Julian Tudor Hart
Julian Tudor Hart
Dr Julian Tudor Hart, a founder member of the Socialist Medical Association and the first honorary President of the Socialist Health Association died on July 1, aged 91, in the week of the 70th anniversary of the NHS, which he fought so hard to improve and defend.
His death is a sad loss to socialists and campaigners: but his life’s work has left us better equipped to address health inequalities, and to understand the weaknesses and contradictions that limit the effectiveness of the NHS.
Although he was best known for the memorable phrase and approach of his 1971 Lancet paper on the "The inverse care law," Julian was at the same time a consistent and relentless critic of the impact of markets on health care. These were also central to the same keynote article, which appeared almost twenty years ahead of Margaret Thatcher’s government’s legislation establishing an “internal market” in the NHS.
The opening abstract (summary) of that article is an example of Julian’s always compressed and lucid writing style and his skill in the brief exposition of a complex concept:
“The availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.”
These linked themes, so succinctly set out in 1971, have formed a near constant focus for campaigners and progressive academics since the late 1980s. Indeed, the concept can be read more broadly to argue that those with the greatest health needs are almost always those least able to afford the market price of health care as a commodity (hence the absence of any health systems anywhere entirely based on free markets); and it can explain why those areas facing the greatest deprivation are always those with the least political power to force change.
However, Julian in his later years was increasingly reluctant to refer to the inverse care law. We might say that the importance Julian himself attached to the concept and the phrase was inversely proportional to the common acceptance and use of the term. He argued that the inverse care law detached from the wider social and political critique was relatively trite and unimportant.
He was angered by the ways in which the concept had been effectively devalued and hijacked by managers and establishment politicians seeking to claim a fig-leaf of concern for health inequalities while pressing forward with policies to deepen and entrench the purchaser/provider split and market mechanisms in the NHS.
For Julian, the key question was not neat phrases and clever argument, but testing and proving ideas in practice, improving not only the work of GPs but the social and organisational context in which they worked.
He worked for 30 years as a general practitioner in a health centre in Glyncorrwg near Port Talbot in South Wales, which became the first recognised research practice in the UK and pioneered the regular monitoring of blood pressure, proving it could help reduce strokes and premature deaths in high risk patients.
It was also characteristic of Julian to reject hierarchical notions of the GP or doctor standing above other health staff: he insisted that the doctor could only function effectively and fully as part of a team, and his research on blood pressure and other medical issues always stressed the importance of high quality records, teamwork and audit.
For Julian’s later work the concept of the team was widened still further, to include the role of the patient, who, he argued had to be seen as a principal factor in the “co-production” of improved health. This led on to the importance of continuity of care – which has just been underlined by recent research, sadly at the same time as the latest faddish preoccupation with using apps and online consultations serves to weaken the links between GPs and patients.
Julian wrote in 1994:
“Continuity is not in practice valued in a competitive market, in which consultations are seen as isolated provider-consumer transactions, scattered between competing providers”. (Feasible Socialism, p47)
He also emphasised the necessity of doctors (who had been shown on average to interrupt a patient after only 18 seconds of asking them why they had come) listening to patients rather than diverting them with premature questions:
“Studies of medical out-patient consultations show that 86% of diagnosis depends entirely on what patients say, their own story. What doctors find on examination adds 6% and technical investigations (X-rays, blood tests, etc.) add another 8%. To most lay people and even some doctors these figures are astonishing, the reverse of the proportions expected.” (Feasible Socialism, p 42).
As a fierce critic of the competitive market developed by New Labour from 2000, Julian was one of the founding members of Keep Our NHS Public in 2005. His most substantial book-length study The political economy of health care was first published in 2006, with a revised second edition in 2010. The mixture of Marxist analysis and clinical perspective mean that passages can be a less easy read than Feasible Socialism, and Julian was never quite satisfied with it, but the book offers many useful insights.
Julian was also active in collaboration with many experts and academics internationally, and a leading figure in the International Association of Health Policy in Europe (IAHPE): the last time I saw him speak in a public forum was at an IAHPE conference I organised at Coventry University in June 2009.
Julian Tudor Hart receives a special award from IAHPE President Alexis Benos at 2009 conference in Coventry
In his later years Julian became less confident of his ability to set out an extended and detailed argument in writing, and the last time I met him, for lunch at a restaurant in Swansea in the summer of 2015, he persuaded me to take on the production of a book on the clash between professional ethics and the market, and the problems in developing and maintaining patient-centred care.
However, this was just at the point that work began to launch Health Campaigns Together and the task fell by the wayside: Julian’s death is a powerful reminder of the need to return to this task and deliver a book worthy of its originator.
Many will miss the inspiration and support we had from Julian, who was a quietly spoken, friendly but steely-willed ally, with a complete commitment to quality health care and a far-sighted Marxist understanding of the contradictions of the health care system that has arisen after almost four decades of efforts to undermine the principles of the 1948 NHS.
But he and his work will not be forgotten as long as campaigners fight to defend, reinstate and improve the NHS and health care.
John Lister, Co-chair Keep Our NHS Public and Editor, Health Campaigns Together
Phillip, who died in March 2018, was actively involved in the establishment of Health Campaigns Together, attended a number of affiliates' meetings, and played a very important role in our successful November 4 conference in Hammersmith Town Hall. He will be much missed, and we are pleased that we have now received this appreciation of his work as a campaigner.
North Devon Save Our Hospital Services
Phillip Wearne was a journalist and documentary film-maker. He was exceptionally intelligent, knowledgeable, determined and courageous. He was extraordinarily kind-hearted and considerate and performed countless little acts of personal kindness.
He was generous with his time and recklessly spendthrift with his energy. He was enraged by, and fought tirelessly against, injustice, cruelty, environmental degradation and the greed, corruption and folly of our political leaders.
He was always looking for recruits to the fight, and supported and encouraged any he found. He was a loyal and caring friend and was loved and admired, and is now sorely missed, by hundreds of people around the world. The world still needs him.
Phillip joined the march through Ilfracombe in 2015, organised by Green councillor, Netti Pearson, in defence of the Tyrell Hospital. He also joined the Junior Doctors' picket line in 2016 and was one of the founding members of SOHS (Save Our Hospital Services), for which he quickly became the driving force, advising, exhorting, encouraging. He worked tirelessly, attending meetings of the group and also of the CCG and Devon County Council's Health and Wellbeing Scrutiny Committee. He organised the leafetting (most of which he did himself) of practically every house in North Devon. He wrote letters to newspapers, he organised, or helped organise, and spoke at, SOHS's public meetings in numerous North Devon and Torridgeside towns, for which he organised the publicity, delivering much of it himself. He encouraged contact with other health campaign groups. He spoke at rallies for the NHS in Barnstaple and London. He was a constant inspiration for the group, even when he left North Devon in the summer of 2017 to live in London, from where he continued to do research for SOHS and to send countless e-mails to its members.
Phillip was an active member of several other campaigns: Stop Hinckley, Grow Heathrow, Runnymede Eco-warriors' camp, Palestine Solidarity Campaign, CND, Campaign Against the Arms Trade, and he also supported Croughtonwatch and other groups opposed to American use of RAF bases and direction therefrom of drone attacks. Campaigning against the arms fair in London last September he was arrested the first morning, standing in front of an Israeli tank, and spent all day in the cells. The charge against him was, much later, dropped, but day after day, for months, he attended the trials of other protesters, giving them much needed advice and moral support.
In 1990 Phillip was in Haiti for the election of Jean-Bertrand Aristide and was outraged when an US-aided coup d'état toppled that government in 1991. In 1992 he joined the Haiti Support Group and very generously gave them his time and expertise. Haiti held a very important place in his heart. He kept saying that the world owed Haiti so much. He talked of the 1791 slave rebellion led by Toussaint L'Ouverture, which, in 1804, brought about the colony's independence, the only slave uprising that led to a state free from slavery and run by non-whites and former captives. He was in Haiti to cover the 2010 earthquake and was very angry at the failure of the outside world to help Haiti properly and by the UN's carelessness in deploying Nepalese soldiers with cholera there, so that thousands of Haitians, who had no immunity to the disease, subsequently died of it. He remained dedicated to Haiti's cause until his death.
Phillip was a very active member of both North Devon and Torridge Green Parties (and, I think, the Green Party in East London, where he lived from 2017). He attended meetings, advised, nagged, cajoled, encouraged, and tirelessly pounded the streets, leafletting and canvassing for various candidates. He certainly was instrumental in getting Greens elected. He also campaigned for Caroline Lucas in Brighton, for Molly Scott Cato in Bristol and for other Green candidates in Dorset and the Isle of Wight.
Phillip was the author, or co-author, of several books, including Central America's Indians (1984), The Maya of Guatemala (1989), Return of the Indian: Conquest and Revival in the Americas (1996), Tainting Evidence: Inside the Scandals at the FBI Crime Lab (1998), Collapse: When Buildings Fall Down (1999).
Sam Semoff died peacefully on 11 Jan in the Royal Liverpool Hospital after a long illness.
Hundreds of us in Liverpool and elsewhere knew him as a friend and comrade. He was warm,
intense, committed, and ready to engage with anyone he met. He lived in Liverpool 8 (Toxteth) as
an American in exile, an anti-racist, lifelong opponent of Zionism and supporter of the Palestinian
people. We knew each other best through his work in defence of the NHS. As a founder member of
Keep Our NHS Public Merseyside, Sam continued chairing meetings even while carrying an
oxygen bottle and undergoing dialysis.
No-one – porter, domestic, nurse, medic or Consultant - got within a few feet of Sam in hospital
without being asked their attitude to the Private Finance Initiative (PFI), or the latest government
plans to undermine the NHS. During the Junior Doctors strike, he persuaded staff to let him appear
at the Atrium window above the demonstration in the ambulance forecourt. Sam phoned through to
a mobile pressed to the megafone and addressed the strikers.
Good morning everybody. I am a patient on the Cardiology ward here in the Royal. I’ve been in
here two weeks and I can tell you the care has been absolutely great.
Sam's deep knowledge of the communities in Liverpool 8 came to the fore when NHS England
handed over the management of a dozen Liverpool surgeries to the private firm SSP. Sam was a
patient at Princes Park Health Centre, which had pioneered community treatment for the whole
person in the 1980s. So SSP wasn't just an affront to his politics. It was personal. Sam hit back with
10,000 leaflets in Arabic, English and Somali, delivered door to door and to every shop on Lodge
Lane. He had been Sec. of Granby Ward Labour Party, and ran this like an election campaign.
Jeremy Hunt is a liar – he says we need a 24/7 service, well we have 24/7 service. I have been in
here two weekends and a doctor was always available, so were support services.
Hunt is also a hypocrite – he talks about patient safety, yet he wants to remove requirements that
limit junior doctors working unsafe hours, putting patients lives at risk.
The doctors went into medicine to help people, their main concern is their patients’ needs above
all else... Hunt knows this and takes advantage of it, he thinks he can push them to the limit and
they will not do anything.
But they have said enough is enough, they know the risks to their patients in going along with
Hunt’s proposals are greater than doing nothing. I wish a lot more health workers would reach
The Government is determined to decimate the NHS and turn it into a market based health care
system like in America. They have eroded the principles of universality, of a comprehensive
integrated service that is publicly accountable and they are now working to undermine publicly
provided, as the NHS is broken up into bits and turned over to the private sector where the
overriding aim is profit.
When they get around to removing the principle of a service free at the point of delivery based
on need, it will be too late.
I hope to see you out here next week and the week after.
It culminated in a public meeting of around 130, almost all of whom were current or former patients
at Princes Park, furious at how the service had collapsed. It was held in three languages with
interpreters and a PA system, allowing Somali women who sat with their friends in a side room to
address the entire gathering. The meeting led directly to a survey, a report, and the intervention of
the CQC which eventually kicked SSP out of Liverpool, though some NHS staff were victimised in
Sam led the fight against PFI funding for the new Royal Hospital. He was vilified in the Echo,
which ran the scurrilous headline “Bogoff Semoff”, claiming that an American was trying to deny
healthcare to the people of Liverpool. No-one ever apologised for that, even when the newspaper
finally woke up to the PFI catastrophes at Whiston Hospital and around the country.
Sam brought a Judicial Review which forced the Royal to re-run their consultation as they had not
even mentioned that the new hospital would be funded by PFI. Every Liverpool Labour MP backed
the scheme, as did Cllr Nick Small and Joe Anderson, at that time leader of the Labour group within
the Council. The Royal PFI was signed off by Andy Burnham as Health Secretary on the eve of the
2010 General Election. Sam lodged a second Judicial Review, challenging the claim that the PFI
would deliver Value for Money.
On 17 Nov 2010 BBC Radio Merseyside put Sam up against Joe Anderson, who declared "I know it
doesn't provide Value for Money now or in the future, but it's the only game in town". That
admission ricocheted all the way up to a Treasury Select Committee Inquiry into PFI. But the JR
was derailed when Cllr Small approached the Legal Assistance Board and got them to pull the
funding for Sam's challenge.
Sam had already left the Labour Party over Iraq, but rejoined more recently in support of Jeremy
Corbyn. He joined Unite, and was active in the Community Branch of the union. He knew
construction workers blacklisted by Carillion, but didn't quite live to see the company collapse with
the new Royal half-built. A few days earlier, Sam commented “Workers united, is the only defence
When the news of his death came through, a demo at the Health and Wellbeing Board turned into a
tribute to Sam.
We all miss him. Let's honour him by continuing the fight.
Listen to a recording of Sam