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Alan Gillies. Oxon: Radcliffe Medical Press, 2003. £27.95. 224 pp. ISBN 1 85775 921 4
International comparisons of health policy, healthcare systems, and health outcomes are increasingly popular. In the wake of the World Health Organization’s controversial report comparing health systems and with the growing availability of comparative data from the Organization for Economic Cooperation and Development (OECD), health policymakers and politicians are perhaps both more able and more willing to look elsewhere for lessons on how to fund, manage, and organise health care. Moreover, the problems they face—rising costs, demographic changes, technological advances, and increasing consumer expectations—are pretty universal.
In this book Alan Gilles sets out with the ambitious intent of finding out what we can learn about good health care by comparing the healthcare systems in three countries—the UK (or, rather, England), Canada, and Australia. He starts, unusually and interestingly, with a number of patient case studies which he uses to discuss what we mean by a “good” healthcare system. He offers no universal prescriptions but finds that every healthcare system involves a series of trade offs between social values like universality, accessibility, and social solidarity and drivers like the financing systems and organisational constraints.
He then goes on to analyse the values that he sees underlying the health systems in the three countries and the way they have shaped health policy development. The discussion is sometimes rather confused and is dominated by government policy documents and official reports. Some of what Gillies calls values, others might regard as second or third order mechanisms for getting things done, which have little to do with the underlying social and political expectations of health and health care. In fact, Gillies treats political ideology as a constraint on the values of the healthcare system which seems a little odd since ideologies are almost, by definition, a source and expression of social values. His analysis seems to betray a largely organisational view of the world in which the important things are the structures we put in place or the way we organise ourselves, which consequently misses out on the reasons why things are as they are. There is a huge and well established body of work by political scientists, economists, and sociologists on health policy development which could have informed this discussion but is not called upon.
The book next examines health policy and healthcare systems in each of the three countries, providing a brief but useful overview of the history of each system and the current situation. It uses quotations from a series of interviews with various stakeholders in each country to offer a kind of “vox pop” analysis of the problems and potential solutions. It is very hard for the reader to judge how complete or balanced these accounts are (except for the countries that they know well), but the use of quotations creates a sense of immediacy and moves the book, for the first time, beyond the official view of the world embodied in government policy documents and reports.
Finally, Gillies discusses how three particular drivers have shaped health policy—financial pressures, scandals about the quality of care, and political ideology—and then he returns to the question from which he started—what makes a good healthcare system? This works best when he maps out for his patient case studies the kind of care each would get from the health systems in the three countries, but becomes anodyne and simplistic when he tries to draw more general conclusions.
This book is a kind of health policy travelogue for the three countries studied. It provides a tourist’s eye view (with some of the attendant superficiality and lack of detailed understanding) of how each country’s healthcare system works and what people think of it, although it is never clear why he chose to study the countries he did. But beyond that descriptive purpose, it does not really make much headway in drawing together any wider learning from the countries studied. The question in the title—what makes a good healthcare system—is not answered.
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