with a truly national service. Privatizers now realize that subcontracting to private providers means retaining a compliant, full-time core of personnel that ultimately rely on an underpaid, part-time periphery. The patient must somehow remain afloat between these two shorelines. The alternative, Mohan tells us, is that inevitable outcomes of privatization mean that preventive health measures must be shouldered up in the community; a recommendation echoed by socialists and liberals in the USA (Turshen, 1988). The NHS can only place a limited number of proposals in the leaky policy dike before the rising inequality of care and outcomes flood the debate over the future of the NHS. Joseph L. Scarpaci Virginia Tech
Reference Turshen, M. (1988) The Politics ofPublic Health. Rutgers University Press, New Brunswick,
NJ.
69