Reviews Book

Rebuilding Trust in Healthcare; What is the Real Cost of More Patient Choice?; Patients, Power and Responsibility: The First Principles of Consumer-Driven Reform

BMJ 2004; 328 doi: (Published 01 January 2004) Cite this as: BMJ 2004;328:54
  1. Domhnall MacAuley, general practitioner (domhnall.macauley{at}
  1. Belfast

    Rebuilding Trust in Healthcare

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    Eds Jamie Harrison, Rob Innes, Tim van Zwanenberg Radcliffe Medical Press, £27.95, pp 224 ISBN 1 85775 938 9


    What is the Real Cost of More Patient Choice?

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    John Appleby, Anthony Harrison, Nancy Devlin King's Fund, £6.50, pp 64 ISBN 1 8571 7473 9


    Patients, Power and Responsibility: The First Principles of Consumer-Driven Reform

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    Radcliffe Medical Press, £27.95, pp 272 ISBN 1 85775 924 9

    Rating: GraphicGraphicGraphic

    Where have we gone wrong in medicine? The respect that doctors took for granted has evaporated; medical gods have been reduced to mere mortals. We no longer trust the caring general practitioner, the wise physician, or the conscientious surgeon. And it all seemed to happen so quickly. A litany of medical mistakes, hospital mismanagement, misinformation, subterfuge, and murder has dragged the medical profession through the tabloids and into the mire. Maybe we deserve it.

    Dressed in a bland cover and damned with a boring title, Rebuilding Trust in Healthcare is anything but. It tells it as it is. Compelling as any thriller and unbelievable if it were not true, it leaves the medical reader with a profound sense of shame, embarrassment, and perhaps a little guilt. For old fashioned believers in altruism and the vocational concepts of medicine, this book is bleak reading. While Bristol, Shipman, and Alder Hey are familiar in a vague sense, this book is frightening because it spells out the facts. And the truth is we have failed our patients. It is a blunt message: “Medicine will have to say it is sorry for past mistakes and mean it.”

    If true friends are those who have your best interests at heart, then the book's contributors—Rabbi Julia Neuberger, the bishop of Liverpool, Ruth Etchels, Rob Innes, and John Newton—are among them. They are supportive of doctors, but make some harsh criticisms, and we should take note. There are some positive observations and suggestions about improvement. I would like to believe them. Part of the problem is that we don't listen enough to others. We should ask ourselves how medical school turns wide eyed enthusiasts, whose declared interest is in helping others, into a cartel who listen to few and are strangled by self belief.

    The serial killer Harold Shipman was clearly a nice doctor, well liked by his patients. But being a nice doctor is not enough if we are not good doctors. At Alder Hey—where children's organs were removed and stored without parents' knowledge—the pathologist Dick van Velzen erred, but many others in the university and health service turned the other way. If we reflect on our own careers, we too might recall an error, mistake, or indiscretion covered up. If those who blew the whistle over substandard paediatric cardiac surgery at Bristol Royal Infirmary suffered, can we be sure that we would support a system of reporting underperformance that is fair to all? But times have changed. And if you ever doubt it, it is a salutary reminder that the families' feelings were so strong that doctors and hospital administrators were asked not to attend the Alder Hey church ceremony. It will be a long road back.

    Perhaps the King's Fund booklet What is the Real Cost of More Patient Choice? might offer some reassurance. Surely patients will choose a good doctor who will care for them as a person? No. Although written primarily as a discussion paper in a series on policy analysis, this book offers further insight into the erosion of the primacy of the physician. The power of professionals has traditionally been because of their exclusive access to information, but the wider availability of information on the internet and elsewhere has eroded this power. Informed choice increasingly places the power with the patient. As prescribing rights are handed over to nurses, and other treatments become deregulated, doctors will have a different role.

    This book focuses on the fascinating implications of patient choice, but does not shirk from potential conflicts with equity, efficiency, and quality. It uses cardiothoracic surgery as an example, but the principles are widely applicable. What is important, according to the subtext, is that doctors deliver a service and that the person who really matters is the patient care adviser, usually a nurse. The conclusion, however unpalatable, must be that the personal qualities and personality of the doctor matter little. Doctors are technicians delivering a service.

    John Spiers, formerly chairman of the Patients Association, is even more explicit. His text, Patients, Power and Responsibility, is a whirlwind of ideas, quotations, suggestions, and soundbites. It is overwhelming at times, but the message is clear. Spiers advocates giving power to the individual: patient fund-holding with quality measures so that patients can make informed choices. He seeks a cultural change, where the main challenge is to break the power of the professional. He points out, for example, that “governance is not the answer because it generalizes the challenge and sidesteps the necessity to scrutinize individual practice. We must each be accountable for our own clinical practice.” Spiers believes the public should know about the performance of specific doctors and teams and units within hospitals. And he points out that doctors already know to whom we would recommend our family or friends. It is easy, therefore, to appreciate the argument that information on outcomes at hospitals or in general practice should be available.

    Believing in the importance of personal, primary, and continuing care, I can sense the discomfort, even anger, of many hardworking and caring colleagues. Doctors are human. But if these three books offer an insight into the future, there are tough times ahead.

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