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R Chambers, C Drinkwater, E Boath. 2nd Edition. Oxon: Radcliffe Medical Press, 2003. £24.95. 220 pp. ISBN 1 85775 994 X
This book adds to the burgeoning literature on the subject of patient and public involvement (PPI) in health care decision making. A pessimistic conclusion from this literature is that PPI is fraught with difficulty and makes little impact on the decision making process or outcomes. A more optimistic view is that past failures do not necessarily need to be repeated and that we can, as the subtitle of this book suggests, “do it better”. To illustrate this point the authors present case study examples of good practice, together with practical information for those seeking to undertake PPI initiatives.
This advice—which is presented, as the blurb on the cover suggests, in a “clear and straightforward” fashion—can be seen as addressing technical problems such as questionnaire design, sampling frames, and obtaining and storing data. As the authors acknowledge, however, overcoming the obstacles which prevent us from “doing it better” involves more than a series of technical fixes. While the advice presented might be straightforward, the same cannot be said for the process of engaging with the public and patients. Drawing on recent ESRC funded research on the subject, the authors identify the need for a cultural shift to change attitudes as well as arguing for the need for a shift of power without which PPI will be merely a “token event”.
Achieving a shift in culture and power represents a more difficult process than designing sampling frames or running focus groups, and this may be why there is so much information in the book on the latter and so little on the former. Yet the two are interrelated since it may be that achieving shifts in the balance of power requires a rethinking of traditional methods which, to date, have achieved little success in bringing power to the people—although, to be fair, whether they were ever intended to do so is a moot point! After all, methodologies to involve public and patients are not neutral but embody differing models of citizenship. The notion of citizens as consumers exercising choice in the market place is one that underpins current government policies to increase individual choice in the NHS. However, it represents a rather narrow view of citizenship and one which threatens to increase inequalities in access to care. This suggests that the challenge for the authors is to write a “How to do it better, book 2” which should really be read before their current volume. In this they could explore the development of mechanisms intended to encompass a broader view of citizenship—one which will confer legitimacy on decision making processes and act to mitigate the undesirable effects of unrestrained consumer choice. Such a book would, of necessity, involve a more detailed consideration of processes to address the issues of power and culture change (as opposed to questionnaire design or statistical software, all of which are discussed in the current volume) which the authors see as so necessary to any PPI process.