BMJ  2008;336 (23 February), doi:10.1136/bmj.39497.574525.DE

Editor's Choice

Prognosis and politics

Given how common head injuries are, it’s surprising how little we know about their prognosis. But help is at hand. Based on their MRC CRASH trial, Pablo Perel and colleagues have produced new prognostic models for patients with traumatic brain injury (doi: 10.1136/bmj.39461.643438.25). An editorial explains that better understanding of prognosis will not only improve clinical care but will help us design better clinical trials (doi: 10.1136/bmj.39461.616991.80).

Improving prognosis almost always means rapid diagnosis and effective treatment. Two conditions where this is especially important are acute myocardial infarction and severe sepsis. Christian Juhl Terkelsen and Jens Flensted Lassen conclude that we need more centres that deal with large numbers of cases if we are to get "door to balloon" times down to 30 minutes for people with ST elevation myocardial infarction (doi: 10.1136/bmj.39475.482419.80). Jane Minton and colleagues sought to cut delays in starting effective treatment for bloodstream infections in a 1400 bed hospital (doi: 10.1136/bmj.39454.634502.80). They found that most errors (in terms of delayed or inappropriate antibiotics) occurred on the medical wards. Treatment guidelines, an education programme, and routine review of patients by the infection team cut the rate of errors from 30% to 8%. The authors call for all acute hospitals to adopt this approach. Whether a single before and after study, or even several of them, should justify wholesale implementation of such a scheme is one of many issues that will be hotly debated at this year’s International Forum for Quality and Safety in Health Care in Paris in April (http://internationalforum.bmj.com).

One final word this week on the importance of a prompt diagnosis and well informed prognosis. Alex Webb was diagnosed with xeroderma pigmentosa at 4 years old after several severe episodes of sunburn. Now nine years later, his doctors predict a normal life span thanks to dedicated collaboration between his parents, teachers, and even the European Space Agency to ensure he is always protected from the sun. His mother makes a plea for early recognition of the condition and for health professionals to accept that parents know more about living with it than they do (doi: 10.1136/bmj.39485.698356.AD).

And so to politics. The UK government’s plans for greater involvement of the private sector in the NHS are attacked from several directions this week. Allyson Pollock and Sylvia Godden look for evidence to support claims that independent sector treatment centres offer high productivity, quality of care, or value for money and find it lacking (doi: 10.1136/bmj.39470.505556.80). Chris Salisbury looks at the involvement of private companies in general practice and predicts that the outcome for patients and overall healthcare costs will be poor (doi: 10.1136/bmj.39490.412755.80). He calls for a serious public debate about the type of general practice that people want and need. Meanwhile, Susan Mayor reports that cost cutting rather than quality is driving decisions to grant primary care contracts to private companies in London (doi: 10.1136/bmj.39496.687245.DB). Faced with all of this, you may need Trevor Trueman’s wake-up call (doi: 10.1136/bmj.39485.491493.C2). If we are not to become "bland and humourless participants in a society driven by targets and profit," activism and altruism may be our only hope.

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