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Reviews / Comptes Rendus
| Allyson Pollock with Colin Leys, David Price, David Rowland, and Shamini Gnani, NHS plc: The Privatisation of Our Health Care (London: Verso 2004)
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| POLLOCK PULLS no punches: there is a disaster unfolding in the National Health Service [NHS] of epic proportions. With its pro-business stance the New Labour government has pursued a programme of radical marketization set in train by the Conservative administration of the early 1980s. The outcome has been the systematic undermining of its founding principles of comprehensiveness, universality, and equity of care. At the time of writing this review in early 2006, controversy surrounds proposals to turn primary care trusts (the work of general practitioners) away from the provision of care and towards the commissioning of care. If these changes go ahead, traditional core services such as district nursing (providing care in non-hospital settings, such as patients' homes), family planning, maternity care, and cervical screening could be contracted out or privatized. The Secretary of State for Health believes that the government has substantially won the argument about the use of the private sector to treat NHS patients and announced that the time is ripe to increase the pace of reform. The market imperative in health care continues apace. The critical issues raised by Pollock are therefore as relevant today as they were two years ago when the book was published. |
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There has been a divergence in health policy in the UK following political devolution of Scotland and Wales. The book focuses on England which is seen as fast becoming the "laboratory and test bed for market-driven experiments." It is concerned with health care at the system level, not the experience of patients or those working in the NHS, and concentrates on three areas: hospitals, primary care, and long-term care for older people. By recording what is happening in the NHS, Pollock aspires to convince politicians and policy-makers of the need to reassess current policy and re-establish a commitment to universal health care by replacing the ethos of individualism and competition with collectivism and compassion. The crux of her argument is that the founding principles of comprehensive, universal, and equitable care were secured effectively through the integration of funding and service delivery; that is, when no money changed hands. The internal market of the 1990s severed this link and made treatment dependent on the ability of the purchaser (initially general practitioner budget holders, currently primary care trust commissioners) to pay. Rather than look to more politically contentious solutions to financial problems, such as the privatizing of funding periodically proposed by other political parties, New Labour has so far concentrated on the privatization of provision. Pollock argues that it has sought to convince the public of the rightness of its ideologically driven pro-business policies by a twin approach of denigrating the NHS by likening it to a Stalinist bureaucratic monolith and touting the superiority of the market under the guise of patient choice. |
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The market was stimulated by the Private Finance Initiative [PFI, now called public-private-partnerships or PPPs]. PFI permits consortia of bankers, builders, and service operators to raise money on the government's behalf and, in return for a contract, to design and build hospitals and other facilities, and operate support services for a 30-year period. Responsibility for paying back the debt and interest to shareholders rests with the hospital out of its operating budget for patient care. Pollock emphasizes the damage that is wrought as hospitals seek to resolve the affordability problems that arise from meeting PFI payments by making new hospitals smaller, reducing beds, and reducing service provision. The NHS, with its current. £80 billion turnover and wide range of activities, is a fertile ground for companies seeking to make a profit. This has been stimulated by the recent extension of PFI to clinical services. The involvement of foreign companies, which have for some time sought access to the NHS pot, has been facilitated by negotiations within world trade organizations in the General Agreement on Trade in Services [GATS]. |
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Pollock identifies the first NHS Foundation Hospitals (in 2004) as a "drastic further step towards a fully marketised system." To all intents and purposes they are the nail in the coffin of the NHS. Foundation hospitals are outside of Department of Health control. Their nonprofit- making status is in name only since they are free to enter into contracts with the private sector which can charge fees and distribute profits to shareholders. Pollock predicts that availability of services to patients will be secondary to financial viability and growth. Unglamorous and costly care, such as mental health and refugee health, is highly likely to be cut back. |
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The book is well written and easy to follow, even for those unfamiliar with the NHS. Pollock's analysis of the source of the current problems facing the NHS is adept but not without controversy. The trenchant criticism of the market imperative rests on the strongly held opinion that the NHS was neither an experiment nor a mythical utopia which, for more than 50 years, delivered high-quality care on the basis of need to "most patients most of the time." In Pollock's view, the so-called "affordability problem" that prompted the public discontent that politicians have been so ready to exploit to the ends of privatization, could have been averted if the NHS had been funded on the scale of other EU health systems from the start. Others will undoubtedly maintain that the NHS has become a bottomless economic pit that no amount of funding can fill. Pollock's political broad sweep focus on "financial starvation" of the NHS leads her to demur from considering other nonmarket reforms in any detail. Attention is therefore directed far more to the diagnosis of the problem — and it is this that Pollock does very well — than to future solutions. The book ends with a plea for all concerned to wake up and fully appreciate how grim the situation really is, before Britain's National Health Service becomes indistinguishable from the US health care industry. Objections have certainly been heard in recent years. For example, a House of Commons health select committee of MPs has recently (early 2006) produced a highly critical report on the proposed reforms of primary care, which it describes as incoherent and confusing. But to date objections like this have been piecemeal, sporadic, and short-lived. It therefore remains to be seen whether Pollock's wake-up call will be heeded or if it is too late to turn back the clock. |
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Ellen Annandale
University of Leicester |
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