An all-out attack on a managerial cancer

It was once said of Baroness Thatcher that she read books to confirm her prejudices, not to broaden her mind. For anyone searching to reinforce a world view of a particular kind, Allyson Pollock's contribution will seem heaven sent. If you believe that the current Government is mendacious, greedy, duplicitous and incompetent, that National Health Service managers are concerned mainly with kowtowing to the private sector and that just about anyone in business is engaged in a Machiavellian plot to abolish all that is good and true in the public sector, then the author's analysis will resonate with you on every page.

This is a book where the author regards the world in a certain way and has a tendency to present events, ideas, actions and motives so that they conform to this preset mould. In places, she applies a remorseless logic that is hard to resist, until you realise you did not want to start where her argument began.

The central thesis is straightforward: the health service was a wonderful organisation loved and supported by the British people, a jewel of democratic socialism and equity surrounded by the venal world of international capitalism.

The trouble, according to Pollock, is that the NHS was not only an affront to the ideology that drives the money-makers in business, it also offered them the prospect of rich pickings - billions of pounds of profit to be made out of sick Britons. Under this scenario, the money-makers and the wicked politicians set about destroying and dismantling the great public-sector edifice. In its place, they are erecting a vile market-driven system that denies patients the care they need, exploits workers and "fills the pockets" of nasty businessmen as they "penetrate and corrupt" the fabric of the NHS.

All this is based on a belief that there was a golden age (until about 1980) when the health service was an efficient organisation, albeit an underfunded one, that met the needs of the British people and provided a fair and comprehensive care. If you feel this is all just a tad simplistic, NHS plc will in turns annoy, frustrate and intrigue you. Just take the opening salvo.

"Perhaps nothing sums up the NHS today as well as the credentials of the people who are now at its helm. Its senior managers now include people with no experience in public health or the principles of healthcare delivery; arts graduates of all descriptions, ex-army officers and increasingly people seeking a change from the private sector (or surplus to its needs); former chocolate or biscuit manufacturers, bank managers, chief executives of housing corporations."

Now the logic of this is that anyone with an arts degree or without public-health experience should be debarred from senior management in the health service, as should anyone who has run a major business employing a large number of staff. It also ignores the fact that most managers in the NHS still come from within the service and that army officers are few and far between. More importantly, there is no recognition here or anywhere else that the NHS is a business - a business that needs incentives to run efficiently. Large hospital trusts are £200 million operations; the skills needed to run them are multifarious.

The book also produces plenty of assertions, not all of them supported by evidence or rather supported by only selected bits of evidence. It suggests that the NHS has inspired many other countries to follow suit, but the truth is that few democratic countries have adopted the state-run, state-provided model of the NHS.

It claims that the "key qualification" of the so-called health tsars appointed by the Government is a "willingness to implement the market revolution". Is there anything to support this? Well, there may be a document somewhere indicating this was "their key qualification", but it is not cited. More to the point, the tsars have been more concerned with introducing national service frameworks, encouraging more efficient working methods and driving through targets than with bringing in the private sector. Their key qualification does not appear to have been their enthusiasm for market solutions but the fact that they were credible clinicians who recognised the need for doctors to become more involved in shaping policy and changing the way services were delivered.

And what of the claim that in his time as Health Secretary in the 1990s Frank Dobson abolished fundholding but simultaneously made all GPs fundholders by creating primary care groups. The primary care groups (later trusts) did not hand budgets over to individual practices as before, nor did they allow GPs to send patients where they wanted. We may be heading back to fundholding now, but that was neither the intention nor the effect of the Dobson changes.

Sometimes Pollock lines up her ammunition to support her case and quietly ignores countervailing arguments. Take for example her analysis of the 1990 GP contract. The Conservative Government changed the way family doctors were paid for cervical smears and childhood immunisations from a piece rate to a target, in the face of strong opposition from doctors. The contract stipulated that they would get no money unless they achieved 70 per cent coverage and the maximum payment for children only if they reached 90 per cent. The author decries this, saying that in deprived areas many GPs struggled to achieve even the lower rate. What she chooses not to point out was that tough targets produced a huge rise in immunisation rates, especially in deprived areas. It was one of the great public health successes of the 1990s.

Despite my criticism, there is a stimulating and powerful argument here.

The book's critique of aspects of the private finance initiative scheme is persuasive and should worry anyone concerned that the health service is locking itself into expensive long-term deals. Its warnings about the potential costs and perverse effects of market-based solutions must also be taken seriously, even if it never acknowledges the benefits that patients can gain from greater choice or the stimulus competition can bring to unresponsive monopoly providers.

In the real world, such arguments are seldom resolved in a clear-cut fashion. Few people would want to renationalise our airlines or our phones, but no one could say railway privatisation has been a runaway success. But at least in health we may be able to contrast and compare - the administrations in Scotland and Wales have so far eschewed the market, and over time it may be possible for us to assess the different policy approaches adopted in different parts of the UK.

It has to be said that, at this admittedly early stage, England with its emerging quasi-market appears to be doing rather better, at least in some areas, while the signals from the older-style monopoly services on its borders are less encouraging.

Niall Dickson is chief executive, The King's Fund.