Health systems: where doctors and patients meet

BMJ 2002; 324 doi: (Published 19 January 2002) Cite this as: BMJ 2002;324:i

Arguments about ways of delivering health care are more often grounded in faith and anecdote than good data. Thus Americans sneer at Britain's socialised medicine, while Britons look aghast at the United States's uninsured millions. The opening paper in this week's issue provides some good data—and will probably make our British readers feel rather uncomfortable. In it Richard Feachem and colleagues compare the costs and performance of the NHS and Kaiser Permanente, a Californian health maintenance organisation—and show that Kaiser achieves better performance at roughly the same costs (p 135).

Among the commentaries on this paper is one by Don Berwick in which he speculates that Kaiser is better at “configuring care according to the needs of the patients throughout an episode of illness.” Arguably the NHS is the best positioned healthcare system in the world to achieve the vision of an integrated patient journey—yet, paradoxically, it does not.

Berwick has done much to promote this vision for the NHS for he is a member of the NHS's Modernisation Board, which has just produced its first report on the government's plan to modernise the NHS (p 132). The report marks some progress— 597 more critical care beds, 714 more acute beds, 10 000 more nurses, 17% more cardiologists—but there's still room for improvement. One area where services have been “modernised” is cancer, and on p 164 David Kerr and colleagues (including Don Berwick) describe how nine cancer networks throughout England have used quality improvement methods to reduce waiting times and improve patients' experiences of care.

If “socialised medicine” carries a slur, it's not surprising that the formerly communist countries of eastern Europe have moved fast to change their systems. Yet an obituary this week pays tribute to Regine Hildebrandt, a former minister for health and social affairs of Brandenberg, for trying to preserve what was good in the East German health system (p 175). She valued policlinics, where groups of specialists worked together. “Diabetic patient care was excellent in East Germany, but we did not have the pumps, the tests, or special diet products. Now we have all that but the patients can't go to specialists any more, but to their GPs without specialist knowledge.”

Kevin Barraclough might not agree with this analysis—but he does bemoan the loss of diagnostic skills in general practice (p 179). “All the skills that are rightly revered … listening, communication, empathy—are seriously devalued if major diagnoses are missed.” But maybe he is underestimating his trainees' ability to assess their own learning needs (p 156) and forgetting about lifelong learning. Sandy Goldbeck-Wood and Ed Peile explain how our new section, “Learning in Practice,” aims to be the place where educationalists and clinicians can help each other deliver “better educated doctors capable of better patient care” (p 125).


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