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© 2001 Blackwell Science Ltd

Blackwell Science Ltd

Book reviews

Edited by Bob Hudson

What Works: Evidence-based Policy and Practice in Public Services

By H. Davies, S.M. Nutley and P.C. Smith (Eds). The Policy Press, Bristol (2000), £17.99 (paperback), 380 pp. ISBN 186134 191 1.

What works

provides a valuablecontribution to what is becomingan increasingly vociferous debate onevidence-based policy and practice.From its origins in medicine, theevidence-based movement has, overthe last 10 years, had a profound andsignificant impact across the broadfield of health-care, extending itsinfluence to other disciplines such aseducation, social services and thepolicy process more generally. Integralto the modernisation agenda of thecurrent Labour administration, theemphasis on ‘evidence’ in policy andpractice reflects increasing publicand political scepticism towardsthe actions of professionals chargedwith delivering public services. It canbe attributed to the growth of a wellinformed and well educated public,the explosion in the availability ofinformation fuelled by develop-ments in information technology,the development in size and capacityof the research community, and theincreased focus on effectiveness andaccountability in government. At thesame time, as evidence-based policyand practice (the more generic term)has expanded beyond its medicalorigins, the different conceptions ofknowledge that underpin it and themodels of research utilisation that flowfrom it, have been subject to consid-erable debate and reinterpretation.

The book is organised into fourmain sections. The introduction pro-vides a broad overview of the roleof evidence in different models ofthe policy process. This is followedby a detailed exploration of the

contribution of evidence to policy-making across key service areas: health-care, education, criminal justice, socialcare, welfare policy, housing trans-port and urban policy. These offer arich source of material illustrating thedifferent kinds of legitimacy issuesthat arise in the creation of evid

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ence and the complex relationshipbetween evidence and its imple-mentation in policy and practice.Drawing on the ideas and issuesraised in these case studies, the nextsection pursues a thematic analysis,focusing on methodological aspects ofevidence generation, the relationshipbetween evidence and the manage-ment of change in respect of indi-viduals and organisations, andaspects of research capacity devel-opment. The concluding chapter pullstogether the lessons from this diver-sity of knowledge and experience toidentify some of the conceptual andmethodological challenges in takingforward the evidence-based enter-prise, while at the same time sound-ing a note of cautious optimism.

Some flavour of the contours andcomplexities of the evidence/policy/practice debate are elucidated inthe contrasting approaches to whatis knowledge, evidence generationand the impact of research on decision-making within the areas of health-care, welfare and social policy. Intheir chapter on health-care, Daviesand Nutley explore the dominanceof the experimental paradigm or wayof knowing. Although there are vari-ations within health-care – nursingfor example is less wedded to thismodel – what is seen as legitimate interms of evidence is shaped and con-strained by the conceptions under-pinning evidence-based medicine.This posits the existence of a hier

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archy of different kinds of evidenceof which the randomised–controlledtrial is the ‘gold standard’ method for

assessing the efficacy and effective-ness of treatment methods. Critiquesof the method have not only centredon the methodological issues thatarise in the conduct of randomised–controlled trials and meta-analyses.They also relate to the narrow defini-tion of ‘evidence’ within evidence-based medicine and the view that itpresents a distorted and partial viewof science, threatening to constrainother, equally valid scientificallybased research, as well as prioritisingresearch questions that are amenableto this type of design.

A significant strength of theevidence-based movement in healthis the systematic nature of the sys-tems in place to generate evidencethrough transparent processes forcommissioning research, in line witha centrally developed strategicframework. Such a strategy, more

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over, has not only been aimed at thedevelopment of new evidence but thecollation, review and disseminationof existing research evidence throughsuch initiatives as the ‘Cochranecollaboration’ and the ‘NHS centrefor reviews and dissemination’.

Robert Walker’s discussion ofwelfare policy illustrates the signifi-cance of the role played by researchin shaping policy – albeit rarely asthe dominant influence – researchbeing the supporting cast in a pro-duction that stars ideology, politicalconsiderations and expediency. Alsorevealed within the welfare field isthe complex web of relationshipsthat exists between influentialresearchers, who are shapers ofvision within the political processand policy implementation. Indeed,he argues that it would be undemo-cratic to demand a paramount rolefor research evidence within an arenathat is imbued with values. It is ofinterest also that, within this arena,there is no single methodology that

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© 2001 Blackwell Science Ltd, Health and Social Care in the Community

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dominates evidence generation.Rather, what is revealed is a commit-ment to methodological pluralism.At the other end of the spectrum,Geraldine McDonald’s chapterargues that, in contrast to health-carewhich places as paramount experi-mental ways of knowing, there islittle or no legitimacy offered tosuch conceptions of evidence withinsocial care. Instead there is a focus onuser experiences and processes ofcare that deploy qualitative andsurvey methods. While not deridingthe importance of such questionsand concerns, the antipathy toexperimental methods is viewed asproblematic both in terms of deploy-ing a broad repertoire of methodsand addressing questions aboutoutcomes.

In their thematic chapter of theimpact of research on decision-making, Nutley and Davies point tothe vast differences that exist betweenservice areas in the breadth and qual-ity of available research evidence andthe ways in which this evidence isutilised. Underpinning evidence-based medicine, for example, is therational, scientific model of researchutilisation which posits a direct, prim

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arily linear relationship betweenevidence and practice. From this per-spective, in order to achieve effective,efficient and accountable practice,the key task is to disseminate the evid

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ence to practitioners to ensure usein decision-making. Empirical evid

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ence suggests a considerably morecomplex process, encompassing howboth behavioural and organisationalchange occurs. Drawing on diversedisciplines and theoretical models ofchange management – a diffusionof innovation (rural sociology),problem-solving and learning (psy-chology), and systems and organisa-tional change (cybernetics) – they offera rich source for thinking throughthe research/practice debate.

The crosscutting chapters aroundthe theme of research methodologiespoint to the importance of develop-ing methodological flexibility and ofunderstanding the capabilities andlimitations of different study designs.Crucial here is a consideration ofhow different research designs can

be utilised to broaden out andreshape what constitutes evidence.The key question is not to engagein a sterile debate between qualit

-

ative or quantitative methodologies.Rather, it is the appropriate balancebetween different methodologicalapproaches, which will depend onwhether the interventions are relat

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ively simple, applied to large popu-lations in stable settings, or are com-plex, involving the centrality ofhuman agency and where the pos

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sible causal mechanisms are poorlyunderstood.

In summary, this book offers athoughtful and insightful explora-tion of the complexity of issues inevidence-based policy and practice.It will be of value to both practi-tioners and managers who areseeking to grasp the nettle of incor-porating research evidence intodecision-making. At the same time,researchers will find much food forthought in the elaboration of theresearch/practice terrain.

Mary Godfrey

B Soc. Science M Soc. Science

Senior Research FellowNuffield Institute for HealthUniversity of Leeds

November 200196000000

Book ReviewsBook Reviews

Book Reviews


Nursing, Medicine and PrimaryCare

By Anne Williams with contributionfrom Bonnie Sibbald. Open Univer-sity Press, Buckingham (2000),£15.99, 120 pp. ISBN 0-335-201679.

Partnership, flexible working andcross-boundary collaboration are thewatchwords of current primaryhealthcare policy. The assumption isthat if you create the opportunities towork together through changingfunding mechanisms and organisa-tional structures the different pro

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fessional groups will co-operate todeliver a needs-led National HealthService (NHS). Implicit within thesechanges is the belief that an emphasison professional identity is a possiblehindrance to development andmodernisation. Anne William’s bookmakes an important addition tothe debate and offers a different

perspective. One theme of the book isthe importance of professional iden-tity for practitioner morale. Takingthe current context of primary care, itengages with the long running dis-cussion about the role of the profes-sional. In particular, it considers howthis impacts on the way practition-ers’ contributions are recognised andwhether confidence in a professionalidentity is compatible with the demo

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cratic principles of user–patientinvolvement and empowerment.

Anne Williams examines the cul-tural differences between two of themain players in primary care: medi-cine and nursing. Drawing on workundertaken whilst at the NationalPrimary Care Research and Develop-ment Centre at Manchester, Williamsoffers a sociological analysis of howthe two groups have coexisted inprimary care and the implicationsthat changes in role definition mayhave for effective co-operation in thefuture. The book addresses theeveryday contradictions of workingin primary care and what it meansfor professional groups to live withuncertainty. There is an interestingdiscussion of how differencesbetween medicine and nursing’sinterpretation of the shared values ofcare, holism and compassion affecthow their focus and work is repre-sented. In capturing how commonlyshared ideas can have radically dif-ferent meanings for the two groups,Williams extends the discussionabout the value that is placed on dif-ferent types of knowledge and exper-tise within primary health-care.

The book is divided into six chap-ters. The first two chapters provide auseful introduction and overview ofthe history and development ofprimary health-care. In particularthey discuss what the legacy of theprinciples of the internal marketand the shift to the ‘new’ patterns ofcollaborative working have meantfor medicine and nursing. Inevitably,policy initiatives such as the NHSplan that have been launched subse-quent to the book’s publication haveovertaken the speculation of certainsections as to how primary care willcontinue to evolve. Subsequentchapters address working on the


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boundaries between nursing andmedicine and what opportunitiesexist for innovation and development.

The book suggests that littleattention has been paid to the bound-aries between nursing and generalpractice. It could, however, beargued that research into the role ofthe district nurse and health visitorhas consistently examined the influ-ence of medicine on how their workis defined and priorities for practiceare made. In many respects whatWilliams calls the ‘ambiguous space’between medicine and nursing inprimary care has always been there.In the last 40 years the external influ-ences on how medicine and nursingdefine themselves may havechanged but the themes of uncer-tainty and role confusion persist.Lisbeth Hockey’s early work ondistrict nursing brought out thecontext-dependent nature of primarycare and the inherent ambiguityand diversity of interpretation of whatconstitutes the district nursing roleand its relationship with generalpractice. There are strong parallelsbetween this and William’s discus-sion about living with uncertainty.Reference could also have been madeto the research undertaken in theseventies and later, which examinedthe implications of community nursesattachment to general practice, rela-tionships within the primary health-care team and issues of status, powerand substitution (for exampleGilmore

et al

. 1974, McIntosh &Dingwall 1978). What is enlightening,however, is the analysis of what pro-fessional identity currently meansin general practice and nursing, par-ticularly as the general practitioner(GP) role becomes subject to moreexternal scrutiny and challenge.The examination of the distinctionsbetween delegation, role substitutionand role expansion is particularlyrevealing.

A further strength of the book isthe analysis of the development ofnew roles. The example of the emer-gence of nurse practitioners in theUK and USA explores the interplaybetween external factors such as costpressures, self-interest and a concernfor patient welfare in the develop-

ment of new roles. However, it isdisappointing that the internaldifferences between the three mainplayers in primary care nursing –health visiting, district nursing andgeneral practice – are not discussed.This omission downplays the signi

-

ficance of their different profes-sional histories and focus of work.Although primary care nurses mayshare a common culture they do notnecessarily articulate their valuesand priorities in the same way. Thedifferent emphases on age groupsof the population, public health,management and screening of diseaseinevitably affect how they representtheir work. Quinney & Pearson(1996) suggest this means that theyoften work in parallel rather than incollaboration. Several commentatorshave noted how internal preoccupa-tion and differences within nursinghave often meant that there has beena failure to engage in wider policyissues or collectively respond tochange. The consequence of thishas been that managers and medicinehave overlooked nursing concerns.Williams advocates the importanceof collaboration and collectivity ofpurpose in primary care nursing. Shedoes not discuss how achievable thisis within nursing, the likely barriers,or what might be the prerequisitesfor success. A reference to the devel-opment of integrated nursing teamsin primary care, their involvementin health-needs analysis and whetherthis represents a real opportunity toachieve a shared voice and purposemay have informed some of herconclusions. A clear sense of profes-sional identity and articulation ofthe contribution of nursing is clearlyneeded. However, it underestimatesthe challenges if

all

that is requiredis a clearer articulation of nursingevidence, a responsiveness to healthneeds and a greater confidence inparticipating in forums where thenursing voice is in the minority!

In conclusion, this is a stimulat-ing book that affirms what medicineand nursing hold in common as wellas drawing out the where there isconfusion and uncertainty in howthese two groups relate to each other.It is an important book because with

the development of Primary CareTrusts the concerns of the book willalso be the concerns of these emer-gent organisations and their practi-tioners. It is a very useful text forhelping practitioners to debate theambiguities of primary health-careand should be recommended read-ing on postgraduate courses con-cerned with primary health-care.

References

Gilmore M., Bruce N. & Hunt M. (1974)

The Nursing Team in General Practice

.Council for the Education and Train-ing of Health Visitors, London.

McIntosh J. & Dingwall R. (1978)Teamwork in theory and practice. In:R. Dingwall & J. McIntosh (Eds)

Readings in the Sociology of Nursing

.Churchill Livingstone, Edinburgh.

Quinney D. & Pearson M. (1996)

Different Worlds, Missed opportunities;Primary Health Care Nursing in a northwestern District

. Health and Commun-ity Care Research Unit, University ofLiverpool.

Claire Goodman

BSc MSc PhD RN DN

PgCertEd

Senior LecturerPost Registration NursingUniversity of Hertfordshire

November 200196000000


Book Reviews


The Essentials of CommunityCare: A Guide For Practitioners

By Peter Sharkey. Macmillan PressLimited, Basingstoke (2000), £13.99,164 pp. ISBN 0-333-77289-X.

It is the combination of familiaritywith elusiveness that makes com-munity care an important but oftenfrustrating concept with which tograpple. Ideas promoting a versionof community care have prompted aseries of policy and practice develop-ments since May 1997. Yet, in manyways the agenda remains dominatedby the changes introduced in theearly 1990s as part of a very differentpolitical and even philosophicalcontext. Arguably New Labour hassought to place renewed emphasison both the importance and the roleof the previously fading concept of‘community’, whilst in typically para

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doxical fashion it has also produced


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legislation (in the area of mentalhealth, for example) that has placedsignificant emphases on ‘out of com-munity’ ways forward. In particularwe can see, on the one hand, the (per-haps inevitable) tension between thenotions of inclusivity involving vari-ous ‘communities’ and, on the otherhand, the continuing drive to focusupon individuals’ needs and wishes(as shown in the ‘Valuing People’White Paper). In many ways thisfascinating and crucial aspect is atthe heart of Peter Sharkey’s efforts tocapture the essentials of communitycare in what is inevitably a fastmoving scenario.

Sharkey seeks to place commun

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ity care within a broad social policyframework, noting that develop-ments have neglected both commun

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ity issues and the relationshipsbetween professionals and users andcarers. From the outset he makes hisposition clear: he wants to see ‘thecommunity put back into commun

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ity care’. But this book is aboutmore than some hazy return tocommunity work methods. Sharkeyis clear, for example, that health aspectsare an important feature of bothpolicy and practice. The contents ofthe book reflect the increasingly joinedup way of both viewing needs andseeking effective responses. In aninformative and systematic way helooks at the roles of carers, care man-agement, social support and userempowerment. There is an import

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ant emphasis on working togetherand on involving agencies other thansocial services and the NHS. Aparticularly useful chapter on adultabuse reminds us of just how far wehave to go in the provision of careand support for vulnerable people.Each chapter contains a summary ofpractice issues – confirming the maintarget readership as practitionersand students.

In spite of his stated preferencefor a community focus, the authormakes frequent use of interestingindividual case studies that aboveall remind us what issues are at theheart of community care. He pro-vides a brief account of NHS organ

-

isational changes, but does not reallyget to grips with how the increas-

ingly close relationships betweenhealth and social care practitionerscould work at operational level.There is little reference to personalcare plans that embrace health aswell as social care needs. Similarly,the issues emanating from hiscore point about tensions betweentargeting those in greatest needand developing broader preventivepolicies and practices are not reallydeveloped.

But the book is strong on otheraspects, particularly the importanceof recognising and working withsocial support networks (such asthose chronicled over many yearsnow by Clare Wenger in NorthWales) – Sharkey rightly points tothe major challenge that this way ofworking presents for many profes-sionals. He points to the variouskey aspects of support and provisionoutside social services and the NHSwith which practitioners shouldbe familiar. He draws attention tothe generally sorry history of userempowerment that in some waysmirrors both the failings of com-munity care in the 1990s and therenewed challenges still facingpolicy makers and practitioners.National policy imperatives in thisarea now abound – but is this themost effective way to secure realchange? Care management was onceseen as the key to unlock these andother doors to the meeting of needs.Here, Sharkey’s analysis is both wellinformed and informative but some-how it is locked into the more tradi-tional world of the social carepractitioner whilst the real chal-lenges (for example, partnershipwith other agencies) merit only thebriefest of mentions – perhaps notthe author’s doing.

Peter Sharkey has produced awell set-out analysis and practiceguide that is easy to read, and wouldundoubtedly be of interest to ageneral readership. In the end thoughwhat we have is a snapshot – of abroad landscape that is full ofactivity. There are many points ofilluminating clarity and some of haz-iness. The problem for Sharkey andthe rest of us is the landscapechanges so rapidly – we need a cam-

corder rather than a camera to cap-ture it. Of course, the author is awareof this problem – his community careworld is broad and outward looking,not introspective and professionallydriven. He sets out his own futureagenda in his conclusion: ‘links canbe made in theory and practicebetween, for example, communitycare and social exclusion, commun

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ity care and health promotion, andcommunity care and participation’.Helping practitioners and others tomake practical sense of these issuesis the real challenge for today.

Richard Poxton

BA (Econ) Dip SocialAdministration

Institute for Applied Health and Social PolicyKing’s CollegeLondon

November 200196000000


Book Reviews


Public Health: Policy and Politics

By Rob Baggott. Macmillan, Basing-stoke (2000), £14.99 (paperback),308 pp. ISBN 0-333-6749-1.

Public health, having remained inthe shadows for years, is now backon the policy agenda althoughperhaps not quite as high as manyhad hoped. Concern with food safetyand the growing ‘health gap’ betweenrich and poor have largely beenresponsible for the revival of interest.They were key drivers in NewLabour’s early commitment to astrong public health policy.

The government got off to anencouraging start by appointing thefirst ever Minister for Public Healthin England. There was also a deter-mination to launch a health strategythat would learn from the failures ofthe Conservative government’s strat-egy,

Health of the Nation

. However,the delay in launching

Saving Lives:Our Healthier Nation

, and its counter-parts elsewhere in the UK, seemed tosuggest that the government’s com-mitment to public health might notbe as impressive as had first beenthought. The strategy was criticisedfor the absence of national inequal

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ities targets and for adopting a nar-row, medical model of public health.These fears were confirmed with the


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appearance of the

NHS Plan

in July2000, with its emphasis on acutehospital care, doctors and nurses andwaiting list targets. The chapter onpublic health is thin and its onlyredeeming feature is the proposal toproduce national inequalities targets,which have since appeared. How-ever, having a target is no guaran-tee of its implementation.

If there is a desire to understandbetter why public health struggles toget its voice heard effectively, thenthe reader need look no further thanthis book. As Baggott affirms, it wasever thus. Each time public healthhas been on the threshold of makinga significant impact there has been afailure to follow through effectivelyand in a sustained fashion, with theresult that public health, both as aspecialty and an arena for action, hasfailed to deliver. This book is anexcellent introductory text to devel-opments and dilemmas in publichealth. Using an analytical frame-work comprising ideological per-spectives on the role of the state andthe individual, models of the policyprocess, and theories of risk andexpertise, Baggott takes a broad viewof public health rather than one con-fined to the specialty of public healthmedicine. There are chapters on thehistory of public health, its develop-ment in the twentieth century, thearrival of health strategies, publichealth and the NHS, and the socio-economic context of public health.Some of the material is available inother recent books on public health,but it is brought together here in asuccinct, readable format. There is awealth of detail on many facets of thepublic health function. Taken togetherit is easy to see why public health hasremained so fragmented and con-fused. It is in the nature of thebeast.

A principal dilemma for publichealth is where it should principallybe located. Should it remain with theDepartment of Health? Or should itbe organised independently of theNHS? While the NHS is largely per-ceived as a ‘sickness service’, Baggottacknowledges its considerablepotential to protect, maintain andimprove health. This is very much

the government’s line as the

NHSPlan

and national service frame-works make abundantly clear. Theiremphasis on public health is on whatthe NHS can do to improve primaryand secondary prevention. There islittle reference to the wider determin

-

ants of health over which the NHShas far less influence. However, asthe Secretary of State for Healthadmitted in oral evidence to theHouse of Commons Health Commit-tee’s inquiry into the public healthfunction, a rather neglected areaconcerns the NHS’s role in regenera-tion schemes . It is, after all, a majoremployer and purchaser of services. Itcould do much to contribute to therenewal of local communities.

An issue tangentially dealt withby Baggott is the location of theMinister for Public Health amidstcriticisms that the placing of this rolein the Department of Health allows itto be overshadowed by the NHS. TheHealth Committee wrestled with thisissue and recommended that the leadfor public health should remain withthe Department of Health. The Com-mittee could see no alternative modelwithout incurring massive disrup-tion and transaction costs. However, itpointed out that the Department ofHealth was ‘on notice’ and would beexpected to deliver and re-balancethe health policy agenda in favour ofpublic health.

What might the future hold forpublic health? In a useful conclud-ing chapter, Baggott reviews devel-opments in public health using hisanalytical framework. On ideolog

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ical perspectives he puts the recentrevival of interest in public healthdown to Blair’s ‘third way’ and itscommitment to communitarianideals – ‘combining individual rightswith responsibilities and invokingstate authority when necessary touphold the common good’. How-ever, there is a need to separaterhetoric from reality. Baggott notesthe still influential liberal/individu-alist perspective that has thwartedcollectivist efforts in the publichealth sphere. Indeed, the history ofthe public health movement inthe UK has been one marked by theplaying out of the tension between

collectivist and individualist tradi-tions, respectively.

On the policy process, Baggottnotes the increasingly global dimen-sion to public health particularly inrespect of environmental issues,drug control, and food production.The book only touches on such issuessince its focus is the UK. Never

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theless, with the decisions andjudgements of the World TradeOrganisation increasingly at oddswith much of the public healthagenda global issues must surelyassume greater importance infuture. Baggott also notes the largelydisease-focused bias in public healthand its dominance by the medicalprofession. Widening public healthhas been an aim of the government’spolicy to strengthen the function butthe bias remains. The Health Com-mittee report represents a challengeto this and wants to see strongerpublic health leadership in localgovernment and within regionalagencies. Its practitioners will alsoneed to be equipped with new skillsin change management.

Finally, on experts and risk Bag-gott considers the erosion of publictrust in experts and the confusionwhich abounds. Part of the problemlies in the contested nature of theevidence. The situation is unlikelyto improve as long as governmentswithhold information and continueto function in a paternalistic fashion.Part of the solution lies in greaterindependence for the public healthfunction and openness to scrutiny.There is also a need to incorporatelay knowledge and experience intothe policy process. The book does notseek to provide solutions to thepolicy puzzles it so ably describesand analyses but it does offer acoherent framework for a betterunderstanding of these dilemmas.

References

Department of Health (2000)

The NHSPlan: A Plan for Investment. A Plan forReform

. Cm 4818-1.House of Commons Health Committee

(2001)

Public Health

. Second Report,Volume 1, Session 2000-01. TheStationery Office, London.


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David J Hunter

MA PhD Hon MFPHFRCP (Edin)

Professor of Health Policy and ManagementUniversity of DurhamDurham

Understanding Social Policy

By Michael Hill. Blackwell PublishersLtd, Oxford (2000), £15.99 (6th edition),278 pp. ISBN 0-631-21687-1.

November 200196000000


Book Reviews


Rethinking Social Policy

G. Lewis, S. Gewirtz and J. Clarke.Sage Publications Ltd, London (2000),£16.99, 368 pp. ISBN 0-7619-6755-9.

At times, being a student of socialpolicy – whether altogether new-comer or experienced old-hand – canbe a confusing matter: the ‘what issocial policy?’ question seems toconstantly lurk in the background.Shifting policy agendas and the fluxin social trends regularly raise newquestions that demand inquiry bythose with an interest in social policy.Meanwhile, shifting academic con-cerns periodically expand what areregarded as legitimate – or even fun-damental – issues for investigationby the social policy community.Consequently, the answer to the ‘whatis social policy?’ question is moremuddied now than it ever was. Indeed,it is possible for radically differentvisions of the subject – its purpose,its substantive concerns, its toolsof analysis – to coexist. In readingMichael Hill’s

Understanding SocialPolicy

and Lewis

et al

.’s

RethinkingSocial Policy

, this fact is clearly illus-trated, for, in many ways, these twotexts represent opposites in the socialpolicy constellation.

Hill’s

Understanding Social Policy

isa long-standing classic text that hasbeen a staple of reading lists formany years. Now in its sixth edition,the book first appeared in 1980, andwhile its substantive content haschanged over time, the basic struc-ture and approach have remainedlargely intact, a testimony to its dur

-

ability and general usefulness. By con-trast, Lewis

et al

.’s

Rethinking SocialPolicy

is a newcomer to the market,

an edited collection of 22 essays that– as the title of the book suggests –aims to offer the reader a slightlydifferent perspective on the subjectfrom that found in traditional textssuch as Hill’s.

Turning first to Hill’s book, itoffers an informative – but easy toread – guide to what are regarded asthe key substantive policy areas ofthe subject. Individual chapters onsocial security, health, housing,education, the personal social servicesand employment policy are pro-vided, with each offering an author

-

itative summary of key historicaltrends, recent policy developmentsand prominent analytic and policyissues. These chapters are supple-mented by contextual chaptersexamining the history of socialpolicy, the nature of policy-makingand issues surrounding policy imple

-

mentation. The book as a whole iswrapped in a consideration of therole of social policy: an introductorychapter considers the definitionand purpose of social policy as anacademic subject, and a concludingchapter focuses very much on therole the state – and social policy –should play in modern society. Forthe most part, the book focuses on

policy issues

, aiming to give the readera thorough introduction to the keypolicy debates, policy developmentsand policy dilemmas surroundingthe welfare state. Indeed, the authorhimself describes the task of the bookas being one of enabling an ‘under-standing of what policies are, of howthey are made and implemented,and of the implications of the manyprevailing suggestions on how tochange those policies’ (p. 12).

By way of contrast, Lewis

et al

.’sbook focuses very much on whatmight be termed

theoretical issues

.Rather than offering chapters on spe-cific policy sectors or policy-makingissues, the book offers a collection ofessays that – generally speaking –juxtapose key theoretical concernswith social policy concerns. So, forexample, Watson considers theimplications of Foucault’s work forsocial policy; Lister and Lewis exam-ine gender and social policy; Twigglooks at the body and social policy;

Clarke explores globalisation andsocial policy, and Stanko examinesviolence and social policy. The endresult is a diverse collection of papersthat considers a wide range of keyissues; while the book does not – asHill’s text does – offer a coherentoverview of social policy develop-ments, this is not its intended pur-pose. Instead, it aims to help achievean ‘understanding of the shifts inthe contours and orientation of socialpolicy … on the reconfiguration ofthe social … the dislocation of socialpolicy that has occurred over the lasttwo to three decades’ (pp. 1–3). It aimsto: ‘explore some of the challengesand reconceptualisations of socialpolicy that [have] occurred over thelast 30 years’; demonstrate the linksbetween social policy and (unequal)social relations; ‘map the dimensionsand directions of change’ suggestedby a ‘reworked and expanded’ visionfor social policy, and ‘plot out brieflysome of the new agendas for welfarein the twenty-first century’ (p. 1).

This is an ambitious task and onethat the editors claim only to bepartially fulfilling. The text containsessays from many of the leadingfigures in the social policy communityand, as such, presents much recentresearch in a readable form. Of par-ticular note are chapters by Jessop –perhaps the clearest statement yet ofhis argument that we have movedfrom a ‘Keynesian Welfare NationalState’ to a fragmented and trimmeddown ‘Schumpeterian WorkfarePost-national Regime’ – and Clarke –an excellent overview of the global

-

isation and social policy debate.However, having come to this

book with high expectations follow-ing recommendations from col-leagues, in the end there was a smallfeeling of disappointment that wasdifficult to pin down. While all of theessays are very worthwhile, there is asense that something is missing fromthe book; on reading Hill’s text that‘something’ became a little clearer.While


has anambitious agenda and covers a broadscope of topics, its tools of analysis –it theories and concepts – are drawnprimarily from sociology: it mainlyrethinks social policy by viewing


Book reviews

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it through new lines of inquirydeveloped elsewhere by sociologists.Sociology and social policy havealways been closely connected sub-jects, but, as Hill points out, becausethe latter is an ‘essentially appliedsubject’ which draws on a range ofsocial science disciplines, this createsa problem of ‘defining the extent towhich it is necessary to delve into thesedisciplines’ (p. 11). Hill suggestssocial policy has generally hoped it‘can gain what is required from otherdisciplines without going too deeplyinto them’ (p. 11). However, with


there is occa-sionally a feeling that in the searchfor new insights or new perspectiveson social policy some authors gotoo deeply into one discipline –sociology.

While new ideas clearly comefrom cross-disciplinary work, theinsights which may be offered by thedisciplines that drive Hill’s more tra-ditional approach – political science,public administration, administrat

-

ive law and history – are for themost part overlooked in

RethinkingSocial Policy

. What’s more, in focus-ing often on the sociological issues –rather than on the applied policyissues – it trades off policy relevancefor theoretical depth. While there isnothing wrong with this

per se

, interms of offering an introduction tothe subject of social policy – or stillfurther an agenda for future inquiry– Hill’s text, to my mind, offers acompelling and pragmatic mix oftheory and practice that effectivelydefines what social policy should,primarily, be about. In drawing sucha conclusion there might be a hintof bias and nostalgia; as a politicalscience undergraduate,

UnderstandingSocial Policy

was the first social policytext I read and one that did much tospark an interest in the area; how-ever, far from being old hat, thisrevised version of the text offeredreminders of key issues, pluggedknowledge gaps that have emergedover the years and sparked ideas andinterest. For my students, it willremain a staple of the reading list; theneed to

understand

policy develop-ments and the policy process stillprecedes the need to

rethink

it.

John Hudson

BSc (Hons) PhD

Lecturer in Social PolicyDepartment of Social Policy and Social WorkUniversity of York

November 200196000000


Book Reviews


Alcohol, Social Work and Commu-nity Care

By Stuart Collins and Jan Keane.Venture Press, Birmingham (2000),£13.95, 252 pp. ISBN 1-87-387852-4.

Upon receiving the above text Iwas immediately impressed by a‘substance misuse’ text devoted tosocial work and social work practice.As a team manager of a statutorysocial work specialist substance mis-use team this immediately grabbedmy attention and made me want toread this book. It often feels that theuseful role of social workers is over-looked within the context of sub-stance misuse. It is often seen as thepurview of the health and the volun-tary sector. This is perpetuated by areluctance often to engage by socialservice chief officers and com-pounded by workers’ fears andlack of confidence within this areaof work.

In general I found the text veryreadable, using words which arereadily understandable, irrespectiveof background, in a clear format andlayout and placed within a familiarsocial work context. It offers a goodoverview of the subject area, with anintroduction to the basic conceptsand principles which inform andunderpin substance misuse work,with particular reference to alcohol. Iconsider this to be a good introduc-tion to working with alcohol users,especially for social workers. It bothraises awareness of the issues anddilemmas and directly informs socialwork practice. It offers an almoststep-by-step guide to good practice,often in a check-list-like formula.This serves as an excellent practicaltool for practitioners.

The text takes us through many ofthe challenging areas encounteredby social workers, offering guidanceand advice. The chapter on youngpeople offers an interesting balancedaccount of alcohol use dispelling

popular myths, advising workersnot to over-react to young people’salcohol use, placing alcohol usewithin the normal usual context ofyoung peoples lives and offeringadvice and guidance to socialworkers in the areas of work mostpertinent to them. The chapter onalcohol use by elderly people bringsback the whole issue into the con-sciousness of present-day thinking,as it often gets forgotten by thegovernment, who are often pre

-

occupied with the young peopleand criminal justice system.

I particularly enjoyed the chapteron working with black users. It is noteasy to find directly relevant textswithin the social work professionthat offer clear, concrete advice andguidance to working with blackalcohol users. This was very welcomeas we struggle to offer a good qualityservice to black users, preferringinstead to leave non-specialist minor-ity services to intervene, irrespectiveof their appropriateness, becausewe fear intervening ourselves andperhaps compounding the diffi-culties that black users experience. Iwill certainly use the informationoffered in the text as a guide toinform direct practice and also toinfluence planning via the drugand alcohol team process in CountyDurham.

Each chapter offers a slightlydifferent perspective with often acommon approach being under-pinned by social work values. Itreminds us that social workers caneffectively intervene and do havevaluable skills to offer alcohol users.A worker has to recognise thatalcohol, like other substances, is notto be feared and that they do havethe skills to intervene appropriatelygiven the correct training andsupport from their agency. It offersa challenge to local authorities towork with alcohol users as part oflegitimate social service business,generally demystifying substancemisuse work.

Julie Daneshyar

BA Hons Psychology &Sociology CQSW

Team Manager Substance MisuseCounty Durham Social Services


Book reviews


9

(6), 504–511

511

November 200196000000


Book Reviews


Policy and Place: General MedicalPractice in the UK

By G. Moon and N. North. MacmillanPress Ltd, Hampshire (2000),£14.99, 204 pp. ISBN 0-333-73039-9.

One of the bane’s of a reviewer’slife is the book that one would like tohave written oneself. Given theincreasingly pivotal position ofprimary care in the British healthsystem, it is surprising that thereremain few historically rooted analysesof the development of general practicefor students of health policy. GrahamMoon and Nancy North’s bookadmirably fills that gap. Havingset the scene, the early chapters com-prise historical study with a particu-lar emphasis on the impact of theTory reforms in the 1990s. Theaccount of the historical origins ofgeneral practice is brief but balancedand vitally rounds out the signifi-cance of independent contractor sta-tus as a professional shibboleth. Thebalance of coverage of recent eventswith its focus on fundholding andGP commissioning models inev

-

itably gives this section a slightlydated feel. The evaluative literatureexamining the 1997 reforms is stilllimited, but primary care trusts(PCTs) in particular are very differentorganisations in terms of theirimpact and aspirations. On the otherhand, the later evidence suggeststhat much can be extrapolated fromthe experience of PCTs’ forerunners.Their struggle to develop an effectivecommissioning function for lackof managerial capacity or reliableinformation, or to involve theirpublics have a familiar ring.

The changing nature of GPaccountability is considered indepth. A traditionally inward-lookingprofessional model of accountabilityhas been displaced in favour of amore open system that incorpor

-

ates economic and patient perspect

-

ives for establishing benchmarks foracceptable performance. Attempts torecapture the initiative by strengthen

-

ing self-regulation are unlikely torestore the

status quo ante

. The collec-tivisation of primary care underLabour means greater managerialintrusion. PCTs also offer opportunities

for greater virtual integration (acrosspeer networks) or vertical integration(with colleagues in primary care).

The second half of the bookaddresses core themes in the deliveryof GP services. Successive chaptersexamine the theme of deprivationand attempt to address inequalitiesin the distribution of GPs beforecontrasting urban and rural generalpractice. Arguably, the most revolu-tionary change of new Labour’s firstterm has been to undermine the prin-ciple of a single national contractacross the UK. The next chapterexamines tensions in GPs’ relation-ships with patients and public. Theadvent of PCTs sharpens the ethicalconflict for doctors advocating forthe individual patient against theirnew corporate obligations towardslocal populations. Little attentionis given to the nature of clinicaldecision-making or to the impact ofrecent attempts to increase access oncontinuity of care. Another strongchapter examines the interfacebetween health and social care andpulls no punches in analysing limita-tions to interprofessional collaboration.The authors rightly point out that earlyguidance on effective joint planningbetween health and social servicesand the role of the new primary careorganisations is circumspect, but thereis no consideration here of care trusts.

The book concludes by looking tothe future. The experience of threeother countries is examined for indi-cations of possible developments inthe UK. These comparative analysesare more effective for beginning frompositions of similarity betweensystems. The New Labour project hasdrawn much from the New Zealandapproach; the parallels between theirindependent practitioners associa-tions and Scottish local healthcareco-operatives are great. The alleged‘proletarianisation’ and the move ofsome GPs into providing out-of-hours care in the more entrepreneur-ial environment of their internalmarket provide intriguing pointers. Tocharacterise PCGs as the UK equival

-

ent of the health maintenance organ-isation is something of a cliché. Thetools of ‘utilisation management’designed to reduce costs and lessen

variability in clinical practice arelikely to become a commonplacechallenge to clinical autonomy in theUK. But it is the developments in theNetherlands where sickness fundsexercise increasing choice regardingthe GPs with whom they work thatprovide the most intriguing pointers.For the authors are right that themost important changes in this phasein the development of general prac-tice are in the nature of independentcontractor status. PCTs will in futurebe offering differentiated contracts todifferent employees. They may havethe scope to derecognise GPs who donot perform within defined parametersin an environment with ever greaterregulation and control. A challengefor future policy makers will be toprovide the opportunities for inno-vation and flexibility without whichthe ‘jewel in the crown’ may burnish.

From the perspective of the prac-titioner (and potential readers of thisrich book should include those inGP vocational training), the thinnestcoverage concerns quality assurance,clinical governance and the reformsinstituted in the wake of

A First ClassService

. (The term ‘clinical govern-ance’ is not to be found in the index).The impact of the Shipman verdicton the medical and collective con-sciousness is given scant considera-tion. The feelings of beleaguermentand vulnerability, amplified by theconstant flow of negative medicalcoverage are easily underestimated. Itis ironic that at a time when the influ-ence enjoyed by general practitionersis as high as it has ever been, storiescontinue to abound of poor morale,early retirement and falling recruit-ment. The rhetoric of a ‘no blame cul-ture’ rings hollow in such a contextand has complicated the implemen-tation of clinical governance. Theseare minor quibbles for a book sodensely packed. For all thoseinterested in the challenges facingprimary health-care in today’schanging policy environment, thisbook is strongly recommended.

Steve Gillam

MD FRCP MRCGP FFPHM

Director, Primary Care ProgrammeKing’s FundLondon


Documents

Nursing, Medicine and Primary Care