ByHam Christopher , Palgrave Macmillan; , 2004. , 5th ed., PB £18.99 , 288pp . ISBN 0‐333‐96176‐5
Professor Christopher Ham's Health Policy in Britain was originally based on undergraduate and postgraduate courses he taught at Bristol University. Now in its fifth edition, the book remains faithful to those academic roots while providing edification and insight that reaches outside the classroom to Whitehall and Westminster and well beyond. By recognizing that the essence of the book is ‘the politics of health care: who decides, who benefits and who controls health services,’ Professor Ham has produced a book that can be enjoyed by anyone trying to understand better the universal dynamics of health policy. In this sense, Health Policy in Britain reminded this reader of Graham Allison's classic, Essence of Decision, which artfully uses history viewed through different lenses, each reflecting an alternative perspective, to teach the reader how to understand the actions of government. Allison's models are very much in evidence in the workings of the health policy stakeholders described here, as are Ham's keen powers of observation and analysis.
The recount of early history of British health policy and services is selective. Only the most important developments prior to the establishment of the National Health Service (NHS) in 1948 are included. There is more detail about the policies of the Thatcher and Major governments including the origins and impact of the White Paper, Working for Patients. The approach of the Blair government including the rationale for The NHS Plan and new Labour's ongoing efforts at investment and reform is presented with a richness of detail and insight that reflects Ham's four years ending in 2004 on secondment to the Department of Health.
Astute political analysis is woven throughout the text. And there are chapters devoted to descriptions of the policy‐making apparatus of central government, especially within the Department of Health where there is much interplay with the policy community and interest groups. A particularly illuminating chapter for the reader outside the NHS, or outside Britain, focuses on policy implementation, including the many opportunities for policy to evolve locally as central government's intent is variably interpreted at the level of local NHS bodies. Ham weighs both intended and unintended consequences of this interplay between macro‐politics and micro‐politics.
Ham takes the political analysis to a more abstract level with succinct descriptions of alternative theories about where power resides in the health policy community and how it is used. Ham emphasizes a structuralist approach that defines dominant, challenging and repressed interests, each of which may lose or gain from any changes in the organization of health services. Readers of Health Expectations and others interested in promoting patient‐centred care will be particularly interested in (but not surprised by) the depiction of patients as repressed interests. There is also much food for thought for these readers in Ham's question about who benefits from the prevailing medical model that emphasizes an individualistic, functional fitness, curative approach to health services.
Perhaps the most compelling contribution of this fifth edition of Health Policy in Britain is its description of the evolution of approaches to auditing and evaluating health policy and the way resulting feedback guides the refinement and reshaping of policy. Ham traces early efforts at performance management, through the ‘audit explosion’ in the late 90s with publication of performance results and then assignment of ‘star ratings’ for NHS trusts in 2001, to an expanding role for the new Healthcare Commission in 2004. Ham sees this evolution as a force in the emergence of a regulated market shaped by an eclectic mix of policy instruments including the application of direct financial incentives for providers who achieve positive results, and the further development of peer review among healthcare professionals, along with the competition based on comparative performance information.
The implications of this emerging regulated market dominate Ham's look to the future as he examines the role of patient choice, an increasing plurality of service provision through Foundation Trusts and new diagnostic and treatment centres, and the impact of unprecedented investments in information technology. He sees progress, but argues that sustained progress will require greater integration of services, especially in the prevention and treatment of chronic illness where collaboration is required between providers of primary and secondary care, and also between providers and patients and their carers. A major issue will be better measures of performance that capture such changing patterns of care. The wise use of such measures by managers, and their embrace by providers is essential to true professionalism, may well offer the best hope for achieving better balance between the interests of providers of healthcare and of those who live with its consequences. Though Ham does not take sides in controversial policy areas, he does leave the reader with a firm foundation for opinion, and for following the evolution of policy and its impact.
This being the fifth edition of Health Policy in Britain, Ham has had multiple occasions for revision and refinement. Therefore, it is not surprising that it reads well and that his arguments are easy to follow. Perhaps a presentation of theoretical frameworks for understanding the historical development of policy, including the discussion of sources of power that now appears in chapter 10, would be valuable earlier on. The same might be said for models that explain behaviour within government and other complex adaptive systems. Readers might then be better able to anticipate the syntheses, or even work some of their own, as they learned the history. Nonetheless, as is, this book is highly recommended for anyone who wants to understand the NHS and its ongoing reform. It should be considered essential reading for those who have the opportunity to affect the efficiency and effectiveness of government‐supported health services anywhere. From beginning to end, Professor Ham engages the reader, eliciting anticipation and mounting expectations for what lies ahead… and he does not disappoint. This reader now looks forward to the sixth edition.