David Hunter's new book is at one level a critical analysis of big issues in health policy, and at another it is an old-fashioned tale of heroes and villains. The principal heroes are Robert Alford and Richard Sennett, eminent social scientists whom Hunter invokes at regular intervals in support of his critique of New Labour's health reforms. To Alford he owes the idea that in health care there are structural interests, as distinct from interest groups, whose power explains the dynamics of change (or often inertia) in health care systems. The medical profession is the dominant structural interest and, although its position has been challenged by politicians and managers, it remains a major player in the health debate.
To Sennett, Hunter owes his analysis of the decline in trust in British politics, driven by a government that has absorbed the consumerist ethic and hyperactively piled reform on reform. One of the consequences has been to undermine craftsmanship in professional practice by subjugating doctors and others to targets and regulations unprecedented in the history of the NHS. Although there have been some benefits for patients, as Hunter himself acknowledges, the overall effect has been to alienate many members of the medical profession from the policies that have been pursued. The power of doctors within the NHS, pace Alford, has also meant the partial implementation of top-down reforms.
Hunter's villains fall into two camps. The first comprises the global firms of management consultants who have earned large fees from and exerted considerable influence over NHS reform. The actions of these consultants helped to fuel hyperactive policy making and encouraged politicians to follow the latest fads and fashions.
In the second camp there are the special advisers brought in to work with Ministers in the development of health policy. At this point, I should declare an interest as someone who was involved in health policy making in the period covered by this book, albeit as a temporary civil servant rather than a special adviser. Hunter directs his criticism mainly at Simon Stevens, Paul Corrigan and Julian Le Grand for promoting market-based reforms when the evidence for using choice and competition in public services like the NHS is weak. Pulling no punches, he argues that ‘Policy makers have chosen to surround themselves with a particular group of like-minded advisers and consultants who seem to have attended the same pro-marketisation, pro-choice and pro-competition finishing school and who seem to have no real understanding of how complex systems operate or should be managed’ (p. 199).
Having developed his critique at some length, Hunter sketches out an alternative approach. Sensitive to the accusation that he might be seen to be arguing for some lost mythical golden age in the history of the NHS, he restates the purpose of public services in the twenty-first century, and asserts a need to reengage doctors and other clinicians as co-producers in health care. In so doing, he makes it clear that this does not mean leaving clinicians alone to practise as they see fit.
Rather, he envisages a future in which professional autonomy is balanced by transparent accountability and where patients as well as clinicians are co-producers of care. He also argues for the ‘systematisation of clinical work’ (p. 193) and for greater emphasis on team working. Hunter claims that his favoured approach amounts to ‘an alternative “third way”’ (p. 190) of reform that rejects both benign producerism on the one hand and marketisation on the other. It is at this point that he draws heavily on Sennett's account of craftsmanship to emphasise the need to work with clinicians in improving the performance of the NHS, and of seeing them as part of the solution rather than part of the problem. There are loud echoes here of the final report of the NHS Next Stage Review, led by former health minister, Lord Darzi, that independently arrives at similar conclusions.
Whether or not the reader agrees with Hunter's position, he offers a thoughtful assessment of recent NHS reforms that is more balanced and insightful than many of those produced by New Labour's critics. He is on weaker ground in offering an alternative approach, as this is described in bare outline in the final chapter. While Hunter takes Julian Le Grand to task for failing to work through the detail of how markets might bring benefits to health care, he is vulnerable to the same criticism in setting out his own ideas only at the highest of levels. He also fails to reconcile the potentially contradictory implications of the analyses offered by his heroes. If, as Alford argues, the dominance of doctors acts as a block to change, how can the insights of Sennett's craftsmanship perspective be acted on to achieve the greater consistency in clinical work Hunter argues for when this is likely to challenge medical autonomy?
The Health Debate concludes with a heartfelt plea for policy makers to turn to different advisers ‘with different ideals, values and capabilities’, but the ideas served up here amount to little more than an appetiser with the main course nowhere in sight. In the hard graft of NHS reform, the biggest challenge is to develop policies that offer the prospect of improvement while avoiding the unintended and unwanted consequences that often arise in turning around public services. Policy analysts, whatever their persuasion, need to find a way of combining reflective critiques of the kind Hunter succeeds in advancing, with well thought through alternative positions. These positions have to recognise the inherent difficulties of improving complex organisations like the NHS, and the lack of any single or simple solutions. In a world of heroes and villains, there also need to be pragmatists able to live with complexity and choose between finely different shades of grey rather than bold and contrasting primary colours.
It is to be hoped that Hunter can be persuaded to return to these issues in the future to explain at greater length what his third way entails and how it might be converted into a practical programme of change.
