Books: The State Of Medicine: The Gulf Between Policy and Implementation

The British journal of general practice: the journal of the Royal College of General Practitioners

David Jewell¹ 

[1]Bristol. E-mail: [e-mail]

DOI  :  10.3399/bjgp17X688717

学科分类：卫生学

来源: Royal College of General Practitioners

【 摘 要 】

Nobody who follows the news in Britain, and most especially anyone who has had to use the system recently, can be unaware of the current problems facing the NHS. Those of us who have worked in the NHS over the last 15–20 years are all too familiar with the long history of reorganisations, wasteful initiatives, ill thought out policies, and simple errors. And here they all are, set out in densely referenced detail. Margaret McCartney’s latest book is a truly impressive achievement in the scope and unblinking gaze it fixes on our travails. Even more impressive, it was an easy read, with little that I didn’t know already, and almost nothing to disagree with. She has woven all the different elements into a single narrative by stating what, in a less ideological and politically motivated world, would amount to good policy: careful attention to evidence; regard for the opportunity costs of any change; and, running as a constant thread throughout the book, paying particular attention to the harmful effects. Here the book is an echo in microcosm of a fault that King and Crewe in their book The Blunders of our Governments (2013) identify as a constant in their long list of blunders across many government departments, that the policymakers in Whitehall have no interest in the practical application of their schemes. Policy is for the intellectuals; implementation is for lesser mortals. The policymakers don’t ask, and certainly don’t listen to, the people working on the ground who would be able to tell them the likely consequences of their latest ideas. Above all Margaret McCartney is correct that, if we are to reverse the disastrous effects on stress, morale, and simple efficiency, the starting point has to be the values that are embodied in the NHS’s structure, and the men and women who make the system work and use it as patients. The book focuses exclusively on the woes of the NHS. Although that enables McCartney to examine very closely much of what has gone wrong, it prevents her from considering any alternatives. She has written chillingly of the way that private companies are offering services here and now, and warns that this will undermine NHS primary care. However, there are other countries in the world that manage universal health coverage, with a robust system of primary care and good secondary care, and without placing monopoly powers in the hands of an over-centralised and ideologically driven government. One of my fears is that continuing to cling to the system we have here as the only one that can deliver these benefits weakens the arguments for its retention, rather than strengthening them by testing it in good faith against, for instance, a less monopolistic but still publicly funded system. To criticise McCartney for not doing what she didn’t set out to do is perhaps unfair. Towards the end of the book she asks, ‘How did doctors and patients get so far apart?’ I want to shout back, ‘Why are we all as a society so supine that we have allowed successive governments to act so undemocratically and do so much damage to the healthcare system?’ The book argues not for confrontation but, probably more wisely, for a much better partnership between patients, professionals, and government. If it helps to bring that about then we shall all benefit; if not, then perhaps it will at the very least encourage some righteous anger.

【 授权许可】

Free