International Journal of Integrated Care, 1 July 2007 - ISSN 1568-4156
Book review
New Labour's state of health: political economy, public policy and the NHS
Calum Paton
Aldershot: Ashgate Publishing Limited, 2006, pp 169,
ISBN 978 0 7546 4513 9
Trond Tjerbo, Institute of Health Management and Health Economics, University of Oslo, Norway

This book is about New Labour's health policy and the impact political economy has on public policy. As in other areas of the public sector, reforms based on ideas taken from the market cause reforms in the way the provision of the services is organised. When Labour came into power in 1997, the internal market was officially abandoned but important aspects of the reforms were carried out under Thatcher, such as the continuation of the provider—purchaser split. As Webster [1 p. 236] points out, Labour called their approach to modernisation “integrated care” or a “third way”. But despite the critique of the conservatives' NHS policies, New Labour coming into power did not bring about a major policy shift towards the NHS. Calum Paton takes a critical stance toward New Labour's policy and dismantles what he sees as the fundamental problems.

In the first part of the book, Paton presents a theoretical framework where the focus is on political economy. He argues that health policies reflect general political—economical factors and that these factors make up constraints in which health policies are conducted and produced. In the second part of the book, the focus is on explaining the causal factors behind public policies. Here, the author refers to the most used perspectives in explaining decision-making and policy choices. Paton is inspired by the work of Choen, March and Olsen [2], and their “garbage can” metaphor. The use of the garbage can metaphor helps to emphasise the author's critique of the Labour policies: there is a no coherent ideology or plan behind the policies initiated, and these ideas and policies are not always compatible. In the third part of the book Paton analyses the development in the NHS and New Labour's policy choices.

I have one critical comment to Paton's work: it seems that a comparative approach would have strengthened the analysis. This would have made it possible to distinguish more clearly between the relative impact of the different factors and the theoretical perspective the author applies. At the very least, a chapter where the NHS system could be compared with recent developments in other countries would have been useful. Paton is of course aware of this, and acknowledges that his strategy is somewhat “against the spirit of the age”. He argues, convincingly, that a longitudinal case study gives the best route to understanding changes. Nevertheless, the theoretical perspective Paton chooses does seem to demand a comparative strategy. For instance, the constraints Paton describes based on political economic factors and globalisation should make us expect some clear similarities in outcome between different countries. At the same time, it is likely that specific factors or variables at the national level, which can explain differences in outcome between the same countries, will be apparent. By comparing different countries one could then be able to make a more precise evaluation of the effects of these different groups of explanatory factors or variables. If factors which are not nation-specific are important in order to understand New Labour's policies and the development in the NHS, then a comparative case study seems to be a good way to test this.

In conclusion, Paton provides the reader with a fresh and critical view on New Labour's policies for the NHS, as well as a perceptive analysis of the factors explaining these policies. The theoretical perspective that is applied may be unfamiliar to those who are not trained in the social sciences, but it is not necessary to have a background from political science or the social sciences in order to read the book. The strength of this book is that Paton does not stop at pointing out paradoxes and inconsistencies; he also provides a thorough theoretical analysis, which helps us understand why these paradoxes and inconsistencies appear. Paton not only helps us see these paradoxes, he also helps us understand their origin. This book can be recommended to anyone who wants to understand why the NHS faces its current problems and to anyone seeking a broad analysis of the factors, which shape health policy.

Webster C. The National Health Service: A Political History. Oxford: Oxford University Press; 2002.
Choen M, March JG, Olsen JP. “A garbage can model of rational choice”. Administrative Sciences Quarterly 1972; 1:1-25.