Healthcare in the UK: Understanding continuity and change . Bristol : The Policy Press 2009 £24.99 304 pp . ISBN 978-1-86134-608-7 ( pbk ).
This book is a very welcome addition to the range of thorough research that is now building around health care policy, organisation and management. It takes as a starting point an earlier analysis of the state of health policy from the 1980s, premised on a ‘shared version’ which attests that the NHS is characterised by a degree of incrementalism and inertia, with a dominant medical hierarchy and typically weak management. Greener’s aim is to problematise this ‘shared version’ and to take ‘a look back’ to the history of the service, and his argument is essentially that it is impossible to dissect current health policy and reforms without interrogation of the past, making sense of earlier organisational changes and contexts. He contends that any organisational analysis has to be rooted in an appreciation of the ‘inheritances’ of the past and the decisions of previous administrations.
An important conceptual stance also informs this book, with Greener invoking the idea of how interest groups create specific logics through their interactions. These colour which ‘situational logics’ condition behaviour and choices of key actors. From Greener’s thesis, these are shown to alter over time.
The book is organised in a very clear and accessible way with a chronological as well as thematic and reflective spine. The early chapters revisit the creation of the NHS and discuss the relationship between doctors and the state pre and post 1948. The motif of the organisation of medical practice is strong and Greener carefully explains how the role of doctors, both hospital consultants and GPs, has powerfully shaped the form and function of the service across many decades and reform periods. The third party in this nexus is that of local authority health care provision and as Greener points out, this ‘tripartite split’ is at the core of the funding and policy history from the beginnings of the service.
In the subsequent chapters, Greener documents the role of other key professionals, again using a combination of chronological details and critical analysis. Managers, management and managerialism are all dissected and placed in historical context. Nursing, nurses and public health are similarly scrutinised. The final two chapters knit the analysis together by critically examining the emergence and direction of policy since the Labour government came to power in 1997, taking into account the long shadows of history exposed by the preceding chapters. For Greener, the defining features of the policy under Labour is its retreat from the highly managerialist ethos of the Conservatives to one of regulation and the accentuation of performance targets and ‘return to market mechanisms’, described as resembling ‘an act of faith’.
This is the book I have been waiting for. It is ideal for use with postgraduate students of health policy; health management and organisation; and international health, who often have to get to grips with the complexity of change management and policy of the UK system. It is rare to have such a competent synthesis within one text. The appeal of the text is its clarity and accessibility. The chapters can be read singly or the book read as a whole, as the arguments are cumulative yet each chapter has its own structure and integrity. The author also shows awareness of his reader and this is welcome as he narrates his intentions at the outset. It is pitched at the appropriate level for postgraduate students and provides a precise guide to the last 60 years of policy. Indeed, policy makers and service managers themselves might find this book insightful and illuminating and I can imagine it finding a place in the reading list of NHS graduate trainee management courses as well as public management and political science students.
While as a text book this is a very satisfying book, it could be argued that the novelty impact of the book is less pronounced. The ideas have been aired in many academic discourses and perhaps some complexity is glossed over. There is limited engagement with considerable empirical health policy and management research on change and innovation and the role of clinicians and managers in sense making within organisations or indeed micro-level service and quality improvements. This is not a major issue and derives from the primary emphasis of the author in adopting a macro and political level explanatory lens. Greener has achieved his aim of showing how policy needs to be read with a deep knowledge of its aetiology and pre-conditions. He has also filled an important gap in the market in an accomplished way. I predict this will be a popular and much cited text.