HEALTHCAREANALYSIS VOL 4:353-360 (1996)

Reviews Edited by lan Buchanan

BOOK REVIEWS

The British NHS---Past, Present ... and Future? Health Policy and the NHS: Towards 2000

Judith Allsop, 1995, Longman, Harlow, 370 pages, £14.99, ISBN 0 582 042798 The N e w Politics of the N H S

Rudolf Klein, 1995, Longman, Harlow, 265 pages, £13.99, ISBN 0 582 23882X The Reorganized National Health Service

Ruth Levitt, Andrew Wall and John Appleby, 1995, Chapman and Hall, London, 299 pages, £14.99, ISBN 0 412 620002 Thirty years and more ago Penelope Halt prefaced the successive editions of her classic textbook The Social Services of Modern England with a quotation from Alice in Wonderland. It was all to the effect that however fast you ran, change wa.~ happening faster and as a result it was never really possible to keep up. Each of the books reviewed below could easily have used the same quotation: they are running into new editions, achieving a brief equilibrium only to be overtaken by new events, changed policies, new research findings, a different world for practice. It is, of course, a measure of the success of previous editions that new editions have been commissioned. Each of them have become standard texts on health policy in Britain since they were first published. They regularly feature on reading lists for undergraduate, postgraduate and professional courses in social policy and health management. N o w all three of them have been published in new editions in the same year. How have each of the authors approached the challenge of a new edition? Have they altered the format of their presentation, changed their perspective, developed their coverage? For Allsop this is only the second edition since the first was published in 1984. Klein, first published in the Politics Today series in 1983, with a second edition in 1989, now reaches a third edition. Meanwhile, Levitt, CCC 1065-3058/96/040353-08 ©1996 by John WiJey & Sons, Ltd.

Wall and Appleby is now in its fifth edition, having first been published in 1976 under the sole authorship of Ruth Levitt. Not surprisingly, each of the authors justifies their new editions by the need to inform their readers about the changes which have taken place in the NHS. Thus Allsop writes that 'there have been significant changes in the direction of health policy and the mode of delivery of health services'. For Klein the 1989 White Paper and the subsequent reforms constitute a watershed marking 'the end of the consensus which had contained party differences'. As a result 'the politics of the NHS have been transformed, even more radically perhaps than its structure'. Hence his change of title. No longer The Politics of the NHS, it is now The New Politics of the NHS. For Levitt and her collaborators it is The Reorganised NHS, boldly defined in red on their cover. 'The succession of changes imposed upon its policies and practices' they affirm 'have become so bewildering that even those who work in the services confess to feeling c o ~ d ' . Enter Levitt and her colleagues 'to explain, in clear terms, what has been happening and why'. The consensus clearly seems to be that the NHS has changed. The respective authors, however, have presented the change in different ways. In each case comparison with earlier editions is instructive. Klein's approach is simply one of 'add on'. The first four chapters of his latest edition remain unchanged. What is new in his book are two chapters chronicling more recent change: 'the politics of value for money' and 'the politics of the big bang' together with a new concluding assessment 'ambiguous past, uncertain fuOare'. 'I have resisted the temptation' he writes 'to revise or defend m y interpretation in the light of literature published since I wrote the first edition'. This reluctance is regrettable. Since 1983, for example, much historical research and the availability of documentary sources has re-fashioned our understanding of the 1940s and the creation of the NHS, and has provided new perspectives on the issues of later decades. Allsop's approach is different. It combines re-working and up-dating. Like the post-1948 structure of the NHS her first edition was tripartite with a 12 page coda concerned with challenges for the future and a

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selection of relevant documents. They too form part of her second edition, and a somewhat dated and eclectic selection they are[ The main text of her second edition is organised into four parts. There is some redistribution of chapters between the sections of the first and second editions and some that are entirely new. In the former she has endeavoured to include at least some of the more recent literature and research. The chapter on the founding of the NHS acknowledges the contributions of Webster and Fox; while in the one concerned with expenditure and resource allocation a number of recent studies appear, including some of those undertaken by the Audit Commission. Not surprisingly AUsop's new chapters mainly focus on the recent reforms--'Conservative government policies in the 1980s' and 'The 1990 NHS reforms'--and their impact as, for example, the chapter on 'General practice in the new NHS'. It is Levitt et al.'s approach which is most explicitly indicative of the changes that have produced a reorganised NHS. Even the titles of individual chapters make that clear: "The new health care economy', 'The purchasers', 'The providers' and 'Planning services for patients'. Comparison with the first edition makes clear another difference. Whereas the 1976 Levitt-model focused on England with a discussion of the Scottish NHS consigned to an Appendix, Levitt 1995-style recognises the importance of the comparative study of health care systems. Thus a separate chapter discusses the NHS in Scotland, Wales and Northern Ireland--a set of intra-national comparisons that is often overlooked--while another chapter locates the NHS in an international context. If the historical comparisons between Britain's experience in the 1950s and the 1990s indicates that a concern with the costs of the NHS is nothing new, as we approach the millennium international comparisons suggest that "getting the best health care out of a finite budget is a universal concern'. Each book recognises the importance of the reforms introduced into the NHS in 1990. For Allsop they are "significant c h a n g e s . . , the most crucial since the start of the NHS'; for Levitt et al. they constitute a 'major new direction' affecting 'every part of the service'; for Klein they represent 'the politics of the big bang'. But how did change of such magnitude come about against the formidable obstacles that were ranged against it? For Allsop 'the NHS was the last welfare bastion to be re-structured.., because of its popularity, the power of interest groups within it and also uncertainty about how to proceed'. Though not unaware of the influence of the economic and political ideas of the Thatcher governments, her analysis concentrates on the changes introduced in the 1980s: changes in management, increased charges, the introduction of competitive tendering and the various incentives designed to encourage the private sector. The ideas of Alain Enthoven concerning the purchaser/provider split, the Next Steps review of the Civil Service and the various recommendations and proposals of right-wing think-tanks all took the Thatcher

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government in its third term beyond existing change to more radical reform. The analysis of policy change, however, features less in Levitt's account. But for her and her collaborators the role of Enthoven is again crucial, as is the developing argument that the NHS should be subjected to the discipline of the market economy. To act on these principles represented a considerable political challenge. The NHS was a popular part of the welfare state and, though Margaret Thatcher had affirmed that the NHS was safe in her hands, more voters when questioned expressed themselves more willing to trust Labour on the NHS than the Conservatives. Whatever its outcome, to begin the process of change represented an act of considerable political daring for Conservative politicians. Of the three studies under review it is Klein who most effectively locates the movement to change and the consequences of change within the political climate of Thatcherism. This is the theme of his two new chapters and they suggestively justify the title of his third edition--The N e w Politics of the NHS. 'The story of the NHS' he considers, "provides an attempt to tease out what (if anything) was distinctive about the contribution of Thatcherism to the evolution of health care policy as against the role of those economic and social factors which helped to make Thatcherism possible and which provide the environment within which both the Government and the NHS were operating'. This analysis leads Klein to distinguish the Conservatives' record on health policy between measures that were designed to create better value for money from those which, after Working For Patients (1989), broke the period of inter-party consensus and introduced a 'new vocabulary of analysis and debate, challenging many of the inherited and accepted ways of thinking about the delivery of health care'. One of the practical consequences of the NHS reforms has been the introduction of fundholding GPs. Currently (April 1996) 53 per cent of the population are in fundholding practices, a figure which has increased from 41 per cent a year ago. Levitt et al. provide a clear and succinct account of the introduction and extension of this aspect of primary care, recognising that 'controversial issues associated with fundholding are as yet unresolved'. These include the methods by which fundholders' budgets are calculated as well as their alleged ability to secure better services for their patients compared to their nonfundholding colleagues. Overall, however, they conclude that 'devolving budgets to GPs has empowered them to do good things for their patients and there is much evidence to show that fundholders have caused their hospital-based colleagues to take a real interest in the demands of GPs and their patients'. Allsop treats 'general practice in the NHS' in a separate chapter. This enables her to locate the current focus on primary care in its uneven past development and to discuss the emerging pattern of team-working as well as the changing role and status of GPs--the medical practitioners that constitute one of the most

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significant differences between the British health care system and that of other countries. Like Levitt, Atlsop sees one of the consequences of the reforms as the enhanced power of GPs over their hospital colleagues in terms of the services they provide; but she also cautions that 'recent developments in general practice have tended to favour wealthier practices and do nothing to alleviate the already considerable variations in the way in which GPs practice'. As such, issues of equity which have a long history in the NHS coalesce with the more recent management concern of medical practice variation. Klein's assessment of fundholding is likewise cautionary. He suggests that while in theory it has ~lfilled the government's aim of extending choice, in practice two conditions need to be in place for it to work effectively. The first is the availability of information. This, I suggest, needs to go beyond the type of league table presentation currently available. The second is that there is competition between GPs. On this point Klein argues that fundholding, instead of maximising consumer choice, may, in fact, create its antithesis. 'Since successful purchasing requires a strong infrastructure of expertise and information technology', fundholding may well accelerate the trend towards larger practices. While that may in turn enhance the position of primary care, it also leaves unresolved the development of inter-professional collaboration on which a successfully integrated practice of health and social care depends. Finally, what of the prognoses which these three studies offer for the future? In some respects, each of them reflects the interests of their intended readership. For Levitt et al. the issues are predominantly managerial: priority setting--where they suggest that 'if one thing is certain in the future it is the necessity to make choices between competing demands on scarce resources'---and resources themselves, where they argue that paradoxically the competitive market designed to promote an economically efficient use of resources may, in fact, 'do more to expose the extent of underfunding than any other approach'. Allsop's future is also concerned with management and resources and the continuing issues raised by the 1990 reforms. But it is set within a 'scatter gun' approach that also looks at the political visibility of the "poverty and ill-health debate', 'preventive health' and "policies for community care and general practice': all of them issues, she suggests, that are likely to continue on the policy agenda through the 1990s. Levitt and Allsop both acknowledge the inescapable issue of political decisions on the fu~tre pattern of the NHS. For Klein it is central, and so it provides a stimulating conclusion to his book. The real policy challenge for the future, he suggests, will be the attempt to create an appropriate balance between the paternalism on which the NHS was founded and the consumerism that is the legacy of the more recent reforms. That may suggest a straightforward party political divide between Left and Right. But in practice, Klein argues, 'the two approaches may not be as radically different as party rhetoric would suggest'. As

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such, the 'uncertain future' will be one characterised by tension superimposed upon the increased demand from an ageing population and the opportunities for organisational change presented by new technology. 'In this world nothing can be said to be certain except death and taxes'. The aphorism of Benjamin Franklin applies equally to the NHS. It is the experience of change which justifies the publication of new editions of these standard texts. But continuity is also part of the story of the NHS. And, as Klein reminds us, 'as always, the past limits future options'. David Gladstone University of Bristol, UK

The Troubled Dream of Life: Living With Mortality Daniel Callahan, 1993, Simon & Schuster, New York, 255 pages, AUS$19.95 (paperback), ISBN 0--67170830-9 Daniel Callahan explores the meaning of death and the way in which reflection on death's place in life may help us recover a less terrifying view of it. He identifies three illusions which suggest that the West has moved from a reasonable to an obsessional concern with control over dying, although he does acknowledge a personal allegiance to the culture of sell-determination which gives him pause. In explaining the first illusion (that the achievement of choice in dying offers us a complete accommodation with death) Callahan makes two interesting points. The first is that advance directives, which serve the scientific management model he criticises, have had limited success both in their uptake and their practical application. Since it is often difficult to know clinically just when the stage corresponding to previously directed treatment cessation has been reached, advance directives are often overridden or ignored. Secondly, lack of public confidence that excessive treatment will be appropriately withheld or withdrawn has motivated the impressive increase in public support for the euthanasia movement in recent years. The implication for Callahan's thesis is that if we had confronted death communally instead of legislating choice about it, we would not have witnessed the clamour for practices which are not in the community's interest But, contra Callahan, accounts which provide understandings of autonomy and community in terms of each other can be provided. 1,2 These should motivate us not to discard advance directives, but to make them more consistent with this interdependence. And they should motivate us not to eliminate the possibility of active assistance in dying, but to recognise the importance of distinguishing between requests which are disguised expressions of anxiety about overtreatment (or other matters), and requests which are not founded on conflict.3 The provision of flexible advance directives and of active assistance in dying are both consistent with conditions concerning dying which Callahan thinks we should meet. These

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are that the self must accept death, that ideally we should be conscious and aware as close as possible to the time of death, and that death should be more public. (Ideally, a dying person should be alert, minimally supported by medical care, and in the company of those held dear). The second illusion concerns how we relate our mortality to nature, and how we connect causation and culpability. Callahan wants to relieve us of viewing the withdrawal of food and fluid as starvation, on the basis that it is nature which causes the ensuing death, not doctors. But this does not depend on the fact that nature kills, it is rather that since withdrawals are decisions within our power to make, withdrawals will be subject to judgements of legitimacy. Callahan says, after all, that 'we may be held morally responsible for death only to the extent that we have erected upon nature a set of moral rules and principles to govern our conduct in manipulating the biology of illness and death' (p83). He also concedes that wrongful letting die places doctors in the same category as killers, emphaslsing their moral culpability. It seems that he wants us to feel that we should view nature more importantly than we do in legitimate cases of letting die, but in wrongful cases of letting die, full culpability obtains. But surely we are as responsible in cases that are morally right as in those that are morally wrong. He has argued for keeping the distinction between physical causality and moral culpability, but he then blurs it according to what has already been judged as right or wrong. In this sense, the fact that it is nature which kills in certain cases is morally irrelevant. In recognising this, we affirm the importance Callahan places on distinguishing causality and responsibility. Not surprisingly, the third illusion concerns the drive for legalised euthanasia. For CaUahan, regulating euthanasia is the final neurotic stratagem, since this promises to solve our problems of dying when the going gets too tough, by absolutely burying the reality of suffering. 'What life itself may give us at its end is a death that seems, in the suffering it brings, to make no sense. That is a terrible problem, but it is the patient's problem, not the doctor's'. But this argument is confused. The motivation behind causing a patient's death, where that person is suffering, is one of relieving suffering, where that suffering is unacceptable and not otherwise able to be relieved. The fact that the suffering makes no sense does not entail that in bringing it to an end we claim to provide an account of its meaning. Meaning can logically and literally remain the patient's problem, often a problem not resolved before death, even though we provide assistance to die. Is euthanasia support seen as a solution to our inability to allow patients to die from their disease, as Callahan suggests? An enabling policy is arguably still necessary, even if Callahan has successfully disabused us of an obsession with control, since the two populations served by letting die and active assistance are distinct.

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What Callahan does achieve is a valuable foray into the contingent relations between the self, its choices, and our understanding of mortality. He is on stronger ground, for example, when challenging the presumption to treat. This is at least in part because here he is less prone to conflate the necessary with the contingent facts about control and suffering. He offers a useful staging of justifiable treatment withdrawals which would enhance the possibility of a peaceful death, and rightly says that such a possibility should be as important within medicine as the appropriate treatment of disease. Callahan also has sensible things to say about futility and economic considerations, again looking towards a more communal view. For example, there is something to be said for developing some common understandings of what comprises futile treatment in a public system of limited resources. This would relieve doctors of being primary gatekeepers, and simplify procedures (though not determine them) when patients are excessively demanding. Similarly, communal work on the meaning of death may support those who approach it with tremendous fear, and help them reach an accommodation. Callahan is candid about his own ability to reach a transcendent view of his fate; accepting the assault on the community when individuals are plucked from it is difficult, but it is important to feel the grief which accompanies individual obliteration. In this Callahan delineates a truth about the psychological health of individuals as well as communities. However, in creating more communal possibilities, we need to be aware of another illusion. Reducing the degree to which we deny death as a community, and increasing the quality of our connectedness and caring in the face of death, will pave the way for more peaceM death. But it will not eliminate the fact that some deaths will remain terrible. In these cases, it is not euthanasia which appears to be an obsession but the insistence that one be further supported against one's wish. Callahan aims to show us that a desirable community is one in which no one would express such wishes as would require active assistance to die. But shaping a community in which no one expressed such wishes would involve too complete an eclipse of just h o w variously we express our autonomy. When Callahan insists that we will and must be a burden on one another, and that the flight from dependency is a flight from humanity, he is appealing against atomistic individualism as an exhaustive description of human personality, and he is surely right. But Callahan himself allows a distinction between being a burden on others in a natural, interdependent way, and being a burden in a w a y which destroys others in the family. If we take him literally, we obtain an equally monistic and erroneous account of human nature. The acceptability of burdensomeness and dependency should be contextually determined by the community which, while it must mature in its acceptance of death, ought not romanticise it.

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References 1. Benn, S. I. (1988). A Theory of Freedom, Cambridge University Press, Cambridge. 2. Kukzewski, M. G. (1994). Whose will is it anyway? A discussion of advance directives, personal identity, and consensus in medical ethics. Bioethics

8(1),

41-46.

3. Gillet, G. (1993). Learning to do no harm. Journal of Medicine and Philosophy 18, 260.

Professional Ethics and Organisational Change in Education and Health Care Edited by Christine Henry, 1994, Edward Arnold, London, 144 pages, £16.95, ISBN 0 340 601426 I have a friend who thinks that people who work at universities, especially those who write academic articles and books, are somehow on a higher plane intellectually than anybody else. Why else would their ideas get into print? To dispel any such illusions I have sent him a copy of Professional Ethics and Organisational Change in Education and Health Care. He may be the only person it serves to enlighten. The book is a collection of essays all in some way based on a report, published in 1992 by the University of Central Lancashire, called the "Ethics and Values Audit' (EVA). Several of the contributors to the volume also worked on the report, which claimed to 'audit' the university's ethical status. The tendency to analyse all features of human life in terms of concepts imported from the world of finance is now so widespread that the meaningfulness of applying the concept of 'audit' to the study of ethics is apparently unquestioned by the contributors. To conduct the EVA, auditors sent out questionnaires and interviewed staff throughout the institution, in an attempt to discover whether the 'values' embodied in the university's Mission Statement were 'shared' by the staff. This would determine whether the institution "practices what it preaches', a phrase repeated with great frequency throughout the followup volume which, according to the editor, 'evolved' from the EVA. Christine Henry's opening chapter sets the tone for the volume with the story of Echo, a nymph who spurned the god Pan's advances and as punishment was tom to pieces by shepherds. Henry informs us that only her voice remained, adding poignantly: 'However, she had a Voice. '"Ethics"-the echo heard always within the professional soul'. Henry daims that in what follows this story she will discuss how 'ethical analysis and synthesis may inform effective decision making and subsequently action within a changing organisational framework'. She goes on to state that 'respect for persons' (another phrase repeated ad nauseam throughout the volume) is a 'central principle' which can 'guide' human conduct. By way of guidance she informs us that the term 'person' is 'unanalysable'. Apparently because it is a

'value-term' it is impossible to state criteria which will 'give clear direction on who should and should not be defined as a person'. Nor (presumably for the same reason) can she be very precise about what 'respect' means. It seems to involve 'positively caring and valuing other individuals" and we are told that ' "respect for persons" relates to other moral principles such as autonomy'. Unfortunately, 'autonomy" cannot be given clear definition either, 'since it is value-laden and an ideal abstract term'. (I expect this is why she does not say how, precisely, this 'principle" relates to respect for persons.) How this activity, of declaring certain terms very important and then pronoundng them unanalysable, can be described as an exercise in 'ethical analysis' is beyond me. Equally unclear is how this is supposed to provide 'guidance' for human conduct, since which actions in practice count as respecting persons and their autonomy seems to be a matter left entirely to the intlaitions of the reader. (When key terms are left this vague, one wonders what precisely was discovered by the EVA when certain values were found to be 'shared'.) At no point does she explain, let alone define, the position in metaethics which could make sense of the claim that because a word has an evaluative component to its meaning it cannot be analysed. Even the emotivists offer an •analysis' of moral language. Such a position, if correct, would surely render the very activity in which Henry purports to be engaged (applied ethical analysis) strictly impossible. Her assertions are supported, in the main, by quotation from her own PhD thesis and the EVA report, which she co-authored. The philosopher Wittgenstein once complained that certain arguments about our knowledge of our own mental states were akin to buying ten copies of the same newspaper, in order to demonstrate that assertions it makes are true. Presumably Professor Henry would not see a problem with this style of argument. Other chapters are equally confused. In a chapter entitled 'Applied ethics and managing change in the health field', Jane Pritchard argues that the changes in the organisation of the health service brought about by successive Tory governments should be 'firmly based on sound and shared values' which' must be grounded in ethical theory and wholly endorsed by all the people working in the organisation'. She then sets about trying to find 'Practical ways of putting into place ethical foundations', using 'the EVA report as a model'. It seems that the author at some point became too engrossed in the house-building metaphor which gives rise to talk of 'ethical foundations'. While it might make sense to examine a controversial policy in order to determine its ethical foundations (meaning, examine the arguments its defenders offer in its favour and consider whether they can be justified in terms of any plausible moral theory) it is not clear what it means to 'give' foundations to a set of decisions which have already been made (implying the foundations were originally missing) in terms of assumptions which everyone accepts. If the decisions are controversial, what sort of process is being envisaged

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whereby they can be justified in terms of assumptions we all share? This certainly cannot be done by practically putting anything into place: this idea suggests making further changes, rather than examining the justification of changes already taking place. Needless to say, Pritchard neglects to describe the 'ethical theory' she is thinking of in any detail. The following chapter, by George Campbell, is key to understanding what is amiss with this book and the confusions it represents. Language and reality are treated as virtually indistinguishable, such that changes in one are constantly confused with changes in the other, and it is assumed that we can improve the world by describing it differently. The chapter opens with the "hypothesis" that 'it is virtually impossible to give an objective account of anything', by which the author apparently means that the words we use cannot be judged either to correspond, or to fail to correspond, to reality, but rather a word is 'defined' in terms of 'its difference from other similar sounds'. He goes on to criticise various uses of language without realising that his own 'hypothesis' robs him of any basis for his criticisms. For instance, he objects to sexist expressions and 'the language of ownership' which "falsifies relationships'. If the use of a term is,explicable only with reference to other terms, a person who describes women in offensive terms Campbell mentions (' "tart", "'bimbo", "scrubber" and the like') cannot be wrong to do so since, according to Campbell, there is no question of words either corresponding or failing to correspond to reality. The only support Campbell offers for his view is an appeal to the authority of the continental philosopher Saussure. While Saussure hides the stupidity of his own position beneath layers of incomprehensible jargon, Campbell's account is to be praised for bringing it right out onto the surface. He states that while the dictionary defines 'love' as the opposite of hate, 'in terms of sound it is defined by the sound field around it' and "an understanding of this can be obtained by changing one letter of a word in sequence to obtain its o p p o s i t e . . . Love, lave, late, hate'. In other chapters Christine Henry and Janine Drew • describe the EVA: Henry and Norma Fryer claim that 'traditional western philosophers' have 'made a mistake' by not 'identifying the positive shared principles and values between all persons regardless of gender, colour or creed', and in yet another chapter authored by Henry, she outlines a 'Practical organisational ethical management strategy' whose key virtue seems to be that its initials spell the word 'POEMS" (a point the author emphasises, tempting the reader to apply some critical Saussurean analysis). Glenys Pashley claims that 'ethical b e h a v i o u r . . , can be strategic for organisational survival and success', though being neither a positivist nor a Popperian she feels no need to spell out clearly any circumstances which could falsify this claim. Julie Apps and Margaret Yeomans discuss nursing education, and note that government pressure forces local authorities to 'demonstrate the three Es of Economics, Efficiency and Effectiveness'. They then

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suggest that there is also another E which should be demonstrated. By this stage any reader who cannot guess the fourth E has not been paying attention. Overall, this book is characterised by vacuous uses of language and the constant repetition of key words and phrases, (ethics, values, shared values, respect for persons, autonomy, practising what we preach...) the apparent assumption being that if we can all say that we agree on something (however vacuous) this will somehow lead to real agreement about substantive matters, making the world a much better place. Were I to perform an intellectual audit of the volume as a whole I am afraid I should have to declare it bankrupt. Michael Loughlin

Manchester Metropolitan University, UK

Theory and Practice in Health and Social Welfare Neff Thompson, 1995, Open University Press, Buckingham, 138 pages, £10.99, ISBN 0-335-19177-0, ISBN 0-335-19178-9 In this book Nell Thompson relates theory to practice in the caring professions (here predominantly nursing and social work) whilst demonstrating the strengths and interconnections of both. H e aims to 'give a flavour' of the motivation, commitment and job satisfaction that can be gained from adopting an approach to practice informed b y theory. Indeed he argues that practice is impossible without theory, even if this is unacknowledged and unsystematic. He succeeds in his aim. The book is easy to read even though the topics covered are difficult to write about in an accessible way. Thompson introduces readers to many issues without losing the thread of his argument: theory and practice in the caring professions are inseparable and practitioners can benefit from a dialogue with academic theoreticians and v/ce versa; he defines theory and philosophy; he considers the nature of knowledge and the basis of knowledge claims; he ponders objectivity and subjectivity, and many other thorny issues. He also uses case studies (the Practice Focus sections) to illustrate theoretical points in a way practitioners will be able to relate to. Thompson uses the concept of 'reflexive practice' to integrate theory and practice. Good practice, he argues, must be anti-discriminatory practice. Here he sees the value of sociological theory as a sensitising device to the divisions and conflicts in society and, in particular, he singles out existentialism as a desirable philosophy on which to base professional practice. My main reservations about this book are twofold: the treatment of commonsense and the choice of existentialism as a focal point for the philosophical discussion. Firstly, much recent philosophical debate focuses, as Thompson does, on the need to avoid setting up binaries such as theory/practice and objective/subjective. However, throughout the book, although the point is made that it is not possible to separate theory from practice entirely, theory and

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commonsense are set up as counters to each other. As he points out, commonsense is often based on sociological research. However, commonsense does not dismiss ontology, it is based firmly on being and experiencing, that is to say, it is based on practice. Neither can it be said that commonsense necessarily protects dominant ideology whilst theories offer the ability to counter oppression. This view disregards the power which is inevitably involved in defining what counts as "theory" and what is defined as just commonsense. This can be shown by the example of women, whose commonsense views of power relations (based on lived experience and critical theoretical engagement) remained long unacknowledged by mainstream academic theoreticians. It is debatable whether commonsense approaches were undermining critical reflection and theoretical engagement, as Thompson argues, or whether it is possible to separate theory and commonsense in this way. In fact, the contrasts between the two have been taken too far, with commonsense the loser. Secondly, the sections on existentialism are extremely interesting, but I for one remain in the dark as to why this particular approach is singled out as more anti-discriminatory than other approaches. Nevertheless, for me the hallmark of a successful book is that I feel engaged in a debate, not that I agree with everything in it. On these terms this book is a successful introduction into a difficult area. Bogusia Temple Pharmacy Department University of Manchester, UK

Action Research for Health and Social Care. A Guide to Practice E. Hart and M. Bond, 1995, Open University Press, Buckingham, 244 pages, £12.99, ISBN 0 335 19262 9 (paperback) I was asked to review this book as I was putting together an action research proposal for a social work agency. I approached the review, therefore, not just as an academic exercise but as a 'student' looking for guidance about undertaking research at a ffrne when health and welfare professionals are being asked to offer clear evidence of their achievements. I was not disappointed. The authors bring considerable experience of research to this book and make it accessible to the reader. Their commitment to using research in order to improve professional practice and service provision is obvious throughout, their willingness to open up their practice to critical scrutiny is refreshing and their open writing style is a welcome change from literature which seems intent to mystify and obfuscate, rather than clarify the subject under discussion. The book is organised into three parts, the first of which introduces the concept and process of action research. In four chapters the reader is given an

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overview of the subject area, a historical account of its development, a typology of the distinguishing criteria of different types of action research, and a critical discussion of the process of composing a research proposal drawn from the authors" actual experience. The second part of the book continues the theme of reflective practice by presenting and evaluating five case studies of action research projects. Drawn from both health and social care, the studies demonstrate that it is possible to leave research subjects strengthened--that empowerment, by which the author means a transfer of power, can be achieved through research with practitioners a n d / o r service users in health and welfare organisations. The studies also demonstrate the difficulties and pitfalls of this form of research, indicating issues which action researchers must address when putting together proposals and working on projects. The involvement of sponsors and managers particularly is shown to cause difficulties. The third section of the book contains two chapters, one of which is a 'toolkit'--six collections of materials which the authors have found useful in practice. The first of these is a questionnaire for would-be researchers about their research idea. This is followed by groupwork and ethical guidelines. The other three collections focus on evaluation, attitude scales, and diary keeping. The final part perhaps works less well than the previous two sections. The toolkit is inevitably incomplete. The questionnaire, which encourages potential researchers to ask themselves why?, what?, how?, and when?, is useful. However, the discussions of groupwork and ethical guidelines, and evaluation, are merely introductory. The authors are aware that the chapter is not a substitute for further work by would-be researchers and its inclusion is a further demonstration of their commitment to demystifying research. However, I would have welcomed a more extensive range of 'tools'--for instance, guidelines on working in an empowering w a y with people w h o have experienced considerable disadvantage and oppression; on questionnaire and interview design; and on the dissemination of, and enabling people to take action on, the findings. The book's final chapter underestimates the obstacles against practitioners undertaking research into their practice. In both health care and social work, there is a divide between theory and practice and practitioners frequently appear too busy to undertake researcK This, I suspect, is to do with how organisations are structured and behave--practitioners do not have to be convinced of the importance of researchbased practice, but their working environments tend not to be conducive to enquiry and the expression of curiosity. I believe that professional training in health and social care should be equipping practitioners to act as change agents in their organisations, and the final part of this book could usefully have drawn further on the authors' experiences to guide would-be researchbased practitioners through the maze of organisational

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apathy, fear, preoccupation with tasks, and resistance to research. However, these criticisms should not detract from the strengths of this book: its honesty and openness, the accessibility of the ideas and the emphasis on antidiscriminatory and anti-oppressive values on which this form of research practice ought to be founded. It will not provide a complete guide to action research but it is an essential beginning. Students and experienced researchers alike will find it stimulating. Michael Preston-Shoot Professor of Social Work and Social Care Liverpool John Moores University, UK

Empowering Practice in Social Care Suzy Braye and Michael Preston-Shoot, 1995, Open University Press, 208 pages, £12.99, ISBN 0-33519245-9 Suzy Braye and Michael Preston-Shoot cover an important topic in this book: the links between community care policy, values and practice. They discuss why, for example, "community care' can mean different things to different people and can be underpinned by a range of values. Having given this overview they go on to position themselves as advocates of an anti-oppressive practice, a case which they spell out in detail. In so doing they

REVIEWS

provide a useful service by defirdng terms such as empowerment and partnership which, they argue, are often left undefined. They then go on to discuss tensions between needs, resources, empowerment and 'gate-keeping'. They also document the contribution of feminist literature and anti-oppressive strategies to social care, and discuss similar developments in the disability and mental health fields. A feature of the book which I particularly enjoyed is the way in which the authors attempt to tackle the aforementioned tensions by offering practical suggestions for coping with stress to those who actually have to deal with this problem. The recognition of the relevance of the organisational setting and the limits it sets to change is an important aspect of this approach. Other parts of the book deal specifically with training and development, explain existing strategies, and offer suggestions for change including the incorporation of anti-oppressive practice. In sum, the book achieves its aim of avoiding jargon while nevertheless offering a valuable resource for academics. Its accounts of policy, practice and existing research aid the understanding of a complicated field. The fact that I wanted to read more is a measure of the authors' success. Bogusia Temple Department of Pharmacy University of Manchester, UK