Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Choosing choice
- Mark Struthers (28 March 2005)
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Choice? How?
- Iñigo Romón-Alonso (28 March 2005)
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Choice
- John Stone (29 March 2005)
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Argue against choice we must.
- Jim Boddington (30 March 2005)
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Lead clinician
- Paul F Alford (31 March 2005)
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Heading where exactly?
- Graham Neale, Sisse Olsen (31 March 2005)
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Editor's choice
- Bruce V Court, Timothy F Finnegan Consultant in Occupational Medicine, Wilton. (1 April 2005)
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Fluff and Eye Candy
- Stephen Pearce (1 April 2005)
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The Choice Equation
- Sujith K Dhanasiri (7 April 2005)
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Good Choice Bad choice
- Jayaprakash Gosalakkal (8 April 2005)
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Mark Struthers, General Practitioner Bedfordshire mark.struthers@which.net
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Choice is a many splendoured thing. Choice is the new engine for the ‘patient led NHS’ the politicians tell us. And yet in the febrile atmosphere of an expected election the people are not spoiled for choice of politician. And yet the people must choose. The people must make their choice for freedom and democracy. And yet the politician drives the engine that chooses the kind of politician that leads the people. And yet again the choice is between Pepsi and Coca-Cola. Voting the third way will not choose proportional influence in government and will be a wasted choice. There is a better way to choose our politicians. Make a choice based on quality, not price. Vote proportional representation at the upcoming election. Proportional representation will encourage the politician to listen to the people and do a better job. Make a better more healthy choice by choosing proportional representation. It is hard to argue against choice and it will all work so wonderfully if given the chance. Competing interests: member of the Electoral Reform Society (ERS) who will vote for greater choice by voting STV at the election on May 5 2005. |
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Iñigo Romón-Alonso, Quality Manager Banco de Sangre y Tejidos de Cantabria. 39008. Santander, Spain
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Patient choice is a new hype, which is also coming to Spain. I honestly don´t understand how a patient can make a choice between hospitals. Even we as doctors know so little about other doctors' specialities that we find difficult to counsel our own family or friends. Must GPs add to their daily chores a course on how to compare hospital "rates" ? It´s difficult enough to make light among the same pathologies treated at different centres using statistical tools. How can a patient balance a given % in better results against being attended at a local hospital with better family access? How can I learn if a given hospital is using new techniques or conventional ones, and if they are making a good use of them? Which is the weigh of tradition? And the balance of gossip among village cronies? If differences are known, why aren´t they corrected immediately instead of waiting for the invisible hand of market? That would mean that we accept suboptimal practice. We´ve had enough sad experiences from the financial world, to make up one´s results to gather a greater market share to be cautious enough to let that temptation come into our already troubled house. Competing interests: None declared |
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John Stone, none London N22
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"Choice" is a strategy used by politicians to distract from their inability to deliver universal services like health and education at an acceptable level. There are of course plenty of areas of life where choice is essential but it should not confused with "choice" as a modern political comodity. I share Fiona Godlee's suspicion. Competing interests: None declared |
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Jim Boddington, GP Principal Shoreditch Park Surgery, 10 Rushton St, London N1 5DR
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Fiona Godlee rightly raises concerns about the choice bandwagon, but I refute her suggestion that it is 'hard to argue against choice' in healthcare. Choice is great when buying a car or a bottle of wine, but the advantages only transfer to healthcare if we accept patients as consumers in a marketplace. Such a model is in nobody's interest. Patients do not need choice: what they need is properly funded high quality accessible local facilities, coupled with robust mechanisms to ensure that doctors are fit to practise. Choice is sold to us by politicians as a mechanism to increase patients' confidence in the care they receive. We are asked to believe that if patients choose their doctors from league tables, they will be satisfied they are getting the best. But if one patient gets the best, the next, by definition, will get second best, with an implicit assumption that it is OK for some people to get better care than others. If patients avoid certain doctors, and doctors in turn avoid risky patients, how can any kind of coherent health service be planned and delivered on the basis of need? Out go the NHS founding principles of universality and equity. Of course the public has a right to feel confident that doctors are up to the job. Revalidation and the increasingly rigorous mechanisms of clinical governance will assist in this. Quality data should be used in these processes to ensure good clinical care, not to compile league tables to facilitate spurious and ultimately damaging choices. Politicians propound choice for cynical motives. They need us to embrace the concept, so they can impose their 'mixed economy of healthcare'. When I refer patients for specialist care, they will soon be given a choice of 5 providers, one of whom will be in the private sector. An increasing proportion of NHS revenue will end up paying the shareholders of private healthcare companies. We should have no illusions: choice is wholly a political agenda, the hidden aim of which is to incrementally privatise the NHS. Argue against choice we must. Competing interests: None declared |
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Paul F Alford, GP Principal; Education lead SW19 3DA
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I was very concerned to read Craig Gannon's personal view. It is very distressing to find care appearing to be provided in such a fragmented and uncoordinated fashion. The GP's role in this particular case is pivotal. He/she should be coordinating and providing the patient with both holistic and high quality care. In the modern NHS, there is no excuse for a clinician not to establish the entire needs of an individual patient e.g. a patient on Lithium needs to be adequately monitored. This is the responsibility of the prescriber. The age-old excuse that someone else is doing the monitoring does not wash. I am very sorry for this patient's suffering, but feel that attention to detail and 'thinking' would have changed this patient's journey! Paul Alford. Competing interests: None declared |
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Graham Neale, Visiting Professor Clinical Safety Research Unit, Academic Department of Surgery, Imperial College, St Mary’s Hospital,, Sisse Olsen
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EDITOR – Your commentary on Dr Craig Cannon’s “Will the lead clinician please stand up”1 prompts us to provide additional evidence from a study that we have completed at a district general hospital in which as part of a research project we persuaded clinical teams to examine the quality of care in their own units. We found evidence of adverse events or critical incidents in 60/154 medical cases and 27/134 surgical cases. Most of the issues were relatively minor – commonplace problems that one might find in any hospital ward e.g. Venflon cellulitis, over-infusion of intravenous fluids - but in at least 12 medical cases and 16 surgical cases there was evidence of a lack of integrated care, in some cases with serious consequences. Dr Cannon suggests that we need to re-vitalise the role of the lead clinician. Our findings support his contention. However, is that possible and would it be enough? Over the past 20 years hospital doctors have striven to become specialists rather than consultants. As long ago as 1985 Sir Christopher Booth, former Director of Medicine at the Royal Postgraduate Medical School, warned of the effects of technology on the practice of medicine2 and today we live with such predictions. In our study we tried to assess causation. Inevitably superficial appraisals are subjective but at least half the problems appeared to arise from a ‘failure of overall care.’ The specialists of today do not have the time to be ‘lead clinicians’ for all the patients they see. So should we not be training all members of the clinical team to take overlapping responsibility – developed as ‘Total Quality Care’ in the Japanese car industry and subsequently applied to medical care3 – and should we not nominate individual secondary care doctors to relate to individual patients to ensure the adequacy of integrated care? Graham Neale, visiting professor Sisse Olsen, research fellow Corresponding email: g.neale@imperial.ac.uk Clinical Safety Research Unit, Academic Department of Surgery, Imperial College, St Mary’s Hospital, London W2 1NY 1 Godlee F Heading where exactly? BMJ 2005;33:680 2 Booth CC What has technology done to gastroenterology? Gut 1985, 26:1088-94 3 Milakovich ME Creating a total quality care environment. Health Care Manage Rev 1991;16:9-20. Competing interests: None declared |
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Bruce V Court, Consultant in Public Health Gloucester, Timothy F Finnegan Consultant in Occupational Medicine, Wilton.
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EDITOR—Your pre-All Fools Day deliberate mistake has not gone unnoticed! The comments in the last paragraph of Editor's Choice relate to Barbara Starfield's article on US and UK health care.(1) It is Barbara Stocking's enjoyable and informative review of Sebastian Mallaby's book, that appears on page 736. Writing from the perspective of health economics, Maynard also compared health systems in the USA and the UK, in 1998. He reported that the managed care "revolution" had been disappointing because it had not sufficiently taken account of quality in terms of outcomes i.e. the improved health status of patients.(2) In highlighting the importance of ascertaining quality of care by its effects on health, rather than concentrating on structures and processes, Starfield has provided a timely reminder about the need to focus on outcomes. Progress towards incorporation of outcome-based measures of health, within national health systems, does indeed seem slow. What might account for this? Undoubtedly, reaching agreement about which measures of health outcome matter, and how these should be translated into health policy, is no small matter. However bringing about change is more than just agreeing technical solutions; it requires organisational development that brings about combining top-down and bottom-up approaches - an important part of which is engaging clinical leaders and opinion formers at strategic and grass-root levels.(3) In this context, notwithstanding deliberate mistakes, Barbara Stocking's book review on page 736, contains two important lessons. Firstly, trusting people is necessary for organisations to deliver. Secondly, you cannot just impose private sector solutions on public bodies and expect them to work. Building trust and acceptable solutions, takes time. BV Court, Consultant in Public Health
TF Finnegan, Consultant in Occupational Medicine
(1) Starfield B. US and UK healthcare: a special relationship? Why is the grass greener? BMJ 2005; 330:727-9. (2) Maynard A. Competition and quality: rhetoric and reality. Int J for Qual in Hlth Care. 1998; 10 (5): 379-384. (3) Ham C. Improving the performance of health services: the role of clinical leadership. Lancet 2003; 361: 1978-80. Competing interests: None declared |
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Stephen Pearce, Biomedical Scientist NHS
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Dear Editor, Whilst i work in the NHS i would like to speak as a tax paying, voting citizen of this country. How can i make decisions based on limited information better than a proffesional in the field ? The amount of information required to make a truly informed decision would be immense, and dare i say it beyond the capability of most people. Lets not pretend everyone has the willpower and ability to analyse complex statistics, even if they are given all the neccesary information. Personally i think it is a show of fluff and eye candy from the goverment. I'm not convinced there will be any actual choice. I'm not convinced there will be truly informed decisions and i'm not going to ask my electrician which tires i should buy for my car either. Thats what mechanics are for. Regards S.Pearce Competing interests: Citizen of the UK |
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Sujith K Dhanasiri, Health Policy Student London - WC2A 2AE
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The introduction of Choice into healthcare service sector is based on the premise that it would act as a tool to enhance performance. Choice is integral to a free market health sector and is inextricably linked to price and quality. Choice and effciency is a yes in a free market , but the same does not gel in a nationalized health sector where the equation is primarily between equity and efficiency. Competing interests: None declared |
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Jayaprakash Gosalakkal, Consultant Paediatric neurology UHL Leicester LE1 5WW
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It is interesting that patients are allowed choice between hospitals but the unmentionable is choice between consultants.In further attempts to discourage waiting list which may be uneven patients are reallocated at random by those in charge .Even in situations where patients are willing to wait for the preferred consultant or the matter is non urgent policy dictates may order such reallocation . Continuity of care seems an expedient principle.Anybody who may oppose this is branded a non team- worker which is worse than being branded a kulak in the old soviet union.Dr Struthers is right anger is sometimes a useful emotion though we are working very hard to banish it as a manifestation of primitive thought Competing interests: None declared |
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