Review

Heartfelt but hazy

The invisible hospital and the secret garden: an insider’s commentary on the NHS reforms
John Spiers
Radcliffe Medical Press, 1995, £18.50

I must confess to not having read every word of this book. I lasted 70 pages or so before the repetition, unfocused polemic and disjointed arguments got the better of me, and I skimmed the rest. But this is not to say that the third of the book I did complete was a wholly negative experience.

For John Spiers — formerly chair of Brighton healthcare NHS trust and now director of the Patient’s Association — is clearly impassioned on behalf of NHS patients. His earnest desire is that the ‘culture’ of the health service be transformed to put the patient first. He sees a hundred ways in which the experience of patients is not as good as it should be, and he has a hundred ideas on how things might be improved. It is hard not to believe that his heart is in the right place.

But if passion is the book’s strength, then analysis and clear solutions are its weaknesses. Proposals for change are never expressed unambiguously enough for us to judge their practicality or likely worth. Ideas come thick and fast, but are not developed. Sometimes the ideas sound good. Sometimes they contradict what has gone before.

For example, in the introduction Spiers proposes the idea of ‘patient fundholding’, but tells us this ‘is not “the voucher”, nor is it direct consumer payment’. But by page 36 we are informed that patient fundholding ‘means that wicked word “the voucher”’. We never get enough explanation of the idea (of which Spiers seems particularly proud) to judge exactly what it does mean.

Spiers’ emphasis on rhetoric over analysis is apparent even from page one of the introduction to the book. ‘It is only individuals, not “experts”, who can know how to satisfy their own wants, which may be different to the “needs” specified for them,’ he states. Yet a sentence later he claims that ‘very large sums could be redirected from wasteful, even harmful, treatments’. The conflict inherent in the principles which underlie these statements is not acknowledged.

Spiers is at his best when he trying to view life from the patient perspective, though paradoxically his portraits of the medical profession are more convincing than those of users. But in the end, it is the recurrent managerial preoccupations which come over most strongly: how can we control this wayward workforce? And how can we keep the customers satisfied?