BOOK REVIEWS

BOOK REVIEWS

Managing Scarcity by RUDOLF KLEIN, PATRICIA DAY

AND SHARON REDMAYNE. The Open University Press,Buckingham and Philadelphia, 1996. No. of pages: 161.ISBN 0-335-19446X.

This is a very readable book which, disappointingly,goes nowhere. At the end of the day we are none thewiser about how to proceed with ‘the management ofscarcity’, since the authors sit firmly on the fencethroughout, and their rather lame conclusion at the endis that:

‘Decisions about managing scarce resources in theNHS — as elsewhere — involve trying to reconcilecompeting values, interests and concepts of thegood…. Neither science nor economics will resolvethe pain of choice. The best we can hope for is tostrive to improve the process by which we reachdecisions’.

Since the aim of the book ‘is to analyse process’, thisconclusion sounds like an admission of defeat, since weare offered no vision of what a better process would be,or any advice on how to set it up. They do not advocatemaking decision making more explicit, or improvingaccountability in any particular way, or seeking to makeit more evidence-based, or shifting the power structure,or changing the institutional setting. They just sit ontheir hands and leave us to it.

What makes the book readable is its straightforward,non-technical, narrative style. Its typical approach toeach topic is: ‘Once upon a time there were someoptimistic people who thought that by doing X theycould improve things; It turned out that things weremore complicated than they thought; We can now seethat there are no simple solutions.’ Moral? There justisn’t one.

The optimistic people whose vain attempts toimprove things are pilloried in this way are:

(1) People drawing up national plans, the implementa-tion of which depends on the decisions of others towhom power has been delegated (pp. 16–19);

(2) People who seek to apply notions of need or equity,the implementation of which depends on thedecisions of people who have other objectives (pp.20–26);

(3) People who seek an equitable distribution of

resources but fail to specify how they should beused (pp. 43–47);

(4) People who seek to measure performance in termsof outputs but have difficulty linking outputs tospecific NHS activities (pp. 53–54);

(5) People who tinker at the margin without firstestablishing clearly where matters stand overall (p.56);

(6) People who seek to establish a more synoptic viewof decision making when all the system is deter-mined by incremental adaptation (pp. 60–62);

(7) People who use evidence about effectiveness tostop offering certain treatments and thus generateinequity when other health authorities continueproviding those things (pp. 73–75);

(8) People who use statistical evidence about groups todevise decision rules which are then applied toindividuals (pp. 85–87);

(9) People who believe that science can convert scarcityinto plenty [it is not made clear who these peopleare] (pp. 102–104);

(10) People who believe that clinical guidelines will (orshould) cut costs (pp. 106–108);

(11) People who advocate explicitness but fail to comeup with detailed mechanisms that work satisfacto-rily (pp. 112–115);

(12) People who want the views of the public to play agreater role, but have failed to come up with ananalogue that puts them in the role of decision-makers (pp. 127–131).

So what is ‘the way ahead’ to which the last 40 pagesof the book are devoted? Not money, not science, notthe experience of others. We are eventually offered‘policy options’, which appear to be no more than arestatement of the problems. It appears that we needmore information, more accountability, more system-atic comparison of outcomes using a common currency(but not — perish the thought — anything that econo-mists might come up with in this respect). Economictechniques require information we don’t have, so wehad better fall back on something that can rub alongwithout much information. Aha, here it is…DIALOGUE!

Earlier in the book it is suggested that one way to seedecision making is ‘as deliberation and dialogue, as anexercise in making judgements based not on science buton practical wisdom’ (p. 122). How, then, does ‘practical

HEALTH ECONOMICS, VOL. 6: 99–102 (1997)

CCC 1057–9230/97/010099–04$17.50© 1997 by John Wiley & Sons, Ltd.

wisdom’ get around the problems described elsewherein the book? How does it fill the information gaps thatare apparently fatal to the application of economicmodes of thinking? Where does it get its ‘commoncurrency’ for measuring outcomes from? How does itelicit and use the values of the general public in asystematic way? How does it explain the basis of itsdecisions in the absence of any conceptual frameworkthat links one bit of its ‘practical wisdom’ to the otherbits? If it embarks on incremental adaptation will it befound guilty of lacking overall vision or a clear idea ofwhere it is? Or if it attempts to draw up a generalmission statement which it then seeks to implement,will it be accused of failing to trim its ambitions to takeaccount of the fact that it has to motivate people withan appropriate incentive structure? What exactly is this‘dialogue’ to be about, what is admissible evidence, whohas what role within it, and in the presence of conflicthow are the trade-offs to be established, recorded andmade effective? If ‘dialogue’ were a solution, ourproblems would have been solved by now.

For those readers who think I exaggerate the sterilityof the book, I recommend Chapter 8 ‘Money or Scienceto the Rescue?’, and, closer to home, the bits thatdismiss the economists’ approach because of all thedifficulties it exposes. The implication is we are better

off with a system which does not expose thesedifficulties, since there is no system which actuallyresolves them! (pp. 124–127).

Amongst other bits that made me sit up with a startwas the assertion that ‘interventions designed to savelives cannot be measured on the same scale asinterventions designed to improve the quality of life’(pp. 32–33). And eliciting people’s views as to ‘whichfeatures of human suffering we believe it worthresponding to’ (p. 46) is apparently not a properobjective for ‘statistical ingenuity’ (i.e. systematic sur-veys of the values of the population at large), but has tobe left to ‘judgement’ (whose? how made? howexpressed? to whom accountable?).

I think the authors wrote their own epitaph whencommenting on the attempts of some managers todevelop explicit criteria. Their comment on theseattempts were that they ‘served largely to illuminate theproblems involved rather than to solve them’ (p. 62).That is also true of this book, with the addedreservation that at times the quality of the illuminationis rather poor. As I said at the beginning, it is a goodread which goes nowhere.

ALAN WILLIAMS

Centre for Health EconomicsUniversity of York

Fixing Health Budgets: Experience from Europe andNorth America edited by FRIEDRICH SCHWARTZ,HOWARD GLENNERSTER AND RICHARD B. SALTMAN.Wiley, Chichester and New York, 1996. No. of pages:239. ISBN 0-471-96497-2.

Fixing Health Budgets is a collection of essays takenfrom a two-day seminar held in Germany in 1995. The(multi-authored) book-of-the-conference can often bea disjointed affair, and to an extent this book is nodifferent. Chapters on priority setting, regulation andcompetition in planned health care markets, and thenthe heart of the book, the impact of fixed or globalbudgets in different health care sectors and differentcountries; if it’s chapter 9, it must be Canada.

However, the issue of global budgets is interesting,has a history of advocacy (though relatively littleresearch) and, given the pervasiveness of the approachacross health care systems at macro and/or micro levels,is certainly a subject worthy of detailed investigation.Superficially, when faced with an apparent inability tocontrol health care spending, the obvious and simplestanswer for both governments in charge of commandand control health care systems and private third partypayers, is to intervene directly by Act of Parliament or

legal contract to limit spending by fixing a globalbudget. Why rely on indirect approaches to costcontainment such as complex pay/reimbursement-linked incentive systems when all that is needed is tocut off the funds at source?

As ever, the issue is somewhat more complicated,and though the global budget policy lever may bedirectly connected to the cost containment policyproblem, it also has connections to other (desirable)health care objectives such as access to care andconsumption based on need. Moreover, there is noobjective reference for policy makers as to the appro-priate strength with which this policy lever should bepulled. Are the choices made (generally) by politiciansany more acceptable than those made by the actualconsumers of health care? And, taking one step back,as noted by Wynand and van de Ven’s contribution, itcould be argued from a free market approach that inany case such a lever is wholly inappropriate; we do nothave global budgets for cars or oranges, so why shoulddemand for health care be restricted? Well, this lastview is perhaps easy to dismiss as there is no freemarket in health care anywhere, and the real issueconcerns countries’ (collective) choices about how bestto meet the things their citizens want when not all ofthese things can be resourced and when it is generally

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Health Econ. 6: 99–102 (1997) © 1997 by John Wiley & Sons, Ltd.