BMJ 2001;322 ( 24 February )

Choice GP

Finding the true track

"Fast track" seems to be this week's theme. In the news (p 451) the Secretary of Sate for Health announces 26 fast track surgery units, while on p 473 Douglas Wilmore and Henrik Kehlet explain what fast track surgery entails. We contribute too by publishing two fast track papers (pp 453, 460).

Fast track surgery isn't only good for politicians hoping to reduce waiting lists. As Wilmore and Kehlet explain, the combination of regional anaesthesia, minimally invasive techniques, optimal pain control, and aggressive postoperative rehabilitation reduces patients' stress response and organ dysfunctionand so shortens their recovery time. The next few years may see the insertion of a hip prosthesis or the repair of an aortic aneurysm performed as day surgery. And nor should this increase the burden on general practitioners because patients won't be suffering the usual postoperative morbidity.

Another "advance," designed for patients who no longer need acute care but are difficult to discharge, is intermediate care. On p 453 Andrea Steiner et al report their randomised trial of one type of intermediate carethe post-acute nurse-led unit. The results were no worse than normal care, but neither were they betterand therefore maybe not worth the extra £900m that the British government is investing in intermediate care.

An interesting feature of Steiner et al's study is that they randomised only patients willing to be admitted to the nurse led unit. Patient preferences also feature in two other studies. Paul Little et al's study of patients' preferences for a patient centred approach in primary care (p 468) prompts Moira Stewart to comment in her editorial (p 444) that only the patient can be the judge of patient centrednessand that patients', not experts', views on the subject predict important clinical outcomes. Similarly, Lenore Abramsky and colleagues found great variation in what health professionals know, think, and say to mothers about sex chromosome abnormalitiesto the dismay of parents (p 463). In an accompanying editorial (p 441) Barbara Biesecker admits the difficulties of such counselling but emphasises the importance of doing it well: women "remember the circumstances precisely. . . .Years later they recall the exact words used to deliver the news and many regret the manner in which they were told."

Finally, in the first of our series on asylum seekers and refugees (p 485) Angela Burnett and Michael Peel explode the myth that most asylum seekers are really economic migrants. Most of those coming to Britain are single men aged under 40 coming from countries in conflict; many are skilled and were affluent in their home countries.

Footnotes

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