Book Book

Changing Practice in Health and Social Care

BMJ 2000; 321 doi: (Published 25 November 2000) Cite this as: BMJ 2000;321:1355
  1. Marilynn M Rosenthal, professor of sociology
  1. University of Michigan, USA

    Eds Celia Davies, Linda Finlay, Anne Bullman

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    Sage Press, £15.99, pp 400

    ISBN 0 7619 6497 5

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    In studying social policy we should be guided by two things—a historical perspective and an understanding of the dynamics of change. Both are complex and elusive, but the latter is by far the more difficult to get to grips with. Changing Practice in Health and Social Care does a good job on the former but struggles with the latter.

    Starting with a succinct history of social policy, this collection of essays tries to integrate theory and practice from education, management, and social policy. It examines trends in collaboration between the caring professions; emerging challenges from managers, the market, and clients; the construction of “new” professional identities; and possible futures.

    The book circles around the eternal question of what is a good society. The road has been shaped by the historical debate about individual and collective responsibility for social welfare and the contemporary pressure to keep costs reasonable.

    While heavily focused on social work, the book has something for the thoughtful medical practitioner. Readers get a tour through the byways of social policy evolution: the optimistic, naive, and paternalistic socialism of the 1940s and ‘50s; consensus teams of the ‘60s; the managerialism of the ‘70s; the market strategies of the Thatcher era; and the New Labour search for a “Third Way,” integrating the public, private, and voluntary sectors.

    Today the old ideological labels are meaningless, since the “Left” and the “Right” borrow pragmatically from each other. Along the way, we are told, there has been a gradual withdrawal of citizen trust—a growing sense that “commitment to the public sector has been devalued and discounted.” This is a policy evolution that demands more and more accountability from the caring professions. The authors have some proposals: practitioners should work gracefully in teams, actively respond to accountability, listen more carefully, and include their patients or clients on the team. Envisioned are practitioners who are “positive, critical, analytic yet active.” Alas, beautiful words do not themselves bring change.

    Several effective essays about the medical profession argue that it is essential to understand the complexities and uncertainties of medical care, and to understand how doctors think, if doctors are to be a positive force for change. Instead of facile rejection of professionalism, which marks several essays in the book, we should recognise society's need for the profession and call on it to be a partner in improving its own performance.

    One important voice missing in this march of policy is that of the legislative politician. Among the complexities of social policy are the peculiarities of our democracies (the “dollar democracy” in my own country). We can't escape a tough discussion of the legislative and bureaucratic mysteries of policy evolution. Then there are the problems of creating an ethical capitalism and the overt recognition that universal access is only the beginning (something that we in the United States are loth to face).

    The book concludes with the recognition of “wicked issues,” those that may never be resolved, where the way forward is always provisional. This argument is a bit more persuasive than the effort to see gender issues as the key to change. The continuing impact of the old patriarchal system dies slowly, like most deeply embedded social and institutional characteristics. Change is inevitable but often agonisingly slow. One sound piece of advice from this book is that “no road is entirely right.”

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