Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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A need to change the culture in the NHS?
- Richard G Fiddian-Green (28 November 2003)
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The NHS Lottery
- Simon V Hennessey (30 November 2003)
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Undervaluing the Role of Information in Assessing Quality
- Michael J Rigby (1 December 2003)
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Re: The NHS Lottery
- Gareth Williams (1 December 2003)
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And just who gets to choose which data will matter?
- Peter Davies (2 December 2003)
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NHS - Better or Worse
- David Vernon Thomas (3 December 2003)
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Measurement in the NHS - better to be vaguely right rather than precisely wrong
- David Kernick (3 December 2003)
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Making use of information is key
- Leela M Barham (4 December 2003)
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Are we asking the right questions?
- Robert Leckridge (4 December 2003)
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Primary Care potential is transformed
- Rupert Gude (14 December 2003)
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The NHS is not getting better
- J M Walshe (5 January 2004)
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Is the NHS getting better or worse
- Michael G Pearson, Carol Black (7 January 2004)
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Richard G Fiddian-Green, None None
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Richard Smith's comments are appropriate. Consider them in the context of colo-rectal surgery. The overall mortality for surgery for colon and rectal concers in the study published in last week's BMJ was 7.5%(1). In a comparable study in the VA hospitals 5,853 patients were identified; 4,711 (80 percent) underwent resection and primary anastomosis (2). The 30-day mortality rate was 5.7 percent (335/5,853). [From my observations during a brief tenure as chief of surgery in a VA in New York whose performance before I arrived had fallen in the middle of the bell-shaped curve, there were gross deficiencies in the standard of care which accounted for these unacceptable figures]. This mortality was no different from the overall mortality reported in non-VA hospitals in the US (3). Thus the overall mortality for surgery for colon and rectal cancers in the NHS would seem to be some 30% higher than it is in the US. Both figures are unacceptably high. The figures do not reveal the wide range in standard of care between institutions and between surgeons, the 7.5% and 5.7% being mean values. There are considerable differences not only in outcomes but also in ostomy rates between institutions and between surgeons (4). Some high-volume surgeons operating in high-volume hospitals have achieved mortalities as low as 0% to 1% even in alarge number of consequetive cases. Some low- volume surgeons operating in low-volume hospitals can have mortalities and ostomy rates much higher than the means. Hospital volume would seem to be of greater importance than surgeon volume, a low-volume surgeon working in a high-volume hospital being likely to get better results than a low- volume surgeon working in a low-volume hospital (3). The inference is that skills of both the individual surgeon and his/her team determine outcome and ostomy rates. It is, however, dangerous to make generalisations on the basis of volume alone for there are striking exceptions. The danger in reputable bodies publishing median outcomes as high as these is that, in providing a benchmark, they might increase the likelihood of mediocrity being interpreted as an acceptable standard of care to which both individual surgeons and the institutions in which they operate should aspire. There are managerial implications too for the actions needed for a surgeon/institution in the lower percetiles to achieve mediocrity may be very different from those required to achieve the highest standard of care. Whilst the former might be achieved by boot- strapping, or total-quality-improvement (TQI) initiatives, the latter may not. To change from mediocrity to excellence may require an infusion of new staff large enough to change the institutional culture. 1. Paris P Tekkis, Jan D Poloniecki, Michael R Thompson, and Jeffrey D Stamatakis Operative mortality in colorectal cancer: prospective national study BMJ 2003; 327: 1196-1201 2. Longo WE, Virgo KS, Johnson FE, Oprian CA, Vernava AM, Wade TP, Phelan MA, Henderson WG, Daley J, Khuri SF. Risk factors for morbidity and mortality after colectomy for colon cancer. Dis Colon Rectum. 2000 Jan;43(1):83-91. 3. Harmon JW, Tang DG, Gordon TA, Bowman HM, Choti MA, Kaufman HS, Bender JS, Duncan MD, Magnuson TH, Lillemoe KD, Cameron JL. Hospital volume can serve as a surrogate for surgeon volume for achieving excellent outcomes in colorectal resection. Ann Surg. 1999 Sep;230(3):404-11 4. Schrag D, Panageas KS, Riedel E, Hsieh L, Bach PB, Guillem JG, Begg CB. Surgeon volume compared to hospital volume as a predictor of outcome following primary colon cancer resection. J Surg Oncol. 2003 Jun;83(2):68-78; Competing interests: None declared |
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Simon V Hennessey, . Bristol
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Richard Smith's editorial asks whether the NHS is getting better or worse? With the publication of the NHS plan in December 1997 there was a tacit admission by the new Labour government that the NHS had to change. Six years on despite millions of extra money spent, the rise of clinical governance, modernisation and monitoring agencies such has the Commission for Health Improvements and a report by the Nuffield Foundation, Smith concludes that we can’t answer the question and need more data. If the experts can’t decide what does the public think? A recent MORI Social Research Institute poll showed that most people thought that whilst education and policing would get better in th long term the NHS would get worse. A sad indictment of our new NHS: Modern and Dependable. Statistics and reports written by experts shy away from the growing problem that despite National Service Frameworks, Integrated Care Pathways and other clinical tools the medical care delivered within an individual NHS trust is actually determined by the diligence and expertise of the frontline junior medical staff who interact with the patient. Numerically we have more junior doctors than ever before but has this lead to better patient care? First it is important to admit that increased junior doctor numbers was never undertaken to improve the standard of care but rather as a result of the New Deal and the impending European Working time directive. To enable this rapid expansion in junior staff medical teams are usually made up of a mixture of trust doctors, clinical fellows, GP vocational trainees and a smaller number of career SHO's and Calman registrars. Many more doctors but most with limited experience and interest in hospital medicine. Whilst house officers used to spend most of their time clerking patients, this grade of medical staff has been reduced to no more than clerical phlebolotomy; it is not then difficult to see why junior SHO’s have such little experience. Patient's admitted to District General Hospitals are entered into the “NHS lottery” usually with about a 1 in 5 chance of winning. Take for example a patient presenting with gross cardiomegaly admitted on a Friday evening. Most physicians would agree that this patient would benefit from echocardiograpy however but the availability of this test depends on whether the registrar on call happens to be a cardiologist. Similar examples abound throughout all acute branches of medicine; deskilling and reduced experience has raised the question of whether temporary pacing wires should even by attempted by non-specialists in District Hospitals. These examples are not to denigrate the ability of one doctor against another but to simply state the obvious - an expert will have more knowledge and technical skill in a particular area than a non-expert and that doctors who work few hours will have less experience. This type of care lottery also operates within teams. A new outpatient referral seen by a junior SHO could well obtain a different initial diagnosis and management plan from that chosen by a consultant. Is there any evidence that patient care is suffering? In a provocative paper published this year in Clinical Medicine by Seward et al. they found that out of 200 deaths in a District Hospital there were shortfalls of care in 25 cases that in the opinion of two independent assessors may have contributed to their deaths. The major problems were delays in seeing doctors, inaccurate diagnoses, delays in investigations and initiation of treatment. Most of these problems occurred in those patients admitted at night where 64% of admissions had delays in establishing the correct diagnosis and starting appropriate treatment. This report provides some evidence that the inexperience of junior staff contributes to inaccurate and delayed diagnosis and treatment. The Nuffield Trust report cited by Richard Smith tells us that 76% of patients with coronary heart disease are being treated with aspirin, ß-blockers and statins but what of the other 24%? Why was there treatment sub-optimal? Does this mean that the answer to the NHS lottery is a consultant delivered service at the point of care? The government state that they are striving for this but when consultants were asked to vote for a contract that allowed even the possibility of evening or Saturday morning work there was a strong vote against. Look at rationally: What consultant in middle age with a family would be willing to sit in a casualty department at two o'clock in the morning clerking patients? If no consultant delivered service is available what then for the NHS? The medium size DGH is at the heart of the problem, the lack of critical mass of senior trainees, akin to the old senior registrar grade, means than inexperienced juniors primarily staff these hospitals. Until we recognise this and alter the service deliverer patients will continue to be exposed to inferior care. Competing interests: None declared |
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Michael J Rigby, Reader Centre for Health Planning and Management, Keele University
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The Editorial on assessing quality of and in the English NHS, based on a Nuffield Trust study (1), underscored the essential role of good information at all levels. It was timely, in that it appeared on the same day that the Nuffield Trust launched a volume of essays on the importance of vision, value and innovation in health information (2). However, the editorial perpetuated the frequent confusion between information and data, and assumed that evidence would emerge by osmosis. And the underpinning study proposed yet another quasi-autonomous and confusingly titled agency, a Quality Information Centre. Meanwhile, the government, NHS, health professions, and commentators all continue to abuse the information sector in health – assuming that top-down direction on IT and short-term programmes will automatically yield the “right” answers to expedient questions. But true investment in information, its development and use, and above all in trust in the data and authoritative analyses, get sidelined. At the same time, the leadership role of the NHS Information Authority is undermined and the field fragmented by the allocation of sections of activity to the central procurement function and to the Modernisation Agency, so no one body is empowered to lead the information function. Other models exist but are ignored. For example, in Canada the much respected Canadian Institute for Health Information is managed and funded under the joint aegis of the government and the Provinces’ health systems, and has a clear sapiential leadership on all aspects of information from principles and techniques to authoritative published analyses of topical issues, often in partnership with Statistics Canada in order to combine health and wider official datasets (3). And recently Detmer has called for a new authoritative independent UK body to guide health policy development, founded on the impartial gathering and analysis of evidence (4), based on the model of the US Institute of Medicine, which has been so effective in using sound information analysis to challenge then develop clinical practice and health policy, not least on quality but set in an inclusive context (5-7). An integrated commitment to a true health information function would seem more robust than fragmented special agencies, but of course is politically unattractive, being a combination of additional cost and reduced political control with the potential for unwelcome findings. The Nuffield Trust meeting on vision and value in health information concluded that a meaningful and objective approach was needed, including engagement with all professions and stakeholders, together with vision and innovation. It was disappointingly symptomatic of the ambivalence to health information that neither the Department of Health, nor any of the representatives of the health press invited (including the BMJ) felt it worth attending the discussion. We may not be sure whether the NHS is getting better, as we lack the information. But we can be certain that the understanding of and commitment to health information are not improving as they should despite investment in technical systems, because of the lack of core commitment to an objective integrated approach. Michael Rigby 1. Leatherman S, Sutherland K. The Quest for Quality in the NHS: a mid term evaluation of the ten-year agenda. London: Nuffield Trust, 2003. 2. Rigby M (ed.). Vision and Value in Health Information. Oxford: Radcliffe Medical Press, 2004 (sic). 3. www.cihi.ca 4. Detmer DE. Improving the United Kingdom’s Health System: an adaptive model to harness information and evidence. In Rigby M (ed.). Vision and Value in Health Information. Oxford: Radcliffe Medical Press, 2004 (sic). 5. Institute of Medicine. To Err is Human: building a safer health system. Washington, DC: National Academy Press (2000). 6. Institute of Medicine. Crossing the Quality Chasm: a new health system for the 21st. Century. Washington, DC: National Academy Press (2001). 7. Institute of Medicine. Unequal Treatment: confronting racial and ethnic disparities in health care. Washington, DC: National Academy Press (2002). Competing interests: MR writes and edits in the field of health information; he provides independent academic advice on this topic. |
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Gareth Williams, Professor Bristol
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Dear Sir Who is Dr. Simon Hennessey? As errudite as the discussion appears, clearly having been written by someone involved at some level with NHS healthcare, the identity of the author remains in question. Is SVH a nom de plume derived from the film - PAPER MASK? In 1991 - Matthew Harris (Paul McGann) is a lowly, disgruntled attendant in a dreary London hospital. When one of the staff, a physician, is killed in an automobile accident, Harris, noting the similarity in their ages, is intrigued by the possibility of assuming the dead man's identity. After all, he has worked in and around hospitals all of his adult life. What's more, the dead man is an applicant for a new post at a Bristol hospital and even has a firm date for his initial interview. Matthew determines to do the interview in his stead and, because he is personable and presentable, gets the post in favor of several other applicants. Matthew becomes Dr. Simon Hennessey, charged with working in that hospital's emergency room. He manages quite miraculously not to kill anyone and, in fact, handles several crises. Matthew is helped out by Christine Taylor (Amanda Donohoe), a sweet and capable nurse who, in the process of helping the appealing young "doctor" get his bearings, falls in love with him. Matthew's lack of knowledge seems no more evident than that of other colleagues at the hospital who are fresh from years of training in medical schools but have no hands-on experience. His humility, too, endears him to the nursing and technical staff at the hospital. Inevitably, Matthew makes a fatal mistake while ministering to a patient who dies because of his negligence. At the subsequent coroner's court hearing, Christine comes to his rescue and assumes the blame for the accident. Emboldened by the whitewash and by the fact that the other doctors at the hospital have closed ranks around him, Matthew applies for a better post at a hospital in Salisbury. But one of the few friends he had during his days as a porter in London suddenly turns up, and Matthew resorts to murder to protect his charade. PAPER MASK was popular due its capcity to question many of the absolutes (some mad) that we stick to in the NHS. Almost every review used the word DEBUNK. Could our colleague have aquired an alter ego, in order to debunk the myths of an improving NHS? Spirit reveal thyself! Competing interests: None declared |
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Peter Davies, General Practitioner Mixenden Stones Surgery, Mixenden, Halifax, HX2 8RQ
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Sir, Richard Smith's editorial asks an important question about whether the NHS is working better. He places a lot of faith in gathering better data about the workings of the NHS to help us answer this question. However this approach begs the question of "what would the appropriate data be?" And behind that is the intensely political question of, "Just who gets to select the data?" Data have the facade of being somehow neutral and objective. Data may be seen as factual, and figures may appear to add up. However the real smoke and mirrors trick has already been laid by the person who has chosen the frames of reference around what data are to be selected. We may have been set up by this frame to react in a predictable way, even before any data is presented. Behind even the simplest data someone in the background is chosing to highlight some facts, and to fade others out. As we do not have an agreed idea about what a working NHS would consist of, any statements such as "the NHS is working" or "the NHS is not working" at present have no clear meaning, and serve largely as political slogans rather than debatable propositions. We need first to decide what we would mean by a "working NHS" and then choose what data would give us the measure of our concept. And both doctors and patients need to make their concept far clearer than the politicians' meaningless phrases and grasped straws of data. Competing interests: I work within the NHS and see patients regularly. Therefore I clearly have the perspective of a service provider.(or a vested producer interest as the government would describe it) |
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David Vernon Thomas, Ret Santa Barbara , California 93101
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I have often read about long waiting times for consultant appointments and for operations. Waiting for a hernia repair or a new hip seemed to me tolerable in a \"free\" system. BUT , I now have personal knowledge of a terrible example - a close old friend , a retired GP in Bridgend , OBE'd for long and good service , suffered acute urinary retention in July this year. He was catheterised and equipped with a bag. Waited a month to see a consultant, another 3 weeks to get an ultra-sound to decide the size of his prostate, then put on a wait list for suprapubic prostatectomy. He is still living, I should say existing, with the catheter and bag! Almost six months now. He has been told that they hope to operate in December, IF they have a bed. Much is said and written about the deficiencies of US medical coverage , BUT - and I cannot prove it - it is almost impossible to imagine the poorest unemployed, uninsured, man in the US being made to live with a catheter and bag for such a long time. Something wrong somewhere! Competing interests: None declared |
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David Kernick, General Practitioner St Thomas Health Centre, Cowick Street, Exeter EX4 1HJ
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In a recent editorial (1), Richard Smith asks whether the NHS is getting better or worse. By falling into the reductionist trap of assuming that the health care system can be understood by dissecting it into its component parts, he succeeds in being precisely wrong rather than vaguely right. Underpinning his argument is a belief that the transfer processes that relates inputs to outputs in each element of health care are well understood. Information is used as feedback that is compared with a desired state (performance assessment) allowing the system to be engineered towards the desired objectives using incentive manipulation (performance management). His ultimate folly is to infer that all we need is enough data and a “complete, validated, interpretable and uncontested” picture will be revealed. The truth really is out there. His observation of “muddling through” against a background of “improvement, stasis and deterioration” offers a more useful perspective - the metaphor of an ecosystem rather than a machine. All parts are adapting by learning to survive in a topography that is provided by co- existing and changing elements. This approach sees health care as a network of inter-related systems that interact in a non-linear fashion, i.e. there no simple relationship between cause and effect - small inputs can have large and unexpected consequences in any part of the system. This is due to multiple reiterative feedback loops (the output of one interaction feeds back as the input of the next) operating at a local level. The characteristics of the system are not represented by the sum of its parts - each element cannot be understood in isolation (2)(3). Evidence is beginning to emerge that this model, underpinned by insights from chaos theory, may be a more accurate representation of the health care transfer process and why measures such as waiting times are a very poor indicator of system performance(4). An over emphasis on outcome measurement constrains us within a set of unreliable assumptions about the relationships between cause and effect in health care and invariably a number of unhelpful conclusions. It produces carrots and sticks, overlooking the fact that the NHS workforce are not donkeys but individuals who are not only discharging organisational functions but making sense of the situations in which they find themselves. There must be an appropriate level of aspiration for the use of information where rationality is often bounded and progress is invariably by mutual adjustment, and negotiation. In complex systems there may be fewer causal links than we may like to hope for that offer tools for analysing, predicting and controlling system behaviour. Analytical power is often gained by standing back rather than bludgeoning our way to solutions through increasing data acquisition and analysis. The challenge is to accommodate measurement of costs and benefits into accessible frameworks that reflect the realities of the health care system rather than seek the elusive “correct organisational solution”. REFERENCES 1. Smith R. Is the NHS getting better or worse? BMJ 2003;327:1239- 1241. 2. Kernick D. The demise of linearity in managing health services: a call for post-normal health care. J Health Service research and Policy. 2002;7(2):121-124. 3. Kernick D. Complexity and health care organisation. A view from the street. (In press March 2004). Radcliffe Medical Press, Abingdon. 4. Papadopolous M, Hadjitheodossiou M, Chrysostomu C, et al. Is the national health service at the edge of chaos? Journal of the Royal Society of Medicine 2001;94(12):613-6. Competing interests: None declared |
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Leela M Barham, Analyst National Economic Research Associates, 15 Stratford Place, London, W1C 1BE
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The editorial by Smith (1) suggests that the NHS needs to gather more information. Whilst more information is a common call from researchers and policy makers alike, it can only lead to change if it is used (presumably we collect information so that if the NHS is doing well we can all sit back and relax, if not it's time to try something new). The recent opinion piece from Alan Maynard in the Times (2) makes it clear that information that is currently collected is typically poorly used in the NHS. What use is a new agency to collate information if it still isn't used? We need to make sure that information gathering doesn't simply stop there, and that information will lead to real change. (1)Richard Smith, Is the NHS getting better or worse? BMJ 2003; 327: 1239-1241 (2)Alan Maynard, Statistics that could cure the NHS, The Sunday Times 23rd November 2003 Competing interests: Leela Barham works for a consultantcy firm and is paid by the private and public sector for research. No financial gain will be made from comments on this topic. |
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Robert Leckridge, Associate Specialist Homeopathic Medicine Glasgow Homeopathic Hospital G12 0XQ
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Richard Smith’s editorial is entitled “Is the NHS getting better or worse?” Better or worse at what? Maybe one of the reasons “we don’t have the data to answer the question reliably” is that the question is not well formed. This is a basic starting principle of evidence based medicine. To get a clear answer you need to ask a clear question. What do we want to know? Maybe asking how much harm is caused by the NHS would be one question worth asking. What are the rates of iatrogenic morbidity and mortality? If those figures are shrinking then at least we can argue that the NHS is getting better at not subjecting patients to harm. However, only to focus on the question of harm, fails to provide us with answers about the positive impact of the NHS. It’s a bit like defining health as the absence of disease. It’s a long time since the WHO argued against that definition of health. Maybe we should ask about numbers – numbers of doctor-patient contacts, numbers of nurse-patient contacts, numbers of procedures carried out, amounts of drugs prescribed. At least those numbers constitute data. However, do they tell us anything other than how good the NHS is at being busy? Being busy is no guarantee of either quality or effectiveness. Richard Smith is right to say “Elegant and imaginative reforms at higher levels are worthless if they do not translate into an improved experience for individual patients…” But how do we understand individual experience? Is it measurable? Hans Georg Gadamer, whose life’s work was in philosophical hermeneutics, in his collection of essays entitled “The Enigma of Health”, argues that health is not measurable because it is a phenomenon which is subjective and is enigmatically present when nothing tells you it isn’t there! I know – a strange thought, but read the essays for yourself, you might re-think what you are trying to do as a doctor and what the NHS is trying to do as an organisation. Mary Midgley, the contemporary English philosopher argues against reductionist scientism by saying that the value of ignoring our subjective experience of life has run out. More than that, it actually leads to frustration and failure. Eric Cassell, the American physician, describes in his books, “The Healer’s Art” and “The Nature of Suffering”, how he changed his practice by asking all his patients “Tell me about your suffering”, knowing that this would create a different doctor-patient agenda – one led by the patient and one which focussed on the patient’s lived experience. This isn’t a minor point. It is lived experience which patients bring to us daily and that lived experience contains pain, distress and suffering – none of which is “measurable” with instruments. So, if the NHS exists to reduce the burden of human suffering then it will not be able to demonstrate whether or not it is achieving that simply by accumulating data. It needs to effectively describe patient experience. It’s not “We need better data to answer the question”, it’s that we need to have a debate about what question we want to ask, then we need to devise the ways of understanding (not just measuring) the experience of the individuals the NHS was created to serve. Competing interests: None declared |
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Rupert Gude, General practitioner Abbey Surgery, Tavistock, Devon PL19 8 BU
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From a primary care perspective I have a subjective view that my practice has been transformed for the better by measures instituted by the Labour Government over the last few years. 1. Banning of cigarette advetising.The advertising hoarding closest to our secondary school used to consistently carry adverts for cigarettes. It now carries an anti smoking advert. 2 Support of smoking cessation. The use of frequent adverts on television with support for nurse training and provision of free nicotine replacement products has resulted in frequent requests for help from smokers. There has been a dramatic ( but unmeasured ) increase in interest in chronic users. (It helps to have a minister of health who does not support BAT or is happy to have his photograph taken whilst smoking ) 3. The 2 week wait has revolutionised the care of patients providing them with rapid access to consultant care. Let us not forget that it is a reasonsable aim that all referrals for whatever problem should be seen within 2 weeks. This would still be considerably longer than most European countries. That the 2 week wait has distorted care in the secondary sector has more to do with the lack of foresight in the nineteeneighties of the Government to expand medical schools due to a wish to keep taxes down and because there is no pressure from the consultant sector due to a wish to preserve the lucrative private sector from increased competition. 4. Rapid access chest pain clinics has revolutionised management of new onset angina. They have been introduced with remakable lack of enthusiasm from many cardiologists but they are hugely appreciated by patients and their General Practitioners. 5 The National Service Framework has set standards for the first time that it expects General Practitionerss to follow and to measure their activity. The new contract gives some financial incentive to it ( as articulated by Enoch Powell concerning wallets ). The change that this has brought about is dramatic. 6. The expansion of the number of nurses and the empowerment of nurses to run clinics and make clinical decisions has been greatly facilitated in the last 5 years. The nurses in our local Minor injury unit were forbidden to give even paracetamol in 1995 but are now liberated to initiate many appropriate treatments. 7. Access to ultrasound was on a 4-6/12 waiting list and echocardiography was only through a cardiologist with a similar wait. We now have open access provided by the Primary Care Trust not the secondary sector. The patients being seen do not realise the vast improvement but think this is just normal and appropriate ( as they should ). I could go on but time and space preclude. Only those with memories of say the 2 year wait for Coronary artery bypass graft or hip replacement will see the 9/12 wait as an improvment. From this side of the fence things are getting better and better for the patient. Rupert Gude Competing interests: None declared |
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J M Walshe, Retired Home
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I feel constrained to comment on your editorial, 'Is the NHS getting better or worse ? It is not, I fear getting better. I claim some entitlement to comment. I entered the practice of medicine in 1945 and continued in active practice until the year 2000. During this time I saw prehealth service medicine followed by the birth, rise, decline and,...well not as yet the fall of the Health Service. During most of this time I worked in teaching hospitals, UCH, Addenbrookes Hospital and the Middlesex Hospital, I also spent a year at the Boston City Hospital and, during my military service I had short spells of duty in BMH Athens and BMH Nicosia. The year I spent at a city hospital in the USA made me realise the potential for good of a comprehensive National health Service. In the early 1950s I was asked by Dr. Stanley Dorst, Professor of Medicine in Cincinnati, a frequent visitor to this country and a very wise physician, 'How has the health service impacted on patient care'. I replied that, to date, it had placed no constraints on us, we could practice as we wished. I added, with considerable prescience, that as the Government was the paymaster this happy state of affairs was unlikely to last ! The first sign of trouble was in the 1970s when nursing changed from a caring profession with an apprentice type of training to an academic one with degrees and, most recently, a desire to become pseudo doctors. Nurses now appear to spend most of their time filling in forms, drawing up rosters and learning about high tech equipment. Immediate patient care is leaft to auxillaries. There is no longer a single sister in over all charge of the ward with over all responsibility for its smooth running and cleanliness. There is a sister for each shift and sister's office is usually outside the ward. There is no matron to make a daily round to ensure all is shipshape and the patients are well cared for. Number nine, as she has become, has her office in some distant regional HQ and is far removed from reality of day to day care. I have recently watched, with sadness, the care of a friend in a provincial hospital. The ward was chronically understaffed so that the doctors instructions were often not carried out in reasonable time.The contract cleaning seemed to verge on the prefunctory. In the course of two weeks, in a six bedded unit, no less than three patients discharged themselves and one could understand why. One of the sisters confessed to me that the change from her previous teaching hospital was 'A culture shock'. I do not know if this typical of all provincial hospitals but I suspect it may well be so. The much derided two tier health service is, inevitably, already with us. The next disater to overtake the NHS was the introduction of the internal market. However good the theoretical idea may have been, in practice it severely limited patient choice. Low budget hospitals were natrually very reluctant to transfer patients to expensive teaching hospitals where specialist expertise was available; the severe drain on the budget being an obvious constraint. I had a most unpleasant correspondence with one regional authority over a patient who needed and wished for a referrwal to my Wilson disease unit in London. though it was eventually, very reluctantly, granted. A second patient from a neighbouring authority, failed to get her referral. In a correspondence with my MP, Mr John Major, about this case I wrote 'The trouble with the Health Service is that it is run by Civiul Servants who have never seen a sick humnan being in bed'. Patients with rare diseases need to be seen at specialist centres where the physician in charge is familiar with the patient over many years and is conversant with all the possible permutations of their illness I have no experience to comment personally on general practice but two recent pieces in the press speak volumes. The first a crossword clue 'Concept of general medical practice that has now largely died out (6,6)' Answer 'Family doctor'. The second, Matt's cartoon in the Daily Telegraph. A seedy looking husband, standing in front of the chimney piece, is told by his wife ' Two mince pies and a glass of whisky won't make our doctor come'. Need I say more. I am sorry to sound so gloomy about the health service but I fear our profession has lost the will to fight its corner and it has now become like the toad under the harrow. Indeed 'The old order giveth place to new'. J.M.Walshe. Competing interests: None declared |
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Michael G Pearson, Director, Clinical Effective and Evaluation unit Royal College of Physicians, St Andrew's Place London NW1 4LE, Carol Black
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22nd December 2003 Dear Richard, Your editorial of 29th November "Is the NHS getting better or worse" discusses the substantial report from the Nuffield foundation and quite correctly highlights the longstanding problem that there few reliable measurements of clinical care quality. You give a cautious welcome to the suggestion of a Quality Information Centre (QuIC) with the important caveat that "it is essential that the data can be believed by the public and the professions". We wholeheartedly agree and also that the public, patients, and the professions (via Royal Colleges and specialist societies) must be involved. However in your penultimate paragraph, you suggest that "few (professional bodies) have risen comprehensively to the task" with the implication that the professions may have been sitting passively on the bylines. This is far from the case and there are reasons why some may have this impression. The first reason was set out by Dash and colleagues (BMJ 6th December), in a description of their separate Nuffield report into the state of Health Service Research . It noted that the UK invests relatively little in this area. It also observed the problems of linking researchers and users so that the results enter clinical practice, and recommended that “independent organisations” might be more effective. Our experience supports this and highlights other problems. At the RCP we have established two national comparative audit programs that are the first to have achieved national participation (and are developing others). Working with patient organisations, clinicians (of many disciplines), and NHS management, the projects have produced data that are believed and have led to significant improvements in care. We have persevered over the past 5 years while others have withdrawn or reduced their activity. Specific hurdles to be overcome include: ·Funding: It is not possible to collect reliable data without much dedicated effort from (small) central teams and active support (often unfunded) locally within trusts. Obtaining NHS support has been difficult - and for example the third national stroke audit was entirely dependent on the generosity of pharmaceutical industry and patient charities. Although both Royal Colleges and Department of Health share the desire to improve care standards, there has been a "reluctance" to work through the Royal Colleges. ·Technology: The techniques for collecting clinical data reliably must be valid. Variables must have agreed national definitions, and results must be interpreted to allow for different case mix if results are not to be mis-used. It cannot be done without clinical knowledge. ·Prejudice: Winning the confidence of all parties within a specific topic has been tough, given the widespread distrust of the way data have been collected and handled over many years. Many NHS indicators have been based on "thin" data, or have been over-interpreted. Consequently many professionals feel it is more important to concentrate on delivering care, than to collect, or oversee, data collection. ·Recognition: It is also difficult when publications such as the BMJ decline to publish such work with the statement "we do not publish audit...". How can we attract in the best brains to work on such health care research if it is deemed in some way unworthy. Projects such as myocardial infarction audit have significantly improved care within a short time - whereas the best cell biology papers will take perhaps a decade to reach the front line and 90% or more may never do so. We would argue that our projects over the past 5 years compare favourably with other initiatives both in terms of cost and effectiveness. The country still expects the professional to deliver the best front line care for each individual and that is why most of us went into medicine. It is illogical to expect that those same professionals will suddenly want to distort data. However, to ensure openness each of our projects has a multidisciplinary steering group that includes patient organisations. We would be delighted to contribute more and be one of the “independent organisations” that Dash et al refer to as possible solutions, but can only do so if the DH and its related bodies are willing to contract the work from us. We suggest that the problem is not so much one of "engaging the professions", as of changing the national mindset to allow clinicians the time and authority to lead that they entered the professions for - delivering best quality care. Yours sincerely, Professor Carol Black CBE, President Dr Michael Pearson, Director of CEEu 1. Richard Smith Is the NHS getting better or worse? BMJ 2003; 327: 1239-1241 2. Leatherman S, Sutherland K. The quest for quality in the NHS: a mid term evaluation of the ten-year quality agenda. London: Nuffield Trust, 2003 3. Penelope Dash, Natasha Gowman, and Michael Traynor Increasing the impact of health services research BMJ 2003;327:1339-1341 4. Birkhead JS Where are we today? Early results from MINAP, the national audit of myocardial infarction... Heart.2003; 89: 13-15 Competing interests: None declared |
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