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improvement, and that if allowed to practice unchecked, quality management ‘quacks’ could themselves become a cause of needless waste.

Morgan and Murgatroyd might also be criticized for failing in their analysis of health care quality to examine adequately developments in the primary care area and the critically important first interface between service users and the professionals who, given the right values and incentives, could serve to inform and empower patients and carers to make optimal personal choices about their subsequent care. But such comments do not invalidate the basic logic of their book’s approach. Given that quality management really does appear to have opened the way to improved performance in much of manufacturing industry its potential for generating similar gains in the public sector deserves at the very least fair evaluation.

In health care, listening to patients and carers more carefully, responding to what they say as positively as possible, and ensuring that medicines, surgical interventions and other treatments are used with the

maximum of effect and a minimum of harm are surely goals that all professionals and managers can share. And for those concerned to use health resources efficiently, and so to treat as many people as possible as well as possible, the appeal of quality management is that it should offer ongoing opportunities to review and simplify processes, so cutting direct costs and wastage.

Although the other face of quality-cutting neglect and fostering innovation-may require some extra spending, and the workforce security and training needed to create learning organizations (why identify an improvement if all ‘they’ may do is save at your expense?) also has its price, these are costs that it may well be worth paying in all parts of the British economy. After all, we have arguably tested the alternatives to the point of destruction.

DAVID TAYLOR Visiting Senior Research Fellow

Centre for Healfh Economics University of York

European Pharmaceuticals: Switching to OTC Status by SARAH RICKWOOD and AMANDA SOUTHWORTH, Financial Times Management Report, 1994. No. of pages: 109. ISBN 1 85334 213 0.

The increasing size of the drugs bill is a cause for concern in the majority of European countries. This book deals with one of the most frequently suggested policy options available to reduce the size of the drugs bill, namely the switching of prescription only medicines to over the counter (OTC) status. The book is divided into five chapters. The first two chapters describe in detail the size of the OTC markets in the major European countries and how switches to OTC are carried out, while the third chapter reports four case histories of drugs which have been switched (Zovirax, the recently launched OTC for the treatment of cold sores; Nicorette, the smoking cessation treatment; Pollon-eze, a hay fever treatment; and Nurofen, an analgesic) and how these drugs are likely to perform in the future. Chapter Four is concerned with the structure of the industry and discusses recent alliances and acquisitions of some of the major players. The final chapter is dedicated to describing the health care systems in several European countries together with any recent changes which have taken place, and how the switching to OTC status could be affected by these systems.

Though there is a large amount of information in this book, the authors appear to have from the outset, the opinion that switching a certain number of drugs to OTC status must be beneficial, and they continue in this

vein throughout. For instance, the authors claim that moving a limited number of products to OTC is a ‘winlwin situation for all parties’. This however, assumes that the pharmacist is likely to diagnose and treat a (serious) condition in the same way a doctor would, but at present they may not have the training necessary for this. This brings in the whole argument of ‘Who is the prescriber?’ If the individual is the prescriber, is this safe? The authors recognise this point early in the book, but subsequently concentrate on cost containment for government, and increased sales for pharmaceutical companies. This viewpoint is also apparent when alternative policy options are considered; generic prescribing is dismissed as it would have a detrimental effect on branded products and could also create a loss of potential OTC sales. The benefits of generic prescribing are not considered.

The authors appear to exhibit contradictory opinions about the knowledge or expertise of consumers. When discussing the targeted population for an OTC switch, the authors name doctors, pharmacists and the general public, and feel that of these three, consumers are least concerned with therapeutic efficacy but most concerned with enhancements such as flavouring! These people who would suck a fruit gum to treat a migraine, are apparently the same set of people who can correctly self diagnose indigestion as opposed to an ulcer or stomach cancer.

Two slight faults emerge regarding the layout of the book. Firstly, the authors appear to have written independently which has resulted in a disjointed book of two halves; this in itself is not a major problem,

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though some information is repeated (in some cases verbatim) without cross references. Secondly, acronyms are not introduced in the text when they appear but instead the majority are listed in a glossary of terms as an appendix. Unfortunately, a few have slipped through the net and remain unexplained, and though a few moments thought may reveal what a ‘GI disease’ is, who or what the FDA islare remains a mystery to the uninformed reader.

However, allowing for these criticisms and the viewpoint from which it is written, this book provides much useful information and is recommended reading for those studying the workings of the pharmaceutical market in general, and the OTC market in particular.

GERALD RICHARDSON Centre for Health Economics,

University of York.

Diagnosis in General Practice. Art or Science? by DAVID CAMERON MORRELL. Nuffield Provincial Hospitals Trust, 1993. No. of pages: 73. ISBN 0-900574-85-2

David Morrell recently retired as one of the first, most eminent and productive of Professors of General Practice at St Thomas’s in London. In this short book developed from a John Fry Trust lecture he gives an unusually frank and well documented account of how techniques of medical diagnosis have developed. It is said that everybody can write one good book in a life time as long as they make it a short one. This deserves to be seen as one of the handful of classic texts on British general practice.

The young physician of 1952 was expected to frame a diagnosis in pathological terms. ‘Until a diagnosis had been reached it was generally regarded as inappropriate if not unethical to institute treatment.’ The maturing family doctor began to see that such a diagnostic model was ‘irrelevant to much that occurred in primary care in the United Kingdom.’ Patients presented symptoms of illness at an early stage and ‘as most of these illnesses will be self-limiting it is unnecessary to establish diagnosis framed in pathological terms.’ ‘It very quickly became apparent that the biomedical model of diagnosis simply did not have any meaning in the diagnostic response to new symptoms presented in primary care.’ For complaints such as chest pain and acute abdominal pain it was not possible to have a detailed diagnosis.

The book then reviews the interaction between family doctors and medical sociologists who have had more success than health economists in getting their subject

included in the medical school curriculum. He finds support for his intuition that many factors other than medical ones influence the decision to consult. Economists have used the agency model of the doctor- patient relationship but it has often been a black box.

There is a chapter ambitiously entitled The New Diagnostic Model. This gives a good discussion of how medical intuition actually works although Morrell seems unwilling to style this as science.

His view of the future is affected by his bruising experiences of the recent past. He is not a supporter of the new contract and finds that ‘medicine has been infected by the Thatcherite doctrine that everything should have an end product,’ while ‘In civilized society the justification for caring may be caring itself.’ General practice cares for people with chronic or terminal illness. New measures are needed of the quality of care to these patients.

Morrell leaves us on a note of optimism not entirely supported by his recent experience. He worries about the impact of computers on the doctorlpatient relationship but cites the interesting and neglected studies of de Dombal at Leeds in the early 1970s showing that computer aided diagnosis had diagnostic accuracy of 92.5 per cent in a controlled triai for patients with abdominal pains compared to 81.2 per cent for human diagnosis. Perhaps the computer can help GPs to wake up for the exceptional case as well as providing a bridge between their intuitive inner worlds and the restless rationalism of the hospital doctors?

NICK BOSANQUET St Mary’s Hospital Medical Schoolllmperial College