King Edward's Hospital Fund for London. London NW1. Setting Priorities in Prevention.K .... David Miller. (Pp 190; £11.95.) Blackwell. Scientific Publications ...
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variation in the percentage of procedures performed on a day case basis; for example, in some DHAs more than 90% of carpal tunnel decompressions were day cases, whereas in some others the position was reversed, with more than 900, done on an inpatient basis. Britain lags behind many other countries in the use of day case surgery. The Audit Commission's report outlines a number of practical steps to be taken if we are to catch up. These include the provision of self contained, dedicated day case units; better management of the existing units; and changes in attitudes of clinicians and managers.
The report is unequivocal about the benefits of increasing the use of day surgery. However, there is a shortage of research evidence on the extent to which this policy may place an increased burden on GPs and community services, and little is known about the attitudes of patients and their carers to day case surgery. The few studies that have been done are reassuring about the effectiveness of this mode of treatmnent. The Commission is attempting to address some of the problems it has identified: it has commissioned the development of a questionnaire which DHAs can use to assess patients' satisfaction, and it has developed a "basket" of procedures suitable for day case surgery, together with a means of standardising for age and case mix to monitor and compare the performance of DHAs. These will be used in local audits of every health authority in England and Wales to encourage the development of local strategies for change. The true test of this report will be the extent to which it is successful in achieving change in the rate of use of day surgery. It is a model of clarity: well illustrated and jargon free. I hope it will be widely read by surgeons and health service managers. ANGELA COULTER
Unit of Clinical Epidemiology Department of Public Health and Primary Care University of Oxford
What Price Quality? The NHS in
Review. Gordon McLachlan. (Pp 298; price stated.) The Nuffield Provincial Hospitals Trust, 1990. ISBN 0-900574-739.
not
This Rock Carling monograph of 1900 reflects on quality in the National Health Service and the contributions made by the Nuffield Provincial Hospitals Trust. As Secretary of the Trust for many years, Gordon McLachlan is well placed to observe the protean organisations and politics which shape the NHS. In particular, he uses the immediacy of the White Paper to illustrate more general issues which face a state run health service in a democracy. The Trust has sought to promote value for money and quality in provincial hospitals (originally reckoned as covering 90O0 of the population of the United Kingdom) through investment in research and development, and through the publication of results of clinical practice and of health care policy. McLachlan contrasts the independent analytic approach of the Trust with the current mechanisms for
commissioning research and disseminating technology in health care. While evidence of the effectiveness and scientific validation are expected of clinical practice, why is health policy (such as on GP budgets, hospital trusts, and service contracts) not also submitted to study and research? How can legislation be passed to endorse NHS reforms when there is a gulf between executive policy and public opinion? A prime reason, he argues, is that the NHS is funded, managed, and evaluated by the same political national machinery. There is no independent authoritative body "capable of dispensing dispassionate wisdom in the complex field of health care", to evaluate health policy, results of research and quality of health care, and to translate research into practice. He proposes that Britain might adopt the model of the Institute of Medicine of the National Academy of Science in Washington DC in order to separate responsibility for health policy from management responsibility for a government funded service. Similar proposals have come from a Royal Commission, a former chief medical officer, and a former permanent secretary of the DHSS. The idea has merit but who would be the catalyst? McLachlan gives ample details of the Institute of Medicine (and agrees it should really be "Health") but not of who should champion such a cause in Britain. This book is not light reading but it has a wealth of ideas and evidence, a blend of serious generality and appealing detail worthy of a well-stocked library. new
CHARLES D SHAW
King Edward's Hospital Fund for London London NW1
Setting Priorities in Prevention. K Schaapveld, E W Bergsma, J K S Van Ginneken, H P A Van de Water. (Pp 168; price not stated.) Netherlands Institute for Protective Health Care, Leiden, 1990. ISBN
leads to differences in the rank order for different health problems. The preventability of health problems in terms of the health benefits achieved by means of prevention is considered, and some of the models used to calculate these benefits are described. Attention is also given to the cost of prevention, including the use of cost-benefit and cost-effectiveness analyses. Such health gains, however, might be offset. It appears that preventive measures that are successful in themselves in the fight against coronary heart disease and cancer may have other undesireable consequences relating to decompression of morbidity and competing causes of deaths. A framework for a more rational approach to setting priorities in prevention is suggested, based on the concept of efficiency, with a list of interventions scored against a number of criteria. This process makes decisions explicit in the ranking of priorities for prevention. In summary, the report provides a good overview of prevention, but perhaps three particular points should be made on its contribution to the debate of setting priorities. Firstly, the list of interventions covered in the report is based on a medical model with respect to promoting healthy interventions lifestyles; involving organisational change (such as no smoking policies, ban on advertising) are mentioned in passing. Secondly, setting priorities does require consideration of the issue of inequalities-even in an overview-and how this fits into the efficiency equation. Thirdly, while the report gives us a framework for ranking priorities, how the public, professionals and politicians are engaged in the decision making process is crucial if priorities are to have meaning and form the basis for health strategies with leadership, commitment, ownership, and resources. AMANDA KILLORAN
Health Education Authority Hamilton House, London WC1
90-6743-183-4. With the announcement by the Minister of Health of the Health Targets Initiative in England, the debate on setting priorities in
prevention is now a focus of attention. This book is therefore opportune. Setting priorities in prevention is a report commissioned by the Dutch Ministry of Welfare, Health, and Cultural Affairs and prepared by the Netherlands Institute for Preventive Health Care. The report tries to answer the questions: "What can we realistically expect of prevention? How do we measure any improvements? Is it worth it? And is it possible to establish priorities for a list of prevention programmes?" At a general level, it goes some way to answering these questions, through giving an overview of all aspects of prevention. As such, it is a valuable and very readable introductory text, but the reader will need to follow up the useful
list
of
references
at
the
end
of
each
chapter to fill in the detail. It discusses how health, morbidity, and mortality can be assessed by means of health indicators to prepare prevention profileswhich provide pointers for prevention programmes. The use of various indicators
Costs and Benefits in Health Care and Prevention: An International Approach to Priorities in Medicine. Eds U Laaser, E J Roccella, J B Rosenfeld, H Wenzel. (Pp 160; DM48.00.) Springer-Verlag, Berlin, 1990. ISBN 3-540-52708-7.
Setting priorities for health care is a major policy challenge in all health care systems. The analysis of the costs and benefits of alternative, preventive, and curative procedures is an important technique and the collection of papers in this book is designed, according to the Preamble, to give "a valid and accurate review of the state of the art and problems of cost/benefit considerations in selected chronic diseases . . . ". The book was compiled from the proceedings of a conference bringing together economists, epidemiologists, and clinicians from Germany, Israel, and the United States. The problem of international comparisons of costbenefit studies is one of major themes throughout the book. The 19 chapters are divided into four main sections: discussion of economic concepts; case studies, including five on hypertension; quality of life measurement; and finally some different
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perspectives evaluating the present and future developments. The editors of this collection leave the reader to link and evaluate the differing viewpoints of the contributors. This could be difficult for non-economists, and the section containing the different studies on hypertension would have been enhanced by an overview, particularly on the international implications of the results. Read's contribution in the quality of life section, however, could be usefully read in conjunction with the practical studies. The strength of this collection is the wide variety of views expressed although, because contributions are short, sometimes arguments cannot be fully developed. For example, Thompson and Cohen describe an alternative to directly asking individuals to value, in money terms, different health states but do not describe the difficulties involved in obtaining a measure of health status which is needed for their methodology. The measurement of quality of life, an important component of health status, is reviewed well by Wenzel and Laaser. While not being a substitute for standard texts, this book will provide a stimulating read for epidemiologists, clinicians, policy analysts and others wishing to know more about economic evaluation techniques. CHRISTINE GODFREY
Centre for Health Economics University of York
Short Reviews Practical Epidemiology. D J P Barker, A J Hall. (Pp 184; ,C7.95.) Churchill Livingstone, Edinburgh, 1991. ISBN 0-443-03787-6. This is the new edition of this short practical manual of epidemiology for use in developing countries. The approach taken is to present the commonly used methods of epidemiology giving at least one example of each from the developing world. The text has been thoroughly revised and particular attention has been paid to techniques of data collection and analysis made possible by computers. The book is concise and clearly written and is undoubtedly one of the best introductions to the subject for those working in the Third World.
prove useful for others involved in such initiatives. Topics covered in the book include a brief history of mental hospitals v community care, community relations and consumer satisfaction, the management of change in the NHS, and financial aspects. Biomedical and Social Developments in AIDS and Associated Tumours. Eds G Giraldo, M Salvatore, M Piazza, D Zarrilli, E Beth-Giraldo. (Pp 284; price not stated.) S Kargera AG, Basel, 1991. ISBN 3-80555303-X. The epidemic of books on AIDS continues unabated. This one provides a broad but selective update on major areas of AIDS research. Contributions are from an international group of experts attending a symposium on AIDS and associated tumours. The book is organised into sections covering epidemiology and prevention, virology and oncology, clinical and diagnostic aspects, as well as therapy and social developments.
Lecture Notes on Epidemiology and Public Health Medicine. Richard Farmer, David Miller. (Pp 190; £11.95.) Blackwell Scientific Publications, Oxford, 1991. ISBN 0-632-02412-7.
This is a new edition of this short introductory text which has been reorganised and expanded to include more information on the epidemiology of specific diseases and on AIDS. The largest section of the book is concerned with epidemiological principles; another major section covers prevention and the control of disease; and a short section is concerned with health services.
Atlas of US Cancer Mortality Among Nonwhites: 1950-1980. Eds L W Pickle, T J Mason, N Howard, R Hoover, J F Fraumeni Jr. (Pp 186; price not stated.) US Department of Health and Human Services, 1990. NIH No 90-1582. The bulk of this book compris4es maps of the United States showing cancer rmortality rates for each of the major cancers. T'here is a short list of references and also tablles to back up and expand some of the data prresented in the maps. Some of the maps are use ful in showing geographial variations in tirne trends of specific cancers within the Un ited States. F G R FOWKES
Edinburgh to Institutions Mental Community Care. David King. (Pp 119; ,C8.00.) The Nuffield Provincial Hospitals Trust, London, 1991. ISBN 0900574-77-1.
NOTICES "Creating a common profile for mental health", Royal College of Physicians, London, 21 November 1991. This conference will consist of lectures and discussions on the development and use of a profile from a purchaser, provider, and local authority perspective.
"Using the common profile for mental health", Hannibal House, London, 3 December 1991: a workshop based conference examining the use of the profile in the development of the service specification. the Regional Director of Public Health of each region has been asked to send a team of delegates to this conference, so those interested in attending should contact the RDPH. Further information from: Rosemary McMahon, Professional Briefings, 120 Wilton Road, London SW1V IJZ, tel 071233 8322, fax 071-233 7779. The 4th International Symposium on Hypertension in the Community will take place in Jerusalem, Israel, on March 8-12 1992. Abstracts by December 1. For further information, write to: 4th International Symposium, PO Box 50006, 61500 Tel Aviv, Israel.
The 22nd National Congress and 1st European Meeting of Industrial Medical Officers will take place in Nantes, France, on June 2-5 1992. Special themes will be: Occupational medicine and the environment; Health, aging and work; and Occupational dermatosis of chemical origin. Further information from Dr Gendreau, Medecine du Travail, 2 rue Linne - BP 789, 44029 Nantes Cedex 04, France. Hazard control at the workplace: research and development of new risk Fourth strategies. nrevention International Symposium of the ISSA Research Section, Strasbourg, 22-23 October 1992. Sections will cover risk analysis and strategies, prevention appropriate measurement of atmospheric pollution at the workplace, protective equipment, and changing technologies and their influence on human operators. Abstracts by 31 October 1991. Further details from INRS (attn C Skornik), 4e Colloque du Comite Recherche, 30 rue Olivier-Noyer, 75680 Paris Cedex 14, France.
From
In the United Kingdom, governmental policy of running down long term institutions for the mentally ill and devloping community care has had mixed success. This book is a case study of the effects of this policy in Exeter where the author was chief executive of the local health authority. In Exeter the transformation was successful and the author has documented this in a way which may
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