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BMJ. 2007 May 12; 334(7601): 1007.
PMCID: PMC1867911

Why are so many doctors politically illiterate?

Reviewed by David J Hunter, professor of health policy and management, Durham University

The Political Economy of Health Care. Julian Tudor Hart. The Policy Press £14.99, pp 336. ISBN 10 1 86134 808 8. Rating: ***.

Julian Tudor Hart's latest book hauls New Labour's NHS reforms over the coals and laments the fact that so few doctors have the heart to fight back

Any reader who needs reminding of why the NHS was established should immediately seek out this book. Those familiar with Julian Tudor Hart's work will know him to be a passionate believer in the enduring values and principles of the NHS, which he calls a “gift economy.” In this book he takes government to task for embracing wholesale the “marketisation” of health care and for dismantling a unique public service. His critique is wide ranging and questions whether political parties in contemporary life are any longer capable of providing leadership towards a future that does not entail the subordination of public services to global markets and rapacious multinational companies.

Tudor Hart's purpose in writing the book is to provide a big picture for students of health and health care, so that they may appreciate the wider context in which they work. What he really wants to achieve is an end to the “political illiteracy of most doctors.” The only regret is that the book did not appear earlier, when it might have provided timely ammunition to those puzzled by, and angry with, what is happening to the NHS. It might have better equipped them to challenge the prevailing orthodoxy that has swept through the public sector in England with minimal opposition. Indeed, the book ends on precisely this note. If political parties are moribund and incapable of rising to the challenge then new coalitions must be assembled. In health policy, this means professionals becoming “politicised professions”—a conclusion that echoes the famous remark of Rudolf Virchow, the Prussian pathologist turned anthropologist, that “medicine is a social science and politics nothing but medicine on a grand scale.”

There are numerous memorable turns of phrase in Tudor Hart's robust and uncompromising prose. For example, the NHS replaced a world that “plotted and grabbed” with one that “planned and shared.” Only now are we returning to the world of plotters and grabbers—the “dog's dinner of public, private, and charity provision” which existed before 1948; so much for being modern and progressive. Elsewhere, he writes, “chains of command conveying central policies to peripheral communities and places of work have become chains around imagination.”

Tudor Hart demolishes many of the cherished myths and assumptions underlying the government's reform strategy. On choice of referral, he claims that there is no evidence of mass popular demand for it. Moreover, such a policy fails to appreciate that clinical decisions are fundamentally different from business decisions. He caustically accuses the government of being in thrall to a faith based approach to reform that is devoid of all evidence. The criticism would be less puzzling had the government not made so much of its attachment to evidence based policy.

The real tragedy of what is being played out before our transfixed gaze is that those features of the NHS “which made it a distinct, unified, nationwide economy independent of business, designed to meet social needs rather than to maximise profit” are in the process of being abandoned. Instead, the commodification of health care is well under way, with the consequence that its consumption differs little from other goods and services.

Welcome though it is, especially coming from such a respected and authoritative source, the book left me feeling somewhat uneasy. Why are there not more Tudor Harts in the medical profession prepared to argue for their beliefs on the basis of their first hand experience of providing care to people and communities? Perhaps if more clinicians were like Tudor Hart—exemplars of their craft and advocates for their principles—we would not be where we are today. Conceivably, too many health care professionals have been willing accomplices in the government's marketisation agenda. Moreover, fiascos such as that over the GP and consultant contracts have not helped their case, with charges of personal greed combined with a perceived diminution of service lowering trust. And yet, Tudor Hart is by no means uncritical of his peers, accusing many of them of being “arrogant, paternalistic and condescending” and of having failed to “democratise their work” and see themselves and their patients as co-producers of health.

If the book has a weakness it is a failure to confront the implications of such professional duplicity and malperformance. They have undoubtedly fuelled calls for reform and united critics of the NHS who believe that only markets can provide the necessary incentive to improve practice. That nothing could be further from the truth cuts no ice with a government driven by a deep suspicion of the professional hegemony it believes has become the NHS's fatal flaw. It is a major reason why professionals are viewed as the problem rather than the solution and why, instead of experienced practitioners like Tudor Hart advising government, we have a cadre of special advisers who, for the most part, have little real understanding of the complexities of providing health care and even less of improving health. Whether the devolved polities of Wales, Tudor Hart's homeland, and Scotland can do better and show a different way forward remains one of the few truly interesting features of contemporary British politics.

The only regret is that the book did not appear earlier, when it might have provided timely ammunition to those puzzled by, and angry with, what is happening to the NHS


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