128 BOOK REVIEWS

health care and on the liberating benefits of the market and private diversity. There is virtually no acknowledgement of the extravagance, inefficiency, or inequity possible and visible in the private health systems of some ‘established market economies’. Thus, at the end of the day, this reviewer was left feeling that ideology and rhetoric had triumphed over reason and DALYs. This is a pity because the report contains much valuable material about the burden of illness and the potential for effective and inexpensive health gain. The

process by which poverty creates ill health is repeatedly identified and the notion that wealth creates health is implied. One suspects, sadly, that many nation states and their politicians would be more responsive to a message that health creates wealth.

LOU OPIT Centre for Health Services Studies

University of Kent

Continuity and Crisis in the NHS. Edited by R. LOVERIDGE AND K. STARKEY. Open University Press, Buckingham, 1992. No. of pages: 237. ISBN 0-335-15599-5.

The sub-title of this volume is ‘The politics of design and innovation in health care’ but it covers many topics with which economists are familiar, and one paper is co-authored by an economist. Those who bridle at the accusation of over-use of jargon by economists may take some comfort here. Frequent reference is made to concepts such as ‘legitimacy’, ‘cultural values’ and ‘role-sets’, and the text is littered with ‘exemplars’, ‘demystification’ and ‘operational fragmentation’. However, it would be unfair to apply the last phrase to this book as it has more coherence than many ad hoc collections of essays.

Although national political themes feature in the early chapters, the principal focus is on the micro- politics of health service decision-making. One third of the book deals with the changing role of different professions in the NHS, and information systems and hospital design merit three chapters each. The chapters vary in style and quality; those of most interest to economists being the editors’ introduction and conclusion, and that by Cox on the introduction of general management into the NHS. The other chapters report the results of previous research, with varying degrees of relevance to these themes and levels of analytical content.

Most disappointing is Shaw’s reproduction of work from the early 1980s on medical equipment innovation, which makes no reference to the impact of policy changes which have taken place in the last decade (‘Area Boards’ are referred to at one point). The chapters on the politics of hospital design contain some useful historical information, but provide few insights into decision-making processes that an alert participant in an option appraisal would not observe for herself. Belief in the value of case-study methodology is not strengthened by reading that ‘at a time of great financial crisis the presence of the treasurers (on the Manpower and Commissioning Team) was more noticeable’.

The chapters on information systems range from

broad policy review to detailed case-studies, and ‘war- stories’ of intra-authority bureaucratic in-fighting. The reader can choose between the medical view (Ahmad) that ‘the technology is available that with a visionary’s application can solve many of the monumental problems of the health service’; and the cautionary tone of Coombs and Cooper who suggest that ‘IT systems will not-and should not-provide a fix for these problems’. Closer inspection shows these views to be less divergent than at first appears. The former is arguing that lack of managerial vision hinders the sensible use of IT, while the latter are arguing that until health authorities sort out their objectives and management structures, IT systems will never be effectively introduced.

Questions of de-professionalisation of community pharmacists on the one hand and the unwillingness of practice nurses to undertake more responsibility on the other, are discussed in some detail. A recurring theme in the early chapters is the need for professional groups to rethink their organisational roles in the NHS in the face of an increasingly managerialist approach-begun with the Griffiths report and enhanced by the white paper. There are some lessons to be learned here by economists seeking to gain more influence over NHS decision-making .

Although a new approach to familiar issues can be refreshing, this is a book to confirm economists’ prejudices and suspicions rather than one which opens up new prospects for research. The discussions of broad themes are illuminating, but given that most of the authors adopt the case-study approach, some of the errors of detail are surprising. In the introduction the distinction is not made between the NHS in England and in the UK. In a book relatively free of quantitative analysis the numbers are accident prone. For example, the introduction prematurely reduces the number of English RHAs to eleven, and on page 166, seventy seven hospitals subdivide into over six hundred. In all, a book for the committed student with prior knowledge, rather than the general reader.

JOHN HUTTON BatteUe MEDTAP

London