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Desert Island Texts

Every so often one comes across a book, monograph or paper that makes a big impression. Perhaps its the result - cure for previously incurable disease - or the method, or just the way it's written. Whatever the reason it is a paper to take to a desert island (Oxford Textbook of Medicine and a work of theology being assumed).

Bandolier wants to start a regular feature of Desert Island Texts, and editor's privilege rules.

Archie Cochrane's little book

I never knew Archie Cochrane, who gave his name and ideas to the Cochrane Centre in Oxford and the Cochrane Collaboration. I think I would have liked him, not only because of a shared background in Welsh mining valleys and along the coast between Barry and Rhoose, where he lived, but because this was a man who could think the unthinkable, question the unquestionable and be thoroughly interesting.

His book, the one I would take to my desert island, is called Effectiveness and Efficiency: random reflections on health services. It is probably out of print now (though reprinted a few years ago), but worth stirring up a librarian to get from the shelves.

Though barely 100 pages in length and written originally over 20 years ago, it still encapsulates the most important issues in healthcare today - effectiveness, efficiency and care. It is also apolitical: both sides of the political spectrum will find sections to cheer, and other sections which make them think, and perhaps question their thinking. The reason for that is Cochrane's absolute dictum that what's best is what is shown to work.

The basis of the thinking is that randomised controlled trials are the best way of determining what works, and not just in selected therapies like medicines, but in diagnosis, medical devices and management - it sounds modern today, and was a bit revolutionary in the '60s.

There are fascinating chapters on the NHS and its growth during the first 20 years or so after 1948; Cochrane makes the point that it actually had no spending at all on operational research for many years after its birth. I think he would be cheered by the knowledge that the NHS now had an R&D Directorate, but perhaps unhappy that more resources were not being pumped into it.

The chapters on the evaluation of evidence, and on evidence and effectiveness are as fresh now as they were when they were written. Reflections is a chapter of what the future of the NHS would be like; accurate in parts, like the numbers of beds falling rapidly in a more intensive service, and perhaps not quite accurate in the prediction that the services of the pathologist would be replaced by experts in effectiveness and efficiency, though that is certainly the direction where public health medicine is headed.

Most important of all is that this book, (written during the tenure of a Rock Carling Fellowship, and originally published by the Nuffield Provincial Hospitals Trust) retains immense freshness. It's as if Archie Cochrane was talking with you by the fireside after a good dinner: just what you'd need on a desert island.

Andrew Moore, Editor

AL Cochrane. Effectiveness and Efficiency. Random Reflections on Health Services. British Medical Journal & Nuffield Provincial Hospitals Trust, Cambridge University Press 1989. [ISBN 0 7279 0282 2].

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