books

Health and society in Britainsince 1939

By Virginia BerridgeCambridge University Press 144 pages£7.95 paperback£19.95 hardback

Histories of UK health policy and healthcare are commonplace these days, so what is the distinctive appeal of this latest addition? Though spanning a period of more than 50 years, from 1939 to the 1990s, it is short and readable.

The history does not concentrate on healthcare services but includes the wider health experience. And by including recent history, it offers a useful backcloth against which to locate and understand the current reshaping of health policy and the challenges it faces. Most of these have their origins before the NHS and have survived its inception.

The book's brevity belies the breadth of its coverage. While some of the themes touched on receive rather superficial treatment, the book's main strength lies in synthesising a vast amount of material and making connections between the healthcare reform agenda on the one hand and the public health agenda on the other. It offers useful insights for anyone wanting to understand how we have got to where we are today and anxious to speculate on the likely outcome of the raft of policy initiatives that the government has launched.

Perhaps the biggest obstacle to changing the paradigm in health policy from a fixation on healthcare to a greater appreciation of health has been the NHS itself: it was established as a doctor-dominated, hospital- focused sickness service. Without belittling the NHS's considerable achievements, its very success and public popularity may have inhibited the adoption of a tougher stance on health.

For example, although widely discussed in the pre-war years, preventive medicine did not figure in the NHS, and public health certainly did not fit the model, oscillating uneasily between the analysis of health problems and the administration of health services.

The failure to base health services on local authorities was seen by some observers to sow the seeds of later problems, such as the narrow focus on a medical model of health, and the emergence of a 'democratic deficit' in the way the NHS was organised locally.

These concerns take on a striking contemporary feel when set alongside the government's assault on health inequalities by strengthening public health capacity and experiments with new organisational forms like primary care groups and health action zones.

What Berridge's account of past policies tells us is that progress will be disappointing unless the government gets a grip on some of the deep-seated barriers to change that have eluded previous reforming administrations. Professional and departmental bailiwicks remain fiercely protected despite all the fine words about partnership working. Moreover, reformers should be wary of the 'organisational fix' to which the NHS has been subjected since the early 1970s. It rarely delivers and the problems to which it is directed often survive.

Historical work may be defined by the present, but the present is also shaped by past events. Many of the themes, including the medicine-management interface, tension in public health between public health medicine and the broader health perspective, GPs' independence, and the need for interdepartmental action to tackle social problems, are all very much alive.

The success of the government's ambitious reform agenda hinges on resolving some of these policy dilemmas. The book offers pointers to whether or not a successful outcome can be expected.

David Hunter

Professor of health policy and management at the Nuffield Institute for Health, Leeds University.