Sot. Sk Med. Vol. 16, pp. 841 to 852. 1982 Pergamon Press Ltd. Printed in Great Britain

Cbaaging Health Care: Perspectives from a New Medical Spinal Cord wrier: PsywaZ Saeial and Vocational Care Setting, by GWLD T. PEr%off. Health Administra- Adprtmcot, by RECTA B. TRIEXHMANN. Pergamon tion Press, Ann Arbor, MI, 1979. 160 pp. No price given Press, NY, 1980. 234 pp. 525.00.

Changiw Health Care is a description and the author’s int rpretation in an anecdotal, historical narrative form of th I events which occurred in the development of the Medi- cal Care Group of Washington University. The description is the evolution and implementation of a teaching and research prepaid group practice. The book takes the form of a personalized narrative describing the development of this prepaid group practia. Of particular importance are the descriptions of the intra- and extra-institutional politics which are involved in the development of any such pro- gram in an academic institution and urban community. Anyone interested in beginning a university-based practia in a full-time system would probably benefit from the anec- dotal experiences of the author. There were many repetitive themes related to initially unanticipated challenges from the academic institution and the community. Solutions largely involved communication, reassurances and ac- cumulating experiences from the practice setting. The re- petitive nature of problems which occurred in the develop ment of the practice is a lesson which the author reiterates. The problems involved in prepaid health care and the re- lationship of marketing lo success is clearly described in the text. It appears that the MCG’s goal to effect gradual change and improvement in medical care within an aca- demic institution with a prepaid program was partially successful although the time to accomplish the implemen- tation of the program was extraordinary. However, rather than the practice becoming institutionalized, it was gradu- ally excluded from the school rather than acting as a conti- nual experimental program for change in teaching and research, Despite the political problems it is impressive how the community and the academic institution re- sponded in compromising to allow the development and implementation of the practice. A constant theme which the author describes is the physician’s fear of loss of their professional autonomy. This became a recurring lesson which had to be faced on multiple occasions when dealing with medical organizations, medical faculty, and members of the group practice. The goal of doing research to pro- vide information on the relative cost of a prepaid and non- prepaid health program utilizing a control group in the experimental design was partially sucassful, but incom- plete because of the relatively small numbers enrolled. They appear to have started and maintained a controver- sial medical care program in a major academic institution. This program clearly created controversy and the author and his staff had to devise alternative ways to deal with problems which arose and had no1 been anticipated with the original idea. Compromise was the main function of the developers of this new medical care program.

Spinal cord injury rehabilitation is a complex, multidisci- plinary area in which much has been written, but few good research projects accomplished. This boor, which is a review of the psychological, social and vocational rehabili- tation literature in spinal cord injury to 1978 has been needed, not only to summarize the current state of the art, but also to point out the many gaps in the literature. Areas of special interest which have not been dealt with suffi- ciently in the rehabilitation literature such as (1) the effect of the treatment environment, (2) therapeutic techniques, and (3) social factors are covered well here. An empirical approach is needed. in this area of rehabilitation and this book, with its approximately. 375 references, provides a well-organized, well-written accuunf useful for experienced professionals as well as students.

A good example of theorizing in the absence of data and applying untested concepts lo patient care is shown in Trieschmann’s treatment of the construct, depression. She presents a number of theoretical definitions of depression and descriptions of the few empirical studies in adjustment to spinal cord injuries which have attempted lo measure depression. Her review indicates that professionals should rethink their ideas about whether or not depression is a necessary precondition for adaptation.

Another useful feature of this book is a chapter on research methodologies. Finding appropriate dependent variables in this complex field is aided not only by the listing and critique of the various measures which have been used, but also the inclusion of several new outcome measures in process of development. The discussion of these measures, presentation and critique of various work in the field, and highlighting of current deficiencies in the literature makes this a book of 1000 dissertations and should be very valuable for a graduate student in rehabili- tation.

The chapter on Social Factors in adjustment to spinal cord injuries reviews an area which until recently has been ignored in most rehabilitation centers, i.e. the social conse- quences of spinal cord injury. In addition to the more com- mon social factors such as family involvement and demo- graphic variables, Trieschmann cites evidence which shows that not only are attitudes towards physically disabled people negative, but that these attitudes are reflected in behavior. The spinal cord injured person is seen as a member of a devalued minority group “who has suRered a great misfortune and whose life is consequently disturbed distorted, and damage (p. 91). A later chapter on Thera- peutic Techniques discusses Social Skills Training, one way for the person with spinal cord injury to deal with these attitudes and behavior.

1 believe that many physicians involved in either the development or participation in a group practice, politi- cians and administrators would benefit from reading this personalized description of the development of a prepaid medical group practice.

Department of Medicine Unirersiry of Colorado Denver. CO. U.S.A.

RICHARD L. BYYNY

One can perhaps find a few papers to which no reference is made (notable to this reviewer is the lack of coverage on psychophysiological intervention in spinal cord injuries) and one could argue that more space needs to be given to one area or another. However, in a field which publishes in so many different journals, it is difficult lo cover all the literature. Areas of emphasis. of course, are, within li_mits. subject lo individual interpretation. so that criticism of the author here is a matter of individual preference.

In sum. the book is an excellent textbook or reference

BOOK REVIEWS

841

842 Book reviews

volume, well written. amply documented. and a valuable the options facing the reformers and the chances of their addition to the literature. success.

Stofi Psychologist &inn/ Cord lniurv Sorcice Q.A. Medical i‘eker Palo Alto. CA. USA.

MICHAEL DUNN The limitations of this simplistic juhgement is illustrated

in the second phase of the book. Four chapters are used to describe the reality of central power. the ‘internal dy- namics’ of health authorities. the activities of members and senior officers of health authorities. and the impact of medical staff. Two conclusions in this analysis stand out for me: the negative non-directional power of central government, and the dominance of the medical profession.

Crisis in the Health Service. by STEWART HAYWIXD and ANDY ALASZEWSKI. Croom Helm, London, 1980. I54 pp. f11.95.

The title of this book is misleading. A more accurate title would be Management and Change in rhe British Health Service: the 1960’s and rhe 1970’s. In the text there is no mention of a crisis. Instead the.authors describe and evalu- ate the organisational and administrative reforms, and the purpose of these referms. in the National Health Service in the last two decades.

There were times during the reading of this book when I was not clear about its purpose. On completion I would state the aim of the authors is to argue that firstly, the intentions of the administrative and orpnisational changes

* made during the last 20 years have not been achieved: and secondly, these reforms have not succeeded because they were based on a centralist, managerial philosophy of change. From this the authors conclude that to be success- ful a change strategy must meet 4 rquirements (pp. 148-9). There must be recognition of the local dimension of the N.H.S. There must be recognition of the likely pre-domi- nance of the local political system in decision-making. Change strategies must be directed at the total local system for management and not just managers. There must be orientation to the end product of the service.

The authors have succeeded in their first aim: their de- scription of the changes, the purpose behind the reforms, and some of the results of the new procedures and struc- tures, is well written. They have not succeeded in their second aim, to show that the causes of the failure of reform is because of a centralist, managerialist philosophy of change. While 1 have some sympathy with their findings, the analysis and arguments advanad do not support the conclusions.

The book is divided into three phases. The first is a historical background (Chapter 2) of the major commen- taries on the N.H.S. since 1948. The second (Chapters 3-6) analyses the internal dynamics of the N.H.S. ihe third phase (Chapter 7) is a discussion of the sianificana of the previous analysis.

The purpose of the first phase as stated at the beginning of Chapter 2 is to show how and why a centralist, mana- gerial perspective has come to dominate thinking about the N.H.S. and that it has prevented an adequate analysis of local health agencies. This purpose is not real&d. The authors rely very heavily on work by Carpenter and Man- son in Health and the Diuision of L&our. Unfortunately the Carpenter and Manson .material does not support the interpretation of Haywood and Alaszewski. The terms ‘centralist’ and ‘managerialist’ are too simplistic. There are numerous ways in which the balance of authority between top. middle and bottom management can be struck. There are greatly difliring styles and techniques of management. Consensus management is one of many. To describe the changes during the last 20 years as ‘centralist’ and ‘mana- gerialist’ obscures important distinctions. If the diagnosis is misleading, the prognosis must be flawed. The choices were not just between consensus and non-consensus manage- ment, between ‘scientific’ management and muddling through, between management and politics, between day- to-day administration and planning. What would have been more useful would have been to describe some of

From this analysis it is possible to argue that any future change strategies should be based on a positive and direc- tional rqle for the centre and a management and organisa- tional style based on firm delegation and accountability rather than imprecise group consensus. These conclusions are just as plausible on the evidence provided as the 4 requirements for change strategies suggested by the authors and stated at the beginning of this review.

I would recommend this book to anyone who wanted a good description of the organisational and administrative changes and theii effects in the N.H.S. during the last two decades. For an analysis of the problems facing the present service, and the future opportunities and limitations for change, the book is useful but not as comprehensive as the descriptive aspect.

Corporare Planning Unit Wellington Hospital Board New Zealand

ROBERT HOWELL

!Soeial and EeonomIe Impacts of Coronary Artery Disease, edited by EDGAR D. CHARLES and JENNIE J. KRONENFELD. D.C. Heath, Lexington, MA, 1980. 141 pp. 517.95

Cardiovascular disease consumes more of our attention and resources than any other medical problem except, per- haps, cancer. Coronary artery disease is largely responsible. This pervasive disease interrupts the lives of the middle- aged with sudden death and disabling pain and provokes enormous anxiety in the worried well. As a result of our haste to invest in clinical research and prevention, we are now confronted with new methods, many of them depen- dent on high technology, that promise relief without guar- anteeing it and only uncommonly are accompanied by use- ful measures of the human and economic costs involved.

Irrespective of this, people like myself who are not car- diologists or cardiac surgeons have to marvel at the heart doctors’ ability to reclaim life and restore health, whatever the cost. Perhaps we should also praise those who submit their skills to the scrutiny of professionals from other disci- plines and those who have begun to use techniques from these disciplines to evaluate their own work. The principlei of decision theory, economics, management, and even sociology are now regularly used in the best cardiology literature to assess patient care.

This book constitutes one such multidisciplinary effort. It is edited by an economist and a sociologist and written by them along with their colleagues from cardiology, car- diac srirgery and public health at the University of Alabama. Chapter 5, the book’s central chapter, recounts work that was first published in the 1979 volumes of the American Heart Journal, the American Journal of Cardiobgy, and Circulation. This chapter reports the hos- pital ‘costs’ of medical and surgical therapy and describes the effects these two therapies have on patients’ employ- ment, family income, and perceived health. Chapter 5 is supported by an introduction and four other chapters that provide summaries of the epidemiology, pathophysiology and management of coronary artery disease, followed Ijy a discussion about how all this information might be used to formulate national health policy.