Medicine and books: Non-random Reflections on Health Services Research
Authors: Michael Clarke
Journal: BMJ (1998)

Ed Alan Maynard, Iain Chalmers 

BMJ Publishing Group, £23, pp 112 

ISBN 0 7279 1151 1 

Archie Cochrane, one of the great postwar epidemiologists, argued the case for applying the best clinical science methods to the nascent subject of health services research. This book is a delightful compendium of reminiscences and reviews of progress that also develops the theme that “researchers and health professionals will serve public interests more effectively when they come to regard lay people as the ‘coproducers’ of the knowledge needed for effective and efficient promotion of their own and the public health.” 

This volume celebrates the 25th anniversary of the publication by the then Nuffield Provincial Hospitals Trust of Cochrane’s Rock Carling Monograph Effectiveness and Efficiency: Random Reflections on Health Services. This slim volume of 80 or so pages was a great success: translations were made into Spanish, French, Italian, and Polish, and one American commentator described it as the work that might have the most influence on health policy in the decade. This was despite, or perhaps because of, the fact that the book ignored the existing copious American literature on health services research and evaluation and, indeed, cited only two American references. 

The real pleasure in reading Non-random Reflections on Health Services Research, and the original monograph, is that it is about much more than extolling the virtues of experimental methods in medical research. The original volume emphasised the importance of “care” as well as “cure,” while the authors of the current book discuss issues of equity and the importance of lay perspectives. One chapter, by Julian Tudor Hart, which should be read by all shoe leather epidemiologists, describes the social and political understanding and compassion that enabled such high response rates to be achieved in the field surveys undertaken in the Rhondda Fach—all done without the need for alsatians. 

Archie’s original book was full of statements about economics, including the wonderful “all effective treatment must be free.” Maynard and Sheldon reflect on the past 25 years of health economics and conclude that there is a serious risk that clinicians see economists as those who merely contribute the economic and quality of life components to clinical trials—the health service research equivalent of “Kwik-Fit fitters.” The role of economists is much broader, encompassing behavioural issues such as incentives, the demand for health and health care, and the supply of labour. 

This book should give pleasure to an even wider audience than the original monograph, which was written for “medical students and non-medical intellectuals.” Archie was in the best traditions of the slightly eccentric scientist, in many ways rather shy and often needing reassurance that his endless questioning was legitimate. There seems no doubt that the gargantuan efforts of Iain Chalmers and his colleagues will ensure that Archie’s name lives on through the Cochrane Collaboration, described in the final part of the book. 

PS—Archie, I almost managed to do this without mentioning an RCT.