BOOKS

New beginnings Towards patient and public involvement in primary healthcare Edited by Stephen Gillam and Fiona Brooks King's Fund 153 pages£14.99 This slim volume has the modest ambition 'to provide reassurance about what counts as progress, realism about what can be expected and encouragement to invest energy in some of the approaches described here'.

To do this, it introduces the reader to the theoretical and policy contexts that shape user involvement while at the same time enabling a number of researchers and practitioners to explore ways in which user involvement can be taken forward.

Part one focuses on theory and policy and offers clear, concise introductions to existing work.

It explores why users should be involved in primary healthcare, the shape of developing policy, the opportunities created by primary care groups for public involvement, and partnerships between patients and doctors in the clinical consultation.

Each essay gives an overview of current work, together with a comprehensive bibliography, making it easy for the reader to follow up any study that looks particularly interesting.

Part two is more of a curate's egg. Some of the contributors follow a similar approach to those in part one (but within a much narrower focus), whereas others adopt a more practical approach, complete with checklists of tasks.

The seven case studies explore the involvement of women in primary care, the experiences of asthma therapy among different ethnic groups, involving users with mental health problems, the contribution of carers, developing services with older people, patient involvement and clinical effectiveness, and community development in primary care.

The book covers the whole field, from lay involvement in health policy decision-making through to patient empowerment in the face-toface clinical consultation, but the approach is bland and unadventurous. Several of the case studies, for example, highlight the desirability of a more co-operative approach to clinical consultations in which the patient's expertise in understanding their own health is properly acknowledged.

Yet nowhere is there any recognition of the political realities that dominate the face-to-face encounter between patient and clinician.

For without a change in clinicians' attitudes, patients will never be able to break through the anxiety, insecurity and deference which prevents them from developing any kind of real partnership with their clinician.

The book's lack of ambition is even more clear in its discussion of lay involvement in decision-making, where Will Anderson's contribution fails to grapple with the challenges facing primary care organisations.

It is left to one of the other contributors to make the obvious point that the very different governance of primary care trusts opens up the bleak prospect of the boards behaving much more like the boards of health authorities and acute trusts than of the primary care groups that preceded them.

In reality, there is a danger that the small but real gains that were made in PCGs will be thrown away in the new structure, where lay chairs and non-executive directors are drawn from the same tiny sub-set of the population that they have always come from, and PCT boards become the bland, remote bodies so familiar in existing NHS boards up and down the country.