Pergamon

Health & P/ace, Vol. I. No. 3, pp. 191-194. 1995 Elsevier Science Ltd. Printed in Great Britain

Book reviews

London After Tomlinson: Reorganis- ing Big City Medicine J. Smith (ed.) British Medical Journal London (1993) 127 pp E8.95 paperback ISBN 0 7279 0783 2

This collection of papers from BMJ brings together commentaries on the ‘Tomlinson Report’ (Report of the Inquiry into London’s Health Service London, HMSO, 1992), which was the basis for the Department of Health’s current policy for rational- ization for hospital care in London (Department of Health, 1993, Mak- ing London Better, Department of Health Publications Unit, Heywood, Lancashire, UK). The main ele- ments of this policy can be pieced together from reading the commen- taries in the book, although it would have been helpful, particularly for readers not already familiar with it, to have provided a more detailed outline in the introduction.

The reader needs to understand, for example, that the policy aims for access to the full range of health care for Londoners. cost-effective ser- vices of a good standard, as well as medical education and research. The elements of the strategy for London emerging in response to Tomlinson’s Report include: deployment of ad- ditional resources for development of higher quality, more accessible pri- mary and community health services in the capital (especially in the Lon- don Initiative Zone, which was ident- ified as comprising areas where pri- mary care was judged to be particu- larly below standard); changes aimed at a better balanced hospital service on fewer sites; a rational- ization of specialist services and the merging of eight undergraduate medical schools into four of the multi- faculty Colleges of the federal Uni- versity of London. The impacts of implementing this policy are contro- versial (widely publicized in the

campaign to prevent closure of St Bartholomew’s Hospital, for example). All this is in the context of the internal market which now operates in British health care, and against the backdrop of the chal- lenges presented to the health ser- vices in London, which are usefully summarized in Maxwell’s paper in this collection (exceptional levels and concentration by differential migration towards the suburbs; poor living conditions for many residents; a large shifting population of com- muters and tourists; primary and community services which are vari- able, often poor, in quality, leading to use of hospitals as the first point of call for primary as well as secondary health care; uneven, often extreme degrees of specialization in hospital care causing fragmentation, dupli- cation and some gaps in specialist care; stringent containment of public expenditure).

The authors contributing to this book come from a variety of disci- plinary backgrounds. The issues co- vered include: how to shift care from the secondary to the primary sector; strategies for extending good stan- dards of primary health care more widely in London; co-ordination be- tween partners inside and outside the health sector to achieve objec- tives of public health and community-based care of ill people; the scope to develop secondary care inside and outside its traditional hos- pital setting; strategies for maintain- ing and developing excellence in spe- cialist services; the organization of undergraduate and post-graduate education and of clinical research; effects of major change on the moral and well-being of staff.

The chapters give a succinct account of these important issues and offer views on how they should be addressed. Many of them also underline the aspects of the policy which raise doubts among both poli-

cy analysts and the general public. Will the resources allocated for new initiatives be sufficient to achieve the objectives set out in the policy? Will the changes be appropriate to re- spond to the (sometimes specific) needs and demands of patients in London?

As some of the contributors point out, many of these issues (and the responses being proposed) are neith- er new, nor unique to London. This collection is therefore relevant to a wider readership, beyond those with a partrcular Interest in London’s health care.

Sarah Curtis Queen Mary & Westfield College

Medicine, Rationality, and Experi- ence: an Anthropological Perspective (Lewis Henry Morgan Lecture Series) Byron J. Good Cambridge University Press Cam- bridge (1994) xvii + 242 pp f35.00 hardback ISBN 0 52141558 6

This scholarly book leads the reader through core theoretical and meth- odological challenges for contem- porary medical anthropology, arising from the juxtaposition in the sub- discipline of anthropology’s concern with the historicism and cultural location of all knowledge, and the instrumental rationality of medical science. Good focuses on epis- temiological issues through discussion of the theoretical development of medical anthropology, analyses of ethnographic data from Iran, Turkey and the USA, and the presentation of a refined interpretive approach informed by theories of aesthetics. He locates his debate within the cen- tral problem of the ‘crisis of repre- sentation’ common to the social sci- ences, and aims to break down the common-sense view that medicine mirrors ‘objective reality’ by demon-

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