PHA-Exchange> Interesting book on political economy from a clinical perspective

[Anders Jeppsson]

Political economy from a clinical perspective.

 

Julian Tudor Hart: The political economy of health care. A clinical
perspective. Bristol: Policy Press 2006.

 

 

Julian Tudor Hart is a retired General Practitioner who has worked in the
mining districts of Wales during his professional life. He is an atypical
representative of his profession in several ways. One feature is his
interest in community generated research, which has resulted in concepts
such as  "The inverse care law" [1], which means that the ones in most need
of health care gets the least, and vice versa. He has also formulated the
"The rule of halves" [2], which in principle means that half of all diseases
remain undetected ("half" refers to magnitude rather than  exactly 50%),
half of the detected diseases are untreated, and half of the treated
diseases are not controlled. 

 

Another of Hart's traits is, that he was one of the few medical students who
supported the creation of  the  National Health Service (NHS), at its
formation in 1948, and that he has remained a strong advocate of public
health care.  NHS was at its commencement extremely unpopular among the
medical community in the UK, and in particular among the British Medical
Association. The reason was that the doctors feared deteriorated working
conditions. The economic conditions from working with NHS were, however,
much better the conditions they had before, and NHS was accepted by the
doctors and loved by the people. Hart's book is advocating for a continued
public health care for all, and against Blair's attempts to dismantle NHS
and to sell it to the private market. 

 

In his book, Hart describes the background of the creation of NHS and its
history. Although NHS was relatively under-funded in the 1960s and 1970s, it
was still extremely efficient: The UK was under a long period of time the
OECD country with the lowest government allocation for health. Despite this,
the outcome was impressive: Equal health care for all, evenly distributed
throughout the country. The cost for administration was unbeatable:
Initially it was 2%, but increased to 6% when the conservative government
introduced the principles of "New Public Management". Since NHS became
subject to privatization and the introduction of internal markets, the
administration cost ahs risen to 12%.

 

One of Hart's points is that  public health care is cheap, partly because
the administration cost is low. He shows theoretically and practically why
this is the case. NHS was for a long period a 'gift economy' without any
need to cost the procedures. This is one of the myths of our time, that the
administration of the private sector is cheap and effective. For anyone
still believing in the myth, it should suffice by looking at the health care
system of the US. This sight is far from impressive.

 

Another of Hart's points is that the quality of care and patient safety is
considerably higher in the public sector compared to the private one,
despite the cream-skimming of the private sector.

 

But the book also goes into depth and addresses current economical theories,
where Hart argues that they are not only insufficient, but inadequate to
describe health care. 

One reason for this is that health care is not a commodity. All health care
begins with the consultation process, where the doctor (or any other health
staff) gets engaged in a 'creative negotiation' or, preferably, in a
'creative collaboration', which results in a clinical decision on how to
carry the process forward. This has nothing to do with consumption. It is
not commodity production and it is therefore not suited for the market.

 

Hart's book adds considerable value to the current debate on health policies
and the negative effect neoliberal policies on health systems of. Its
perspective is very different, since in starts in the community and in the
consultation process, and from there expands on a theory on how a public
health care system can be instrumental in improving the society (by
replacing neoliberal solutions).

 

I have serious difficulties to find good reasons not to read the book. Even
if it is well embedded in the British context, is also provides useful
information for us non-Brits. 

If somebody still chooses not to read the book, I would recommend the
author's website, which is well worth visiting:: www.juliantudorhart.org
<http://www.juliantudorhart.org/> 

 

 

Anders Jeppsson

Senior Health Adviser

Ministry of Health and Social Welfare

Dar-es-Salaam, Tanzania

Email: anders at hspstz.org

 

References

 

1. Hart, JT (1971) The inverse care law. Lancet vol 2, pp 405-12.

 

2. Hart, JT  (1992) Rule of halves: implications for underdiagnosis and
dropout for future workload and prescribing costs in primary care. British
Journal of General Practice, vol 42, pp 116-19.

 

 

 

 

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