208 BOOK REVIEWS

its origins in the initiative of Doctors Award Redistribu- tion Enterprise (DARE), a group of doctors who allo- cated some of their 1983 pay award to fund schemes which would be unlikely to be paid for in the NHS.

Books of this sort tend simultaneously to please and disappoint, and this one does both. Papers are of quite varied quality; few offer new or previously unpublished research results but overall the book brings together the information from a very wide variety of sources that is relevant to health policy. Most of the authors are well known in their fields, and the papers display a good grasp of the issues and the literature. The book will act as a very useful source for students who want an overall grasp of policy challenges in the UK health services. Managers and health care professionals may also find it useful as a source of information and reference.

The strength of the book is its breadth of coverage, with chapters on changing patterns of disease, primary care, prevention, the training, recruitment and remuneration of staff, the consumer view, priority client groups, technology and several aspects of finance and management. Authors come from a wide range of disciplines, including economics and other social sci- ences, medicine and accountancy. The weakness is the lack of depth in some of the analysis. The reader is sometimes left with a desire for the analysis to move up one gear. For example, in an informative chapter on recruitment and remuneration, there is little discussion of the research evidence on the reasons why people stay, and why they quit. Similar comments could be made about the chapters on support services, private medi- cine, nursing and training of doctors. A book con- cerned with opening up the debate could afford to be a little more hard hitting.

The book is perhaps at its best when addressing areas where the biggest gaps exist in our knowledge. The dis- cussion of health promotion is balanced and interesting, and there is a wideranging chapter on measuring output. Neither of these try to move the

debate on to any great extent, but both set out the issues in ways that help to clarify.

For the economist this book 'helps to identify oppor- tunities for more rigorous analysis. By reviewing much of the research evidence, a number of areas emerge where researchers might do more to identify costs and benefits, and to understand production and cost func- tions more fully. There are also areas where more rig- orous sociological and psychological analysis would be fruitful. It is a very concentrated source of information about health services in the UK, and gives insights into the arguments and controversies. It should find its way onto many course reading lists, and will provide a useful source of reference, although there are a few irri- tating errors in the citations. Although the book looks at the UK as a whole, most of the discussion is confined to England. More might usefully have been made of differences between the four parts of the UK, seeing if lessons can be learned from these. In its aim to consider the future for health services it is perhaps disap- pointing, but is a first step.

CHARLES NORMAND Health Services Research Unit,

London School of Hygiene and Tropical Medicine

REFERENCES

Department of Health Working for Patients, CM555, London, HMSO 1989. Department of Health Caring for People: com- munity care in the next decade and beyond, CM849, London, HMSO 1989. Leading for Health: a BMA agenda for health, London, BMA 1991. Smith R. (ed.) The Future of Health Care, London, BMJ Publishing 1992.

Competition and PIanning in the NHS: The Danger of Unplanned Markets CALUM PATON. Chapman and Hall, London, 1992. No. of pages: 157. ISBN 0-412-47060-8.

In his book Calum Paton sets out to provide a critical commentary on the development and implementation of the NHS reforms, and considers alternative options for provision and finance involving competition and/or planning. Paton is a general health policy analyst, and so is concerned as much with the general political environment and the NHS structure, as with the more analytical concerns of economists. He begins by briefly setting out the alternatives for financing and providing

health care. Paton then quickly turns to the under- funding of the National Health Setvice, outlines his critique of competition or at least the shambolic com- petition introduced by the NHS reforms, and set out his main contention ' . . . that full blooded planning is still necessary in the NHS, and can be efficient as well as effective in meeting need'.

In chapter one he reviews the US health care system, since at least during the 'Downing Street Review' it was thought there were Iessons to be learnt here. He describes the pluralism of the U.S., the rise of Health Maintenance Organisation, and the failure of the Federal Competition Policies. [Does anywhere have genuine competition in health care?] He repeats the

BOOK REVIEWS 209

conclusions of other commentators that the U.S. experience is of little relevance in the U.K. In addition to reasserting the role of planning, he considers the pos- ition of the consumer in competition. The absence of consumer choice in the internal market was first recog- nised by Alain Enthoven. Paton draws attention to the Netherlands, where there is now (at least in principle) a choice of purchasers, and sees this as the only real form of competition. He regards it as ironic that while others are looking to integrate demand and supply, the UK is introducing a purchaser/provider split.

In chapters 2 and 3 he describes the domestic political background to the review. This may be of considerable interest to people who wish to know how health policy develops in practice, and in particular quite how the NHS reforms came to be. Paton adheres to a view that politically the white paper was a smoke screen, hiding the real problem of underfunding.

In chapters 4 and 5 Paton elaborates on his competi- tion versus planning thesis. He makes the point I have heard many times before that ‘... in some ways the White Paper (ie NHS reforms) will merely be formal- izing existing planning practice’. He believes planning can achieve all that can be hoped of from contracting and competition, without their disadvantages including fragmentation, ‘gaming’ and administration costs. From my reading, his planning proposal contains the following features (1) Regional Strategic Manage- ment-ie. where a region identifies the need for health care, seeks the resources to meet this need, and has a strategy to situate the facilities and other resources based on access modelling techniques. (2) Hospitals, (and presumably other providers) will be reimbursed at nationally set costs per Diagnosis Related Group, (3) GPs are free to refer patients at their own discretion. The novel feature in the current climate is the return of top down planning, which he believes is forsaken in the NHS reforms from an ideological obsession with com- petition. There is Little detail to his proposal, however he supports the management reforms and stresses health outcomes. The criticisms of this ‘prospective payment system with planning’ are many.

At this point, it is disappointing that he doesn’t address in more detail how the planning would be done. Past experience in the NHS and elsewhere with plan- ning is not a happy one. He is uncomfortable with rationing (‘some rationing may be inevitable’) and on a more formal approach to it says ‘A political objection is that such approaches institutionalize rationing’. As

would be expected therefore QALYs are not favourably received.

Chapter 6 becomes a more general discussion on poli- tics and policy, and includes the authors personal critique of past Conservative governments. He returns to priorities and consumer choice, where there are echoes of Dr. Loewv’s classic NEJM (1980) letter: ‘This leads us to question of the slippery slope: is it true that it is only a quantitative and not a qualitative leap from such an approach (ie QALYs) to the approach of, say, the Nazis?’ Having raised interesting and important philosophical issues, he fails to suggest how these can be tackled in practice. Paton seems content to leave their resolution to the vagaries of chance, class and medical prejudice, rather than open, public debate.

In the final chapter he examines the future without the hindsight of the British April 1992 elections. He rightly comments on the Governments extremely ‘vis- ible hand’ approach to overseeing the internal market, and the irony that despite the rhetoric of the white paper, its implementation has increased central control and for most people reduced their choice.

It was high time someone set down on paper the curious way health policy has developed in the U.K. in recent years. On these matters, Paton provides helpful and insightful documentation. Many of his comments on the implementation of the reforms accord with the impressions gained from conversation with the staff involved. Where the book is less convincing is on more analytical issues, addressed better elsewhere (eg. Culyer et a / . , 1991). Planning in health care is clearly here to stay, but I do not feel the ‘prospective payment per case with planning’ proposal made by Paton has been suffi- ciently appraised in theory, let alone in practice, to commend itself. This book may, however, provide a useful reference for future students who wish to under- stand the political background to the NHS reforms.

JOHN BRAZIER Medical Care Research Unit

University of Sheffield

REFERENCES

1. Culyer, A. J., Maynard A. and Posnett J. (eds) (1991). Competition in Health Care: Reforming the NHS. London, Macmillan Press.

2. Loewy. E. H. Cost should not be a factor in medical care. New England Journal of Medicine, 1980; 302(12): 697.

Restructuring Canada’s Health Services System : How Do We Get There From Here? Edited by RAISA B. DEBER AND GAIL G. THOMPSON. University of Toronto Press, Toronto, 1992. No. of pages: xi + 420. ISBN 0-8020-6005-6.

This volume contains the proceedings of the Fourth Canadian Conference on Health Economics, held at the University of Toronto in August 1990. The Conference was co-sponsored by CHERA, the Canadian Health