Book Review

The Political Economy of Healthcare: A Clinical Perspective

N Engl J Med 2008; 358:1973-1974May 1, 2008

Article

The Political Economy of Healthcare: A Clinical Perspective
(Health and Society Series.) By Julian Tudor Hart. 320 pp. Bristol, England, Policy Press, 2006. $80 (cloth); $28.95 (paper). ISBN: 978-1-86134-809-8 (cloth); 978-1-86134-808-1 (paper).

This altogether splendid book provides an incisive critique of the politics and economics of health care — the major determinants of who gets what kind of care and how much of it. What makes this book unique is that none of “the usual suspects” (economists, management experts, or health policy wonks) have written it. The author, Julian Tudor Hart, is a clinician, a British general practitioner who recently retired after serving for 30 years in Glyncorrwg, a Welsh mining town. Thus, the book is informed by his intimate knowledge of the exigencies of the daily practice of primary care, against which he assesses the operations of, and proposals for change in, health systems. Although his principal focus is the United Kingdom's National Health Service (NHS), he extensively references the United States as its counterpoint.

Hart is no ordinary doctor. Before entering medical practice, he had been a student of the celebrated clinical epidemiologist Archie Cochrane. Early on, Hart's clinical experience led him to propose, in an article published in the Lancet in 1971, the “inverse care law,” which states that “the availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces. . . .”

The legislation that created the NHS was approved by Parliament in the face of bitter opposition and strike threats from the British Medical Association (BMA), whose membership is primarily made up of general practitioners, and the Royal College of Physicians (RCP), whose membership is primarily made up of hospital-based specialists. Aneurin Bevan, the Minister of Health, surprised them all by nationalizing hospitals in the United Kingdom and then buying off the RCP consultants by “choking their mouths with gold” (his famous phrase). By allowing specialists to serve part-time and to use the nationalized hospitals for private practice, he effectively silenced them. When the RCP defected from joint action, the BMA simply collapsed. Does this chain of events remind you of what happened in the United States? In the 1960s, President Lyndon Johnson skillfully undercut the American Medical Association's (AMA) bitter opposition to Medicare and Medicaid after they had been enacted into law. The AMA leadership was invited to the White House and doctors were assured that they would receive “usual and customary” fees, thus converting charity cases (the indigent and the elderly) into paying patients and guaranteeing doctors' higher incomes.

Hart lauds the NHS as it was put into place in 1948 by Britain's postwar Labor government. Medical care in the United Kingdom became steadily better, more effective, more humane, and less authoritarian, until Thatcherism and Blairism reintroduced the market; the system has yet to recover its social solidarity. The NHS was universal, free at the point of service, and based on a “gift economy” that was funded by progressive taxation, and it assured continuity of care. Local staff and local populations took moral ownership of their neighborhood units. Hart's characterization of the NHS as a “gift economy” is borrowed from Richard Titmuss, the sociologist who compared the blood transfusion system in the United Kingdom, in which blood was collected solely in the form of gifts from volunteer donors, to that of the system in the United States, in which some transfused blood was provided commercially by payment to donors. Costs were lower and quality was higher in the United Kingdom — the risk of acquiring viral hepatitis, for example, was much lower. In the United States, down and out “donors” sold their blood — the only asset they had — to maintain their drug habits, which they were at some pains to conceal from those who bought their blood.

Hart provides an incisive critique of evidence-based medicine, defined by David Sackett, one of its pioneers, as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” The principle is unarguable, but what constitutes the “evidence” that is applicable to primary care practice? How relevant are data derived solely from randomized controlled trials that are conducted on patients with single diseases and summarized in meta-analyses from the Cochrane Collaboration? Clinical guidelines based on these meta-analyses are useful, of course, but they have severe limitations. Many, if not most, patients seen by general practitioners have multiple conditions, and few of the experts who prepare guidelines are actually engaged in medical practice — which means they are therefore unfamiliar with its realities. Pharmaceutical companies with a stake in sales have a hidden influence on guidelines; some guideline authors receive honoraria from pharmaceutical companies. If guidelines increase the workload of general practitioners disproportionately and benefits are not clearly evident, should we be surprised if physicians tick more boxes on the forms that are now required, but practice remains unchanged?

There is no way to do justice to this remarkably fresh book in a short review. I've chosen to retell a few of its many interesting stories. I wish I could persuade our presidential candidates to read it — they, and we, would be better off and wiser.

Leon Eisenberg, M.D.
Harvard Medical School, Boston, MA 02115