Category Archives: Book Review

Jo Marchent: (2016) , Edinburgh, Canongate Books

The obvious thing about the NHS is that it is in a mess. Underfunding has driven it to crisis point. Part of the crisis is the way that the administrators have come up with thousands of ways of solving the problems on a shoestring. Reorganisations, restructurings and reconfigurations seem to flow in a continuous stream.

Meanwhile we all still need to solve our health problems. In ordinary times, we apply a mix of common sense, medical science and mysticism. Common sense has guided us around thousands of decisions. It has also long told us that our minds affect our physical health. However, our author has set out to test this proposition systematically. She is well qualified to do so. In the biomedical sphere she has a BSc in genetics and a PhD in microbiology.

A problem is that on one side of the argument are airy fairy alternative people who will create a cure out of mind alone and on the other are many medics who will focus on bodies and symptoms as if they were vets with clients who have no language.

Vital to Marchant’s exploration is the placebo effect. This is the positive impact of a treatment with no known curative properties. It has long been known to exist. Modern drugs trials use a control group receiving either a placebo or the current treatment while another group are given the new drug. Those running the trial should be “blinded”, that is neither they nor the subjects know who is getting the real thing and who gets the phoney. Thus the placebo effect can be eliminated in assessing the new treatment. But the author points out science is missing a trick here. If the placebo effect works it can be beneficial in itself.

The placebo effect is not just a con trick. For example, patients with Parkinson’s disease were seen to receive a flow of dopamine to the brain and to improve accordingly after a placebo was given.

There are a couple of problems with this simple story. The first is that there is also a “nocebo effect”. If we think something will damage us it may well even if it doesn’t have the physical properties to do so. Another is that the placebo is inconsistent. The same placebo helped 60% of ulcer suffers in Denmark but only 7% in Brazil.

The arguments about alternative/complementary medicines rage on. Most such therapies do not seem to work as the practitioners say they do. However, plenty of people swear by them. Again the placebo effect may be important here. Linked with this is time and concern. The typical GP appointment of about 10 minutes is pushed into a brief transaction, ending with a prescription. Against that an hour with somebody taking an interest in real problems may do more good, even if the benefits do not stem from the therapy itself. Homeopathy comes under particular criticism here as a treatment based on implausible explanations. Yet many people find that it works for them.

We all know about Ivan Pavlov and his dogs. But even the conditioned response he understood can be used in health care. An example is a group of children diagnosed with ADHD. They were given their normal drug plus a pill they knew was inert. Later the inert pill was given alongside half the normal drug dose. It worked! The drug regime had been halved with no ill effect – the placebo did the rest.

The placebo is not the only way that the mind alters physical change. A simple change in childbirth was to ensure that the woman had a single person caring for her instead of people coming and going. This reduces the need for pain killers and cut the number of complications.

Meditation has had its followers. They tell us, often with missionary zeal, how good it is. This book confirms that it can lower blood pressure and improve health generally without drugs. There is a detailed discussion of quite how this works.

I often think of Shakespeare’s phrase in Richard II “I wasted time, and now doth time waste me;” It reminds us of the inevitability of growing frailty and decline as our age advances. However, Marchant shows that exercise, mental activity a sense of usefulness will stave off the impact of the years racing by.

One of the more interesting features is a discussion of religion and health. It seems that if you can believe it will keep disease at bay. This probably works by reducing stress.

Where does this all leave socialists campaigning to protect the NHS?

Firstly, this book helps us to avoid the narrow mindedness that an excessive faith in the current level of medical science can bring. All sorts of unlikely things can help. However, that is not a reason to go off to any whacky set of beliefs. As the author shows, beliefs need testing for their impact.

Secondly, some aspects of these mind over matter treatments are being used by the NHS. The term is social prescribing. Thus, the practice I use has walking groups. Others prescribe time in the gym., etc. All of this has to be better than drugs. However, it runs up against the entrenched habits of GPs. They may find it easier to prescribe a drug rather than a preferred activity. Patients also often feel that their problem has been properly acknowledge by a prescription for a chemical of some kind. If the avoidance of pharmaceuticals catches on the drug companies will almost certainly respond.

To return to where we came in, we need two things. We can ask how a work like this relates to health policy. Firstly, to recognise that the integration of social care and health is essential and with it the capacity to use non-medical services. Secondly, we need to develop a more sophisticated understanding of the relationship between mind and body in developing the services needed.

1. This policy is growing in popularity,

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Healthcare before the NHS

Jeannie Duckworth, Austin Macauley  ISBN 978-1784558147  £7.99

The establishment of the NHS in 1948 coincided with the epidemiological transition, something most have now forgotten and which this book reminds us of.  Death from infectious disease, for which there was very little effective treatment available even if you could pay, was common. Children of all social classes commonly died in infancy and mothers in childbirth.  Richer families had better prospects of survival, but not much.  Epidemic illness swept through the population repeatedly.

The limited health service established by the 1911 National Insurance Act only extended to workers, not to their families, and it did not include hospital treatment. Duckworth’s book gives a helpful explanation of such medical provision as was available, but it concentrates on the most significant health problems – childbirth, infected milk, malnutrition, rickets, diptheria and other fevers, polio, and tuberculosis.

There are a very interesting chapters on what are now called special schools, and the amazing open air schools for delicate children, which took place literally in the open air – in parks, mostly.  There were 96 open air day schools in 1937 and 53 open air residential schools.  Lessons sometimes had to be abandoned because of blizzards.

 

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 Why I Love the NHS by Carl Walker

Publishing 27 February 2015 • Paperback • £9.99 • ISBN: 978-0-7198-1443-3

Carl Walker is a principal lecturer in psychology at the University of Brighton.  He loves the NHS on every page of this book. All the royalties will go to the NHS Support Federation.

He tells about 80 stories about his encounters with the NHS over 38 years, starting with a bicycle accident, but concentrating mostly on embarrassing episodes. Some of these are about his genitals, but most are about his anxieties about how to communicate with NHS staff and what they might think about him. Perhaps that is what we should expect from a psychologist.

Interspersed with these tales there a number of accounts of the weakness of the American health system, and celebration of the fact that in the UK we do not have to hand over money at the time of treatment.  But beyond that, sadly, he hasn’t got much to say about the NHS as a system.

One of the stories is about his diagnosis as suffering from temporal lobe epilepsy. For many people this is a long term condition, but we learn nothing of any treatment he might have had for it.   Most of his encounters are at the casualty department, the GP or the sexual health clinic.  He has nothing to say about the management of chronic conditions – which is the big challenge for the NHS and all health systems.  This is the more surprising because he explains how he was involved in research into depression.

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There aren’t a lot of novels about hospital management.  A “business novel about a struggling hospital, Pride and Joy takes the reader through a journey of discovery into why good people with good intent struggle to achieve a breakthrough in performance”.  Alex Knight  is a management consultant who uses the Theory of Constraints; “a belief that inherent simplicity exists: in any goal-oriented system there are only ever a few places that have the power to affect the performance of the whole system—the system’s constraint(s)”.  The theory seems quite convincing, and a welcome antidote to the perverse effects of targets on the NHS.

Pride and Joy cover

The novel – well I read the whole thing, but mostly for its novelty value.  A novel about NHS managers is a bit like  a woman preaching, as Dr Johnson would say.  The main character  suddenly finds herself  Acting Chief Executive of a struggling NHS hospital and calls on her friend with whom she studied for her MBA for advice on how to turn it round.  The Theory of Constraints is expounded at some length and our heroine abandons the old ways in order to enthuse the entire organisation with its principles.  Amazingly length of stay and complaints go down, patient satisfaction and profitably go up.  Our heroine is interviewed for the substantive post of Chief Executive but is not appointed, because of lack of experience, but is recruited to implement a change programme across the NHS by the Minister.  She doesn’t get into bed with her MBA colleague, or indeed with anyone.  Her life seems a bit reminiscent of our own dear Chief Executive, though she doesn’t seem to succumb to so much temptation and she seems healthier. But she doesn’t seem to have any private life – gets to work very early and leaves late.

Alex Knight is an evangelist, and not the first to use a work of fiction to elaborate the principles of his gospel.  Its certainly more fun to read, and more digestible,  than a management textbook, but perhaps  a little too predictable.

316 pages  Published by  Never Say I Know (NSIK), Church Farm, Station Road, Aldbury, Herts HP23 5RS, England £15.99

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Val Iles reviews Health Policy Reform – Global Health versus Private Profit by John Lister

364 Pages.  £25  Libri Publishing

Health Policy Reform

What makes this book different from many others castigating the direction of current health policy is that its disappointment is as great as its anger, and that its remit takes us beyond our own parochial interests. For those of us who have lived through the last 35 years of health care reform in the UK it is not only a reminder of how hopes and ideals here have been dashed but also an instructive look at the impact of similar reforms on a more global basis.

John Lister contrasts the ambition of the 1978 WHO Alma Ata Declaration – that gave us Health for All 2000 – with the situation as we know it today. He reminds us of the language and spirit of 1978 immediately before the Thatcher/Reagan era (elected in ’79 and 80 respectively) when, supported and influenced by the World Health Organisation ‘almost every country with control over its own destiny and policies’ was working towards a health system delivering the principles outlines in the Alma Ata statement: health care as a universal human right; health care based on clinical need and not on the ability to pay; and an emphasis on primary care and the preventive measures of public health.

There was, Lister notes, ‘only one notable and massive exception’ and that was the USA which had a ‘medical -industrial complex too large and powerful for any federal administration to reform fundamentally’.

He describes the factors, in the years since, that have led to a situation where health care around the globe is instead largely medical, curative, and high tech, and offered in markets or quasi markets.

These factors include: the emasculation of the WHO by reductions in funding and its influence being replaced by that of the World Bank and IMF; the near total colonisation of political and technocratic elites around the world by neoliberal ideology (Reaganomics); and the activities of players such as pharmaceutical companies, hospital chains, private financiers of public private partnerships, private equity, and private donors who have all benefitted greatly from this shift. He points out for example that private donors can now dictate the aid agenda in ways they could not when countries determined their own priorities.

Lister usefully reminds us of the reasons why markets cannot function effectively in health care and, rather more unusually, points to the particular problems for developing countries of introducing a market: that private sector providers do not want to target a market where the majority cannot afford to pay for what they need, so, instead, they focus on wealthy and emerging middle class minorities.

Lister makes an attractive case for employing ‘a Marxist framework to offer a coherent explanation’ of these events, contrasting this with the Reformist critiques which seek merely to humanise the neoliberal market system. His aim, he says, is to contrast the reality of care delivered within market systems with the rhetoric of those advocating these markets.

He does point out that ideas about ‘rolling back the nanny state’ were attractive because those on the left as well as on the right were describing public services as inefficient, remote, ineffective, and bureaucratic, although more to castigate those making such complaints than to accept their validity. And this is the greatest weakness of the book: the constant and unexamined assumption that the public sector delivers much better health and care than the private.

Nowhere does he consider that the values against which he is judging services (universality and equity) may not be the only ones, that it is legitimate for people to also want care that is responsive to individual needs and preferences, and that is as effective as possible, and that we must try to find ways of accommodating all of these – or of making democratic choices between them.

The chapters describing the steady change of focus of the WHO, the increasing role of the World Bank, and IMF, are interesting and that on the role and priorities of private donors is especially illuminating. The case studies here illustrate his conclusion that ‘pet projects and varied motivations of these donors inhibit efficient, effective, coordinated assistance’. He observes, for example, that the complexity of this landscape can lead to hugely onerous demands for reports and audits from the tiny number of local people skilled enough to tackle them (over 2000 reports in a year from a country with only 10 people with the skills required).

By now we have reached Chapter 6 and it is here and in Chapter 7 that I found my irritation exceeding my interest. Distinguishing between policies with the primary aim of cutting costs (chapter 6) from those (chapter 7) whose aim was to introduce a market he packs these pages with examples of of both sorts of reform.

Most readers will be familiar with many of these and, as example follows example with little argument being developed in the process, you may find the book as valuable if you omit these. Of course if being scandalised is your thing, well….enjoy!
It was good however to see Lister challenging the ubiquitous and tiresome claims that that because demand for health care is infinite and resources finite some form of rationing will be inevitable, citing German experiences to support his case. And the many quotes expostulating at the lack of any form of evidence of the benefits of market style reforms will surely be useful as well as energising.

Most of his argument here, though, turns on the fact that introducing markets does not cut costs. We can see that only too clearly, but he has specifically separated these two types of reform and markets always purported to be about responsiveness and satisfaction as much as efficiency. Fewer examples and the development of a much clearer argument – one that helped develop new thinking rather than tired old goodie/baddie, public/private stereotypes – would make these chapters much more powerful.
For example: Lister points out that market style reforms were also termed ‘New Public Management’. But NPM is ‘managerialism’ (or MANAGERIALISM as Henry Mintzberg insists it is written) applied to the public sector. It is just as pernicious within the private sector. The problem may not as much be public v private but managerialism.

And managerialism itself is part of a wider set of trends supported by the digital revolution and the audit culture, combined (certainly) with neoliberal forms of globalisation, and (crucially) with our ever present anxiety as individuals (that makes us so easily seduced, not only by the ‘stuff’ that markets excel at offering us, but by systems that promise us certainty, reduced risk and high tech quick fixes). So any argument about how to organise health care has to accommodate these wider trends, it can’t ignore them and focus only on one manifestation of them.

Assuming that market reforms were (and are) introduced by baddies in their own interests also conveniently allows us to ignore the failings of systems like the NHS that arise from powerful professionals being allowed to set their own agenda. Of course many of these professionals are well intentioned, caring, courageous and hard working, and we like and admire them.

They also often feel powerless and fail to recognise their power, and unwittingly confuse their own agenda with that of their patients, so they do not perceive how often they act in their own interests. So this is tricky both to diagnose and to treat(!), but this is supposed to be a Marxist analysis so I am surprised it rated no mention at all. Lister does, after all, quote Marx, talking of – ‘the many wills that combine to make history, though not in a manner of their own making or choosing’. I suggest he needs to include in his analysis a wider range of ‘wills’.

He describes, for example, the scandalous ‘transforming community services’ programme but ascribes its dire process and outcomes to the wickedness of a marketisation ideology. A sociologist with an interest in aspects of status and professional capture would have observed that this was entirely consistent with attitudes to (lower status) community services within the NHS for decades – they have been consistently raided to support higher tech acute care.

Fortunately in Chapter 8 Lister comes back into his own. Referring to the ‘2002 World Assembly on Ageing observation that the dramatic growth in numbers of older people around the world was a “triumph and a challenge” he notes that ‘the challenge is that the economic and political framework of a neoliberal global economy is not welcoming to this expanded population’. He is surely right when he says that it is the dominance of an economic perspective at all policy levels that leads to approaches to policy that start ‘from the wrong questions and almost inevitably wind up advocating the wrong answers’.

The sections on mental health and disability are equally frightening. He points out the almost total lack of interest from World Bank, USAId and Gates Foundation in mental health and points out that the prevailing disease specific and donor funded programmes are much less effective at meeting the needs of disabled people in poorer countries that public health care and community based treatment and rehabilitation would be.

In Chapter 9 ‘It doesn’t have to be like this’ Lister returns to his disappointment. Referring back to the 1978 Alma Ata Assembly he contrasts, movingly, the vision and the reality.
‘Fleetingly the realisation of a global vision seemed possible – a vision of health care …built upwards form local needs… driven by the interests of patients, populations,and communities…’.
‘The Alma Ata vision has been tragically and wastefully supplanted by a mean spirited, divisive, profit focused approach, in which patients are seen only as potential customers, and public and collective funding is a target for appropriation by avaricious corporations and grasping individuals determined to turn health into their business’.
He gives us his set of alternative policies which include (and it is worth remembering he is thinking globally and not only of the rich countries) :

  • Planning in place of a market
  • Risk sharing on the broadest possible basis
  • A tax levy on all the main economic and financial players in country
  • Steeply progressive income taxes – including share income, profits, rents; and a turnover tax on multinational companies
  • Co-ordinated international action against tax evasion
  • A Tobin tax ( FTT)
  • Enhanced primary care supported by hospital services, and specialist mental health and public health expertise
  • A dependable supply of the right mix of affordable and effective drugs available at an early stage at primary care level
  • Public sector ownership of drug companies, or at least a comprehensive opening of the books of drug companies, and no subsidies for research into lifestyle drugs
  • A global strategy to halt the drain of Health Care Professionals to high income countries
  • Making available the expertise of high income countries to the labour readily available in poorer countries
  • Professionals in management roles to be professionals first and managers second
  • A review of all PFI schemes
  • Hospitals to be carbon neutral
  • Rethinking the proposals for centralisation of hospital services
  • A review of funds for mental health and older people
  • Reintroducing democracy in local communities -in ways impossible in a market system, which will result he believes in services that are more responsive to the health needs of deprived, neglected and forgotten groups.

How do those sound to you? Or rather, how do you feel on reading those?
I felt helpless, disappointed and slightly bored. After this passionate argument Lister gives us nothing more than I have discussed in pubs and over dinner tables a thousand times over the last 35 years.

Surely what we know about complex systems tells us we absolutely cannot rely on planning. No we mustn’t rely on markets either, so we have to think afresh. Let’s think as people like Roberto Ungar are doing, of a new progressive way forward.
Lister wants to take us back to 1978 to a world before Reaganomics. But even without that ideological shift our world and our health care would have moved on in other ways.

The problems that Lister refuses to see with State run services would have been addressed in other ways,
perhaps making services more enterprising, more tuned in to the needs of patients and populations than professionals, perhaps not. What we need now is some thinking about what policy alternatives might get us to somewhere new and not to an outdated past.

So do I recommend this book? Yes I do. Partly for the array of facts and figures and examples that bring the situation home to us and the way it makes us care about other countries than our own, partly for the reminder of how it felt to be young and optimistic in 1978 with a belief in progress and a spirit of internationalism so different from today’s globalisation, and partly for the opportunity to think about how to take the argument beyond what is presented here.
I suggest though that it needs to be read alongside others, and indeed that an evening spent looking at how to use the insights of this along with perhaps those in Roberto Mangabeira Ungar’s The Left Alternative, and Nassim Nick Taleb’s Antifragile would be very fruitful and interesting. Anyone interested??

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I went  to see an interesting play, This May Hurt a Bit, about the NHS in Bolton three weeks ago and thoroughly enjoyed it.  It is mostly about the politics of the NHS in England. I especially enjoyed the appearances of Nye Bevan, Winston Churchill and the Grim Reaper.  It’s on at the St James Theatre in London from 14 May – 21 June 2014

The producers, Out of Joint,  have kindly sent me a copy of the script.  There are 26 characters.  They produce it with a cast of 8, doubling up.  The set isn’t complicated.  It would be perfectly possible for amateurs to produce.

The play starts with Nye Bevan’s speech on the appointed day and moves quickly forward to 2011 where David Cameron is looking through the Health and Social Care Bill, which he confesses not to have read, and being briefed by Sir Humphrey.  From there we go to hospital where a surgeon is examining Nicholas’s prostrate gland, and then to outpatients.  The hospital is clearly struggling and Cassandra, a woman all too reminiscent of many NHS campaigners I have met, bursts out of the audience talking about the trade treaty which will enable US companies to take over our public services.

In the next scene a 65 year old confused lady turns out to be the NHS, hooked up to a life support machine, who explains the difficult relationships she has had with a series of Prime Ministers.

Stephanie Cole

Stephanie Cole

Nicholas’s sister turns out to be married to an American surgeon, called Hank, who is an advocate of commercial medicine, but his mother Iris  (played by the wonderful Stephanie Cole) is a powerful, if surprisingly foul mouthed, advocate for the NHS.  The family dinner party is interrupted from the audience by the interventions of Winston Churchill, and Bevan.  Their political argument is then interrupted by a lesson on the Private Finance Initiative.

Subsequently Iris has a fall which causes her to lose her memory and believe herself to be in the 1970s. Transient Global Amnesia, it’s described as, which to my surprise is a genuine diagnosis. The visiting paramedics have more words of political wisdom about the futility of changing structures.  So does the lady from the weather centre, who tells us about hospital closures.  The hospital ward is pretty chaotic. So is the Board of Directors.  But Iris continues to defend the NHS against Hank, who wants to send her to a private hospital.

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