NHS plc: The Privatisation of Our Health Care (review)

Allyson Pollock and her four co-authors, all of them from the Public Health Policy Unit at University College London, argue that the National Health Service (NHS), which was for many years an internationally praised exemplar of effective public service, has been "progressively dismantled and privatized" (p. vii) by successive British governments since the 1980s. The NHS, they write, is "being transformed into a network of local corporations" and "private companies" (p. 75) by proponents of markets. Powerful policymakers have "belittled" and "dismissed" the "historic achievements" of the NHS in large measure because, in their zeal to impose free-market ideology, they do not acknowledge that the "USA epitomizes all that is wrong with making health care a market matter" (pp. 195–97).

The authors glamorize the history of the NHS before the policy changes they deplore. For example, they insist that only a lack of money prevented the nationalization of general practice at the inception of the NHS in 1948 (pp. 14–15)—but a rich scholarly literature describes effective opposition to full nationalization among general practitioners and officials of local government at that time. Similarly, they assume that private-sector entities did not profit from the NHS before the 1980s—ignoring a rich history of NHS purchasing of drugs, medical devices, and equipment from private firms. Perhaps most important, their argument that policymakers have recently betrayed the historic mission of the NHS requires readers to believe that the rationing of health care began around 1991 (pp. 20–21); many authors have, however, documented covert and overt rationing within the NHS since its inception.

Two assumptions underlie the authors' attack on health policy that is informed by lessons drawn from market economies about incentives. The first is that problems of efficiency and effectiveness in the NHS could have been solved simply by infusions of money rather than by reorganization. Pollock and her colleagues disparage and discard the large literature that documents, as an eminent historian and analyst of British health policy recently wrote, that the "NHS had to be transformed in order to be saved. . . . if a tax-funded, universalistic service was to survive, the dynamics of the system had to adapt."¹

The second assumption is that policy that creates market-based incentives for resource allocation and quality improvement invariably stimulates inequity in the allocation of services, fraud, and unconscionable profits. This assumption fuels the authors' hostility to American health-care institutions and experts on health policy. The American institutions that they criticize either directly or by association include Kaiser Permanente, the Commonwealth Fund, and Harvard University; the American experts on health policy whose careers and opinions they misrepresent include Donald Berwick (president, Institute for Health Improvement), Alain Enthoven (Eccles Professor of Public and Private Management emeritus, Stanford University), and David Lawrence (former chief executive officer, Kaiser Permanente).

This book is a primary source for an extreme position in an important debate about how to organize and pay for health care that is occurring, in different ways, in many countries. It is also engagingly written, though sometimes repetitive. The authors are particularly skillful at reporting anecdotes. Historians who study recent events often find it difficult to separate their own opinions from those expressed by their sources. But unlike most professional historians, the authors of this book select their data in order to document strongly held opinions that are grounded in their ideology.