London: The Royal Society of Medicine Press, 2000, pp 139,
ISBN 1 85315 438 5
This book about the modernisation of the British National Health Service (NHS) covers an international topic. There are many reports from several countries stressing the gap between the ideal of the best evidence-based care and the daily reality of for instance long waiting lists.
One would expect this to be an exciting book, because the cultural change necessary to bridge this gap leads to major tensions, disagreements and resistances. Moreover, we are dealing with a paradox: although cultural changes should start from the basis (in this case, with the people involved in daily care), this one is initiated by the government and by policy makers.
This book describes the results of an observational study of The Relational Health Care (RHC), taking three years, involving more than half of the districts of the NHS and using case material of over fifty local Primary Care Groups. It contains ten chapters.
The first chapter, about the agenda of this study, relates to the widespread disillusionment regarding relationships in the NHS and their impact on health. When the project started in 1996, the authors were struck by the despair that pervaded the outlooks of many healthcare professionals and managers. This despair reached far beyond concerns about the implementation of “internal market” mechanisms in the NHS. Although many applauded the improvement of performances, for instance in hospital care, there were many negative feelings.
The chapter about policy presents the major aspirations of a modern NHS: decentralisation, integration, commitment to quality, reinforcement of the role of GPs, long-term policy, and the pragmatism of “third way politics” of new Labour. However, the authors found that such a policy can make people cynical. How should the cynics, resistant to change, be made to go on with the visionaries and the champions of change? How to find a balance between local and central control? An important concern is the integration of relationships between NHS, local authorities and voluntary agencies in pursuing public health. New primary care organisations such as Primary Care Groups (PCGs) and in the future Primary Care Trusts (PCTs) are seen as broad-based multi-professional teams improving health and addressing inequality in the local communities. However, the reality does not always match the rhetoric.
The chapter about resources underlines that relationships are neglected in the NHS. How can Primary Care Organisations find local support for relative priorities? One of the dangers is that money is being moved around while no one has thought through the consequences.
In the chapter on strategy, the authors underline that strategy is not just for planners, but “belongs where the action is”. The key question is how to make inclusive, responsive and effective choices.
Next come chapters on Organisation, on Delivering care, which requires effective relationships between all involved, and on development, which requires real education.
In a review the authors look back and forward paying attention to relationships. The changing relationships create uncertainty about roles, the real agenda and leadership.
The chapter on the quality of care is concerned with clear concepts. In the new NHS it is clear that NHS professionals—doctors and nurses—have the leading roles. Still, the researchers found a lot of ambivalence about this.
In the final chapter, about the prospects, the authors conclude that there are still too many obstacles to bridge the existing gap between policy intentions and practice implementations. Six practical ways forward are formulated.
This study shows clearly that the shift in policy and the intensive structural changes increase the complexity and range of relationships. Clinicians and GPs are no longer just providing care for patients, they must be managers as well. It is quite understandable that it is not easy to develop a better understanding of effective organisations and good relationships, because GPs and clinicians are used to “just doing their job”. So the big changes in Primary Care Groups and Trusts with the increased role and responsibilities of GPs are major issues.
This book about relationships and integration in the NHS is also important from international perspective, as we can learn from each other. Of course each country has its specific problems. Although the NHS is well known for lengthy waiting lists and demotivated doctors and nurses, one should keep in mind that the UK spends a relatively small part of the national budget on health care compared to most other Western countries. We nevertheless share a lot of problems, because of common changes in medicine and society. The change of healthcare systems is on the agenda of all governments. No country has found the right answers yet to create a cost-effective system meeting all the complex needs of patients.
A limitation of this book is that it is clearly written for British readers. Although at least some readers will be informed about the NHS, there is a need for an overview of the specific situation and problems of the British NHS. The aims of the new NHS are described in several chapters, which makes reading difficult. It gives no specific information about important issues as for instance negative experiences of fund holding GPs, even though this was one of the reasons for a new approach by the Labour government. Specific information about important organisations such as Primary Care Groups and Trusts is lacking. Finally, it seems difficult to formulate aims for integrated care without a clear analysis of the problems of modern healthcare. In his book The Rise and Fall of Modern Medicine, Le Fanu  states that clinical science, fortuitous drugs discoveries and innovative technology has led to a New Belief of limitless progress of medical knowledge and technology solving all health disturbances and life problems. However, most successes were a matter of “trial and error” and luck after a lot of negative surprises. Medicine has a limit on further progress. Although medicine has never been so powerful, its success is seriously compromised by several paradoxes. Doctors are disillusioned and demotivated by demanding patients highly dependant on medical help. They are the “worried well” asking for check-ups. Alternative medicine seems very popular, because of the neglect of simple and traditional remedies in evidence-based medicine. Finally, costs are rising dramatically. Integration is not possible without answers on these major issues. Doctors and nurses are working in the frontlines and are supposed to give answers to the questions of patients who are (mis)informed by the Internet and by sensational “news” of the media. It is quite understandable that integration and relationships are not the first priorities of busy doctors and nurses. So the first issue on the agenda for a cultural change seems to be the unmasking of the myth of the power of modern medicine by better information. Still, integrated care and better relationships are the answers to the complex problems of modern healthcare and doctors should be better informed about the difficulties of changing a healthcare system. Especially GPs know that integration means better relationships.
Knowing these limitations, this book can still be recommended to GPs and managers familiar with the specific British situation. Their patients need integrated care. This is one of the major challenges of Primary Care.
The rise and fall of modern medicine. London: Abacus; 2000.