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within the welfare system. According to Wolfes conjecture about the role of government, he considers it important to pre-fund new or existing social insurance programmes and to promote private insurance options. This concept is based upon the British NHS system, and Clintons health plan proposes six key words: security, simplicity, saving, choice, quality and responsibility.

Wolfes careful analysis shows that the direction for change is to promote a pre-funded system rather than a pay-as-you-go system, where people save for their own old age. He argues that a better way is to change the governments financing policy, including private insurance. His new plans for insurance could be exempt from corporate taxation and individual income tax. He also discusses other health and long-term care innovations, such as socialhealth maintenance organizations, long-term care individual retirement accounts, reverse annuity mortgages, vouchers, care rationing, mandatory public insur- ance and expanded private coverage.

Wolfe insists that the best hope for improvements in quality care and coverage lies in expanded self-financing. The problem is how the majority of elderly people can gain from private insurance with reasonable premiums (because expensive premiums will force them to remain uncovered for long-term care). The decisive factor in establish- ing a new insurance system is the willingness of the insured to pay premiums - with full, rational consideration of possible consequences of non- or under-insurance.

There is always the ambivalent relationship between adverse selection and moral hazard which can, however, be resolved through a radical shift in philosophy towards welfare pluralism or welfare mix. In the 21st century, value patterns will have to shift from a concern with efficiency to one of sharing benefit. This will have to be borne out in the insurance system. Wolfe argues that the alternative lies in the single, mandatory insurance plan, because it can avoid adverse selection and thereby provide the average consumer with a fairer and more stable insurance premium.

The Wolfe idea should be combined with a preventive health care policy which then allows the reduction of spending on (acute) health care for the elderly. Thus, health and community care policies should be integrated and allow people to live as full citizens within communities. It will be possible to increase physician and hospital services, if a growth rate of 1% per year in capita real GNP can be ensured.

Comprehensiveness can make a healthy, secure and decent retirement possible for all (p. 138). Through the reorganization of Medicaid, alternative financing of long-term care can provide states with block grants instead of matching funds. The replacement with mandatory or private coverage, and a more rational integration of family and institutional care can promote innovative forms of voluntary private coverage (p. 109).

Examples of innovation are the reverse annuity mortgages or continuing care retire- ment community, in which people are provided with guaranteed lifetime residential and nursing services by paying a lump-sum entrance fee and subsequent periodic fees.

Wolfes theory provides important insights, in particular when elaborating on the sociological classics dealing with the relationship between voluntary choice and equity. In the well-developed US health system, a non-profit organization approach enables people to feel their own responsibility to share the burdens of ill-health voluntarily and to pay premiums willingly.

NAOTO SUGIOKA Hokusei Gakuen Univmsity, Japan

BRITTAIN, J.M. and ABBOTT, W. (Eds) (1993), Information Management and Techno- Iogy in Healthcare: A Guide to Education and Training, Taylor Graham with the support of the National Health Service Training Directorate, 379 pp. Price f60.

The guide provides a variety of chapters written by different contributors. The chapters are grouped into eight sections: What is Information Management and Technology (IM&T)?, IM&T Competences, Skills and Knowledge, Training Strategies and Plans,

142 BOOK REVIEWS

Sources of IM&T Training Outside the NHS, Educational Technology, The Delivery of Training, IM&T Experiences Outside the UK, and Overview and the Future. Through- out the guide it is emphasized that information is a valuable resource which needs to be managed in much the same way as any other resource and that there needs to be a cohesive and corporate approach to information. The section on IM&T Com- petences, Skills and Knowledge provides a useful introduction to the information cycle, organizational differences in IM&T staffing and levels of competency for information management.

The chapter Council of Europe Training Strategies identifies four guidelines on which to develop training strategies for health information systems. It argues that there should be as much emphasis on public health objectives, their application and their impact on health care management and health promotion as on the technical aspects of information management. One of the initiatives is the need to involve patients and the general public as target groups to facilitate their active and effective participation in their own treatment, health education and in the appropriate use of health resources. None of the strategic approaches, described in other chapters, actually includes patient/ general public as a target group. Two simple questionnaires are included as part of the chapter Investing in People for Information Systems Effectiveness. These are practi- cal diagnostic tools for health service managers to use in their own organizations.

(i) provide guidance, help and direction to those in the NHS involved in IM&T; (ii) guide the thinking of general managers and trainers who have to decide how to

(iii) enable NHS staff wishing to be trained in IM&T to seek out the various options

(iv) assist those in further and higher education interested in providing IM&T training

For those involved in IM&T training and education plus NHS staff wishing to be trained, the guide provides an overview of some of the options and types of training, but more detail is required before an informed decision about training could be made. Detailed information is provided about LearnIT 3, but the chapter on Literature and Textbooks would be of more use if a summary had been included, not just a list of references. The nature of Distance Learning is discussed, with a good rksumk of packages and a comparison of traditional and distance-learning modes of study. However, the chapter on Open Learning does not identify any packages. Was the author (Christine Greenhalgh) told not to recommend the RAINBOW I and I1 packages available from her company (Using Information in Managing the Nursing Resource, 199 1; Using Infor- mation in Contracting, 1993)? Health and safety aspects and project management are briefly mentioned, with no references provided for those who would wish to pursue.

People unfamiliar with the topic will find that the guide does promote thought about the need for IM&T training and how to develop training strategies. This book may be a useful library addition for health service staff to dip into rather than a book to be bought by individuals.

The words of the editors sum up the achievements of the publication: We have tried to cover the full range of the subject, but we are conscious that there are some aspects that have not been given as much attention as we would have liked in this edition.

The editors ambitious intention is that the publication will:

develop and deliver IM&T training;

available and make informed decisions about their training; and

and education for the NHS.

REFERENCES

Using Information in Managing The Nursing Resource (1991). Developed by a Five Regional Consortium in conjunction with Greenhalgh and Company Limited. GCL Publications, Macclesfield, Cheshire.

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Using Information in Contracting (1993). Developed by Five Regions in conjunction with Greenhalgh and Company Limited. Sponsored by the NHSME. GCL Publica- tions, Macclesfield, Cheshire.

RUTH ROBERTS AN WaIes Nursing In formation Systems Project Manager, Welsh Health

Common Services Authority, Information Group, Cardiff

PATON, C. (1992), Competition and PIanning in the NHS: The Danger of Unplanned Markets, Chapman and Hall, London, 157 pp. Price f17.95.

Competition and Planning in the NHS: The Danger of Unplanned Markets is a welcome and much-needed analysis in an era when the global emphasis on the virtues of capitalism and privatization is in danger of denying government, bureaucracy and planning any legitimate role in health policy. This conclusion seems both premature and naive when many regimes in Eastern Europe are in transition and others are fundamentally restruc- turing their health care and other delivery systems.

Paton contrasts the policy intentions pursued by British Conservative governments under the rhetoric of competition during the 1980s with the outcomes of those policies, and concludes that equity and fairness need to be reinstated as central goals of health policy. Achieving affordable and equitable health care, in the United States, the United Kingdom or elsewhere, will require clear health priorities, need-based planning and population-based resource allocation rather than blind faith in competition. A recogni- tion of these priorities is even more vital when resources are scarce than at times of budgetary largesse.

It should not be difficult for reasonable people to accept that, stripped of its ideological overtones, the essential meaning of planning is the intelligent use of public resources to meet need in a democratic society monitored in that end by a democratic parliament and a means of co-ordinating strategies for public health. Only dogmatic extremists would disagree with these premises.

Patons book focuses on the consequences of market-oriented and competition-driven health care reforms. He examines the effects of a disastrous combination of incoherent policy with the underlying structural-political problems of the NHS, which included decades of underfunding and inconsistent policy. This unstable and incoherent policy, which alternated between radical and incremental reform, has predictably been the cause of considerable difficulty in implementation and numerous departures from policy intentions.

Readers interested in the history and politics of agenda setting at different policy stages, in the theoretical and political thought processes which influenced alternative proposals, and in the final adoption of health care reforms in Britain, should read chapters 2 and 3. Chapter 3 contains an extensive discussion of the specific elements of reform proposals under the NHS,which include: self-governing hospitals; funding and contracts for hospital services; practice budgets for GPs; indicative prescribing budgets for GPs; capital charges; medical audits; NHS consultants; appointments, con- tracts, and awards; and implications for family practitioner committees. Those interested in a detailed account of the conflicting pressures generated by competition and planning and the arguments on both sides should see chapter 4, which also highlights the key differences between the pre-White Paper NHS and the post-white Paper NHS. Those interested in the actual workings of the contacting system chosen as a tool for implement- ing the White Paper and the outcomes it is likely to produce should consult chapter 5. Chapter 6 takes a broader cut by introducing ethical considerations and discussing the many tradeoffs of the reforms in the context of the political economy of the NHS in the 1980s.

Reforms in the United Kingdom have fallen short of expectations. Among the most frequent criticisms are: lack of ideological, argumentative, political and policy coherence