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Julian Tudor Hart
The Political Economy of Healthcare.
The Policy Press. 2006 PB, 336 pages, £14.99, 9781861348081.
Julian Tudor Hart is respected worldwide for his analytical approach to population and community epidemiology and his passion for the NHS. Both these attributes are in full view in his latest book, The Political Economy of Health Care. Those who know Dr Hart only through his writing and lecturing may not truly appreciate that his words come from 30 years of caring for a community — patients with names, faces, and stories — in one of the most challenging practice locations in the NHS. His work is not theoretical but ‘evidence based’, with his and his health centre's experience in a South Wales mining valley as both the source for and application of that evidence. I know since, 26 years ago, I spent 9 months as an assistant in general practice with him in Glyncorrwg.
Organisationally, The Political Economy of Health Care is two books. The first is the narrative of the nature of the profession, its history and its challenges, particularly the assault from the true believers of the marketplace. Anyone who has been in debates with Julian usually comes away on the short end of the argument and this book is no different. If one has a different point of view on a topic, one finds Julian has usually thought of it already and has an effective argument against it. But the lengthy footnotes for each chapter, which are funny, pointed and passionate asides that read like a journal of what he was thinking as he wrote the first book, are almost a book in themselves
The chief premise of the book is that the NHS, and general practice as the largest part of it, is an economic and cultural force that brings value to British society. The word Dr Hart uses throughout is that the NHS ‘creates’ — jobs, community, health both broadly and narrowly defined, and economic resources distributed through service. I have a photo of the Christmas party for our practice with 15 people, not counting Dr Hart, the GP trainee or me, who were employed by or related to the Glycorrwg practice — a single-handed practice of about 1700 patients. Dr Hart believed that employing staff who could work part time and job share, outreach nurses who did community and maternity work, and local people working as research staff on MRC projects was one way that the ‘healthcare industry’ could bring value to the South Wales Valleys. Short of municipal workers and the primary school in town, his practice was the largest employer in the community, which often is the case with rural and small town practices.
The early chapters of the book are devoted to describing the NHS as a partnership between doctor and patient and between the practice and the community. Both partnerships are based on service rather than commerce. Dr Hart argues that attempts to reify the clinical relationship or commercialise the practice threaten both the mutually caring nature of the doctor–patient relationship and the social capital of the community.
The Political Economy of Health Care is also a book of history and Julian Tudor Hart is a remarkable and knowledgeable historian. For those of us who follow the NHS and general practice from a distance, this book has as concise a history of the origins of general practice as I have seen.
The chapter on Ownership runs from pre-Lloyd George Act medicine through to current attempts to commercialise the NHS and includes heroes (Nye Bevan out strategising the BMA, hospitals and general practice) and villains (the Thatcherites and Labour leaders who continue to sing the siren song of the marketplace). All new trainees in general practice should read these chapters as a historical and political primer of the NHS.
Any future NHS, Dr Hart believes, should be based on fearless science — what he describes as ‘honesty, doubt and respect for evidence regardless of personal consequence’ — and generosity. ‘Health care’, he writes, ‘is a field in which generosity is a natural behaviour tending to create generosity in return.’ Dr Hart's advocacy for the NHS to remain a gift economy founded on solidarity and generosity is both a personal experience of his and an economic and political view he has developed since his entry into the NHS in 1952. This book summarises a lifetime of work and thought and belongs on the shelves of those who work in and think about the NHS of the future.