Who cares? The changing health care system

Book Reviews

Who cares? The changing health care system

Judy Lumby

2001 158 pages Sydney: Allen & Unwin

Eileen Clark
Senior Lecturer, Division of Nursing & Midwifery, La Trobe University, Wodonga VIC, Australia

In this book, Judy Lumby draws on her own career as a nurse to critically examine the structures and functions of health care in Australia today. The central thesis of her book is that while the functions of the health care system have changed markedly since the 1960s, there have been few changes in the hierarchical structures, ideologies and power struggles that determine how health care is delivered.

Lumby draws principally on the work of nurses to illustrate her arguments, but she writes from the patients' perspective, using interviews, observations and anecdotes to illustrate her claims. The ideas are presented in a direct, almost conversational, writing style that is free of jargon and statistics. This makes the book accessible to the patients and nurses who are Lumby's target audience, but serious readers will find it superficial and lacking the objective evidence contained in other accounts of the health care system, such as Duckett's recent book (Duckett 2000).

Each of the eight chapters is devoted to discussing one area of change in the functioning of the health care system. These changes include consumers who are better informed and more assertive about health care, the changing status of women as health care providers, the impact of technology, commodification of care, and different models of providing health care. These chapters provide a good overview of each issue, along with examples of how patient care and nurses' work have been affected. The chapter examining the problem of equity and access takes an original approach to the topic by avoiding the most usual examples in favour of a focus on rural isolation and people with communication difficulties, including the deaf. By skilful use of patients' stories the author conveys the frustration and powerlessness that people in these situations face when trying to access quality care, or indeed any health care at all. The final chapters discuss the present and future challenges to the health care system in a period marked by shortages of resources and greater emphasis on 'user pays'. The key message that Lumby conveys is that while individuals working in the health care system may be kind and compassionate, this alone can never ensure quality care while the system has major structural flaws.

The underlying problems discussed in Who Cares? are not new, but Lumby's handling of them brings them to life in a way that will be attractive to many readers. The book also examines current debates such as the use of nurse practitioners, evidence-based practice and Lifetime Health Cover and questions whose interests such changes really serve.

This book provides a good introduction to the Australian health care system for undergraduate students because of its coverage, readability, and lack of explicit theory. For nursing students especially, it provides a sound analysis of the changes that have occurred in nursing work since the transfer of nurse education to the tertiary sector, and the challenges that lie ahead for nurses. More sophisticated readers may find that the book lacks theoretical substance and is too emotive in its style, and for these reasons it is also of limited value to sociologists more broadly.

Lumby claims (p.xv) that her book introduces the patient's voice into a debate that has largely been the domain of others - politicians, doctors, sociologists and journalists (I would add economists also). If the book is judged with this as its main aim, then it is a success. Health care is about people, and people need to be heard. Lumby gives voice to the sick and the powerless in a way that is compelling yet informative.

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