Editor's choice

A health planner's delight?

This week's issue should please health plannersfor it shows that spending more money on health care doesn't produce better health, that simple interventions can be more effective than complex ones, and that an intermittent treatment may be just as effective as a continuous one.

For people who argue that all the NHS needs is a bit more money, there is a natural experiment to test that assertion within the British Isles. The NHS in Scotland, Wales, and Northern Ireland receives more funding per head of population than it does in England, and Jennifer Dixon and colleagues have looked to see what the Scots, Welsh, and Northern Irish do with their extra money (p 522). Theirmodestconclusion is that funding the English NHS at the same level as the Scottish NHS would "make life easier for providers."

The clinical messages start with a randomised trial from Norway showing that pelvic floor exercises are more effective in managing genuine stress incontinence that either electrical stimulation or the use of vaginal conesand have no side effects (p 487).

They continue with a pragmatic trial based on the observation that, even though long term maintenance treatment is recommended, treatment for gastro-oesophageal reflux is often given by doctors (or taken by patients) in short courses. A multinational European study group has thus performed a randomised trial of intermittent treatment with omeprazole or ranitidine in patients with uncomplicated symptomatic gastro-oesophageal reflux disease (p 502). Half the patients were effectively managed with intermittent treatment, the most important factor being the response to initial treatment.

How much intervention a patient wants is a key question when assessing patients' wishes, and on p 499 Seena Fazel and her colleagues suggest using it as a way of assessing competence to make advance directives in elderly people with cognitive impairment. Their test focuses on future imagined clinical situations through the use of vignettes. The authors tried their test on 50 elderly volunteers from pensioners' lunch clubs and 50 newly referred patients with dementia. It discriminated well between the two groups and they commend it to clinicians managing elderly people with dementia and general practitioners advising elderly people about living wills.

Finally, a lesson on change comes from Mary Black in her personal view about how unsupportive most organisations are to breast feeding mothers (p 545). As she learnt how to change the system she became known variously as superwoman or "the pest with the breasts."

Acknowledgments

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