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<p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt;
font-family:Arial'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt;
font-family:Arial'><o:p> </o:p></span></font></p>
<p class=MsoNormal><b><font size=5 face="Times New Roman"><span lang=EN-GB
style='font-size:16.0pt;font-weight:bold'>Political economy from a clinical
perspective.<o:p></o:p></span></font></b></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'><o:p> </o:p></span></font></p>
<p class=MsoNormal><b><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt;font-weight:bold'>Julian Tudor Hart: The political
economy of health care. A clinical perspective. <st1:place w:st="on"><st1:City
w:st="on">Bristol</st1:City></st1:place>: Policy Press 2006.<o:p></o:p></span></font></b></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'>Julian Tudor Hart is a retired General Practitioner
who has worked in the mining districts of <st1:place w:st="on"><st1:country-region
w:st="on">Wales</st1:country-region></st1:place> 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. <o:p></o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'>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 <st1:place w:st="on"><st1:country-region
w:st="on">UK</st1:country-region></st1:place>, 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. <o:p></o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'>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%.<o:p></o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'>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 <st1:place w:st="on"><st1:country-region
w:st="on">US</st1:country-region></st1:place>. This sight is far from
impressive.<o:p></o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'>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.<o:p></o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'>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. <o:p></o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'>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.<o:p></o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'>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).<o:p></o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'>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. <o:p></o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'>If somebody still chooses not to read the book, I
would recommend the author’s website, which is well worth visiting:: <a
href="http://www.juliantudorhart.org/">www.juliantudorhart.org</a><o:p></o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'> <o:p></o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'><o:p> </o:p></span></font></p>
<p class=MsoNormal><i><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt;font-style:italic'>Anders Jeppsson<o:p></o:p></span></font></i></p>
<p class=MsoNormal><i><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt;font-style:italic'>Senior Health Adviser<o:p></o:p></span></font></i></p>
<p class=MsoNormal><i><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt;font-style:italic'>Ministry of Health and Social
Welfare<o:p></o:p></span></font></i></p>
<p class=MsoNormal><i><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt;font-style:italic'>Dar-es-<st1:place w:st="on"><st1:City
w:st="on">Salaam</st1:City>, <st1:country-region w:st="on">Tanzania</st1:country-region></st1:place><o:p></o:p></span></font></i></p>
<p class=MsoNormal><i><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt;font-style:italic'>Email: anders@hspstz.org<o:p></o:p></span></font></i></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'><o:p> </o:p></span></font></p>
<p class=MsoNormal><b><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt;font-weight:bold'>References<o:p></o:p></span></font></b></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'>1. Hart, JT (1971) The inverse care law. <i><span
style='font-style:italic'>Lancet </span></i>vol 2, pp 405-12.<o:p></o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'>2. Hart, JT (1992) Rule of halves: implications for
underdiagnosis and dropout for future workload and prescribing costs in primary
care. <i><span style='font-style:italic'>British Journal of General Practice</span></i>,
vol 42, pp 116-19.<o:p></o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span lang=EN-GB
style='font-size:12.0pt'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size:
12.0pt'><o:p> </o:p></span></font></p>
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