Health policies: health politics. The British and American experience 1911–1965

DANIEL M. FOX, Health policies: health politics. The British and American experience 1911-1965, Princeton University Press, 1986, 8vo, pp. xi, 234, $25.00. This book is a comparative study of the British and American health systems as they have developed since the end ofthe nineteenth century. It argues that the key to understanding them is the concept of "hierarchical regionalism". Hierarchy describes the process by which the specialized and exclusive knowledge of the medical profession is dispersed to the population at large via health care. Regionalism is the organizational principle on which both the British and American health care systems are based. It involves the dispersal of facilities on an area basis. Daniel M. Fox makes rather large claims for the concept of "hierarchical regionalism". He says that in it lies the key to understanding how the health care systems of both countries have developed. He argues that "Debates about how to pay doctors, govern hospitals and apportion the costs of caring for working class and indigent patients seemed more important to contemporaries throughout the century than did the consensus about hierarchical regionalism"! (p. 208) and that this has led many historians of medicine to the mistaken conclusion that these controversies are more significant than they were. This has led to a neglect of the slow, unwinding, and silent motor of health care systems in America and Britain hierarchical regionalism. Fox seems to be arguing that it was precisely because of its widespread and unspoken acceptance that it has failed to attract the historian's attention. I would not disagree about one aspect of hierarchical regionalism. Underlying this rather unwieldy term is the idea that the professionalization ofmedicine and the emergence ofa caste of doctors and health-care professionals offering specialist medical care are important influences on the way health-care systems function. Many health-care professionals see offering to the public parcels of medical care as the means of secure status and advancement and they see medical institutions as the vehicle for this process. This is an important part of the story of health care in the twentieth century. But, unfortunately, Fox does not carry his discussion very far. Ifhe had, he might have been forced to make some conclusions that modify the force of the concept of hierarchical regionalism. For example, whilst, to put it crudely, the relationship ofdoctors to the health market in health care is very noticeable in the USA, the situation is far more complex in Britain because of the existence of the state-funded National Health Service. Second, the position of many "elite" medical men (and women) in Britain is also more complicated and cannot be analysed solely by the theory of professionalization. Gaining access to and influence among other social and political elites, becoming one of those who tender advice to the political class, has had a very notable effect on the careers of many of the great and good in British medicine. When they achieve the higher level, politics and adherence to the general social and educational values of the elite become rather more important than the demands of professionalization. "Regionalism" seems to me to be an unexceptionable concept, though, perhaps because of that, not very illuminating. Where I do disagree with Fox is in his determination to disenthrone all other factors in the story in favour of hierarchical regionalism. This leads him to exaggerated and misleading statements. He says, for example, that by the twentieth century, "How services should be organised had become the starting question for health policy. Money either to maintain the wages ofmembers of the working class or to finance their access to services had become a subordinate issue." (p. 30). If we believe this, what are we to make of the debates in Britain in the 1920s and 1930s on the relation between low wages and benefit levels and malnutrition and ill health? Many among the medical profession continued to be perfectly clear