Internationally, most people expect successful doctors to be specialists. If you have to admit to being just a GP, they think you must either have fallen off the bottom rung of the ladder of ambition, or never even reached it.
I was a Glyncorrwgologist, the only one in the world. I knew more, did more, and certainly wrote and spoke more about the health problems of Glyncorrwg, than any other doctor. So I became the world expert, a specialist in at least the initial recognition, and often the terminal management, of the entire potential range of health problems in that unique community. I was a broadly informed person able to reassemble into a comprehensible story what an ever-increasing variety of disease-specific specialists had divided. What higher ambition could any doctor have?
Assumptions that community-based generalists are less trained, less skilled, less knowledgeable or less useful than hospital-based specialists rest on apparently logical foundations. If GPs really were generalists, so the conventional argument goes, they would have to know everything. But nobody can know everything. So generalists are bound to fail, and might as well stop trying.1
In fact, the existence of effective generalists is a precondition for the existence of effective specialists. And paradoxically, to be effective, GPs have themselves to become specialists, but of a different kind – specialists in their own locality and population, specialists in general responsibility for initial, continuing and terminal care strategies over lifetimes, and for the huge, still under-explored territory between the outer limits of health and fully formed end-stage disease.
As a production system, the NHS as a whole can be regarded as a black box, with inputs into one end, outputs from the other and a mystery in the middle. What happens inside this black box we call process – all the extremely complex chains of decision and intervention that somehow transform inputs into outputs. This is a generally agreed metaphor for all modern industries, in which production processes have become too complex for non-specialists to understand in the ways that earlier and simpler processes, for example production of coal, steel or cars, could be understood in the past. I hope to show that the nature of what goes on in the black box producing health gain and its social byproducts is qualitatively different from what goes on in black boxes producing commodity goods or services. Health gain is always an addition to national wealth, but it need not be a commodity – and has never in fact functioned only as a commodity, in any modern economy.
To analyse the functions of this box for any theory of political economy, old or new, we have to make some simplifying assumptions. Most health economists assume that within the NHS black box a hierarchy of professionals provides a range of services for patients, first creating, then transferring these services as commodities to patients as consumers, but with the price of sale met in full or in part by the state. Health economists recognise that unlike other transactions in the ideal world of classical economics, consumers of health care in all state systems, whether based on taxation or insurance, are so hugely less informed than providers, so shielded from immediate cost penalties and so vulnerable to abuse by providers through sometimes desperate fears, that major modifications of classical theory are necessary and inevitable.1
Human biology and the practice of medicine are based on a belief that people are nearly enough alike that the secrets of disease in a king may be found by cutting into a pauper. Solidarity, a belief that humans are all of one species, that we are social animals who stand or fall together, whose survival depends on helping one another, and whose genetic diversity is a strength rather than a weakness, has sound foundations in human biology. To be understood, this must include scientific, evidence-based approaches to psychology, sociology, history and politics, because they all help to make our extraordinary species what it is.
Despite this humane tradition of solidarity, doctors were in the front ranks of the imperial and eugenic movements in Europe and North America before the First World War. These laid foundations for fascism – the belief that our species is naturally ranked in league tables of worth and talent, created by eternal competition, rewarding the strong and punishing the weak. These movements rested on denial of shared human identity, on assumptions that differences between people were more important than what they had in common, and that positive or negative values of these differences were obvious, predictable and constant over time.1 They celebrated primacy of intuitive feelings over evidence, of charismatic leadership over socially inclusive and participative politics, and power itself over the ends it pursued. All these features fitted well with the state of medical practice between the two world wars, when medical authority drew power from its still very loose association with science, but kept itself virtually immune from scientific criticism.
All health care systems, even including those so unsystematic that they are hardly worthy of that name, claim to produce something. So one way of looking at them is as production systems, with measurable inputs, outputs and social relationships within their processes, so that different ways of organising them can be compared.
From 1948, when the British NHS began, until the early 1980s, when successive governments began to re-introduce most of the features of industrial commodity production and competitive distribution, the NHS was much simpler than any other national public care system.1 It included every person living in, or even visiting, any part of the country who found themselves in need of medical or nursing care.All contacts between patients and staff, all diagnostic investigations, and all medical or surgical treatments, either at home or in hospital, were entirely free. So were all dental care (including orthodontics), spectacles, hearing aids and a wide range of simple appliances like crutches, sticks and surgical footwear.2 Direct patient charges (in health economists’ jargon ‘co-payments’) were introduced for the first time in 1952, four years after the service began, starting small but ending very big indeed for some services, most notably for dentistry – but even today, compared with almost all other countries, the NHS is still a universally available service for UK citizens, free at the time of use for more than 80% of users.
Virtually all the wide variety of British hospitals were nationalised in 1948, by a single Act of Parliament, making elected government responsible for the employment and distribution of what soon became, and has since remained as, the largest single workforce in the world after the Red Army.
Production systems may be owned by health professional entrepreneurs (singly or collectively), by senior managers and shareholders, by cooperative collectives or by the state (with varying degrees of public accountability or participation). All except a few idiosyncratic single-handed practitioners now have office staff, nursing staff, and land, buildings, equipment and so on – a team essential to effective work. For each of these players, ownership is always a centrally important question. For each of them, ownership is differently conceived and defined.
Because patients are increasingly compelled to accept roles either as consumers (for whom the ownership of a providing agency is a matter of indifference: what matters is the commodity they provide), or as co-producers of health gain (for whom ownership must be important, because this determines the motivation of their professional partners in the production process), so the ideas of patients about ownership of the service, and of its subordinate parts, have become as important as those of all other players.
Ownership relates not only to the buildings, equipment and other requirements for effective work in health care, but to the work itself. Adam Smith recognised that people work more productively for their own gain than to help others. This was his justification for the profit motive, which in itself he did not admire, referring to it as ‘self-love’. This explained the higher productivity of capitalism than the feudal agriculture it replaced as foundation and legal framework for commodity production. It also explained the higher productivity of serfdom than slavery.
Drawing on clinical experience dating from the birth of the NHS in 1948, Julian Tudor Hart, a politically active GP in a Welsh coal mining community, charts the progress of the NHS from its 19th century origins in workers’ mutual aid societies, to its current forced return to the market. His starting point is a detailed analysis of how clinical decisions are made. He explores the changing social relationships in the NHS as a gift economy, how these may be affected by reducing care to commodity status, and the new directions they might take if the NHS resumed progress independently from the market.
This edition of this bestselling book has been entirely rewritten with two new chapters, and includes new material on resistance to that world-wide process. The essential principle in the book is that patients need to develop as active citizens and co-producers of health gain in a humanising society and the author’s aim is to promote it wherever people recognise that pursuit of profit may be a brake on rational progress.
This book has provided evidence, derived from actual care processes, that commercial patterns, no matter how modified, are inappropriate for any health care system aiming to cover the whole lives of whole populations, at optimal efficiency. Health gain for whole populations cannot be produced efficiently as a by-product of investment for profit. Under present UK and EU company laws, wherever responsibility for service is contracted out to private sector providers, they are compelled to ignore such evidence, and subordinate the needs of society to commercial ambitions. The consequences are concealed by laws guarding commercial secrecy, and by politicians and media commentators apparently incapable of thinking outside a provider/ consumer box or of imagining any cooperative rather than competitive society in practical terms.
Fully rational development and use of medical knowledge for all who need it requires a gift economy, congruent with the shape of continuing clinical decisions in continuing real lives. In such an economy, staff and patients could learn together, from their own successes and errors. They could learn to work in new ways, harnessing the reserves of motivation and goodwill that are now frustrated or wasted by confining patients and communities to consumer roles, magnifying wants and ignoring needs. Such an economy would depend on levels of personal trust which are unsustainable in commercial transactions. Its own cooperative processes could build that trust, instead of eroding it by pillorying staff for unexpected outcomes.
A gift economy in health care is justified not only because it could be happier, more imaginative and more human, but because it would probably be more efficient.
Wealth is not a simple concept, as King Midas discovered when his food turned to gold. Gold, or money, represents wealth as a means for exchange, but as we rediscover in times of crisis or war, money is not itself a useful resource. Nothing is more useful for life than life itself, and health through which to enjoy it. This is not the only sort of wealth which the NHS produces, but like all health care systems, whether for fees, profit or public service, this purports to be its principal product. For commercial health care, for professional or corporate trade, health gain is in fact a byproduct. It is necessarily subordinated to the profit required to justify the business of either entrepreneur professionals or corporate providers. Only through public service is it possible to set health gain as a planned social goal and a direct objective. However, even if this possibility is pursued in practice, health gain is not the only product.
Health gain can be measured as the aggregate of healthier births, healthier lives and healthier deaths.1 All public care systems have other social products, the most important of which is stabilisation of society by legitimising the state (or the power of other corporate providers), but any system depends on this central promise of health gain for its credibility, whether this promise is real or illusory.
Healthier births are easily measured by maternal, perinatal and infant mortality rates, but in fully industrialised economies these are generally too low to provide more than a crude measure of output.2
This book explores the representation of teenage pregnancy as a problem in UK and the ways in which policy makers, academics, and the media have responded to it. This book examines who is likely to have a baby as a teenager, the consequences of early motherhood and how teenage pregnancy is dealt with in the media. The main aim of the TPS is to reduce teenage conception rates. However, promoting opportunities for, and offering support to, young mothers is secondary. It is recommended that future policy efforts may be better placed and more effective if they are focused primarily on promoting the well-being of young mothers, and fathers as well, and their children and less on the depiction of teenage pregnancy as a problem.
This chapter focuses on the decontextualised view of teenage pregnancy in the UK. It discusses the use of sometimes inappropriate comparisons between nations and a lack of understanding about the relationship between early conception and aspects of the British demographic, social, and economic landscape. It also discusses the relationship of sexual openness and sex education with low rates of teenage conception. This chapter also discusses teenage motherhood as a normative, and even positive, experience.