Health care for the millennium

Longman (second edition) 236 pages pounds13.99

In many ways Wendy Ranade's well-written and readable book is an excellent descriptive examination of the history of the reforms of the NHS. The problem that texts such as these face is the sheer pace of change in healthcare reform. No sooner has an author printed off their manuscript for the publishers than the world changes again; in this case we have a new government with new(ish) ideas about healthcare policy. Fundholding and the internal market will soon be history, and GP locality commissioning and health action zones the future.

But as Malcolm Bradbury's tank-topped hero in The History Man was fond of saying to his students, you need to know your history. As the new Labour government is finding out, where you start is a major influence on where you can go.

But to start at the beginning: the book opens with a number of ideological views of health and healthcare, the role of the state etc, including feminist, Marxist and New Right perspectives. This and the next chapter (dealing with environmental pressures - population change, information and medical technology) sets the scene for the rest of the book. At the end of a chapter assessing Conservative administrations' record on the NHS, the author quotes Rudolf Klein's observation that, as a result of the reforms, the NHS would have to invent its own future by trial and error. Well, there has indeed been much trial and not inconsiderable error. But in many ways, the fact that the reforms did not clearly specify an end-point or goal was the whole point of the internal market: it was all about process and little, if anything, to do with outcomes.

The basis of the reforms was to establish a new dynamic equilibrium (whatever that may look like) arrived at through a market rather than a planned system. Of course, as many critics of the reforms noted before the changes were introduced, this new process may not produce the outcomes we actually want.

One of the key groups in all this change was NHS managers. The chapter on transforming management (in the NHS) suggests to me the complexity of managers' role in the NHS (and in public life in general). They not only have to provide leadership but also hold the ring between powerful and influential groups - clinicians, government etc. They also have to put up with being shot at from both sides.

Perhaps the most striking thing that emerges from the evidence in this book, and indeed others which have addressed the impact of the NHS reforms, is the fact that change tends to produce good as well as bad. The reforms, as the author notes, were a catalyst in many ways for innovative change, but were also a source of increased inequality for patients and demoralisation for staff.

The political trick to pull off now is to change the direction of healthcare policy to reverse trends towards inequalities while not harming tendencies towards greater efficiency. Despite some additions to this edition written after this year's general election, the concluding chapter is stuck somewhat in the uncertainty of Labour's healthcare policy at around the time of Chris Smith's stewardship. What appears to be emerging now is a process of dismantling the internal market coupled with evaluations of new forms of GP commissioning which are unlikely to yield any definitive answers before the next election. It appears that Labour's strategy is as little real change as possible for now and to wait for a second term.

JOHN APPLEBY

Senior lecturer in health economics, school of health policy and practice, University of East Anglia.