Effectiveness and Efficiency: Random Reflections on Health ServicesBMJ 2004; 328 doi: http://dx.doi.org/10.1136/bmj.328.7438.529 (Published 26 February 2004) Cite this as: BMJ 2004;328:529
Archie Cochrane was an epidemiologist with a maverick streak. In 1935, as a lone medical student, he marched through London carrying a home made placard that read, “All effective treatments must be free.” According to him, nobody noticed. In this seminal book, first published in 1972 by the Nuffield Provincial Hospitals Trust and issued in this imprint in 1999, he called for an international register of randomised controlled trials, and for explicit quality criteria for appraising published research, but neither goal was achieved in his lifetime. Today, the Cochrane Controlled Trials Register has more than 400 000 entries, and an international movement to improve the methodology of research synthesis also bears his name (http://www.cochrane.org/index0.htm).
A passionate early advocate of the NHS, Cochrane described it in Effectiveness and Efficiency as “a favourite child who is now showing signs of delinquency.” Making treatments free had created two perverse incentives: patients expected a treatment for every complaint, and doctors felt compelled to provide one. Cochrane's wartime experience as the sole medical officer for 20 000 inmates in a German prisoner of war camp—in which only four people died, three of whom were shot by their guards—convinced him that the vast majority of illness was self limiting and that medical treatments were generally incidental to recovery. He made it his mission to save the public (and the taxpayer) from the perils of ineffective interventions.
One of the most perceptive sections of the book is Cochrane's review of the Universities Group Diabetes Program study—a well designed, multi-centre randomised trial of the effects of sulphonylureas on the outcome of type 2 diabetes, which showed no benefit (and, indeed, net harm) from this class of drug. This controversial finding, newly published when Cochrane was writing, was largely ignored by diabetologists, perhaps because clinicians are less receptive to negative studies than they are to positive ones. Subsequent trials have, arguably, failed to refute the UGDP findings, but sulphonylureas remain widely prescribed. Cochrane lamented that the well-meaning prescription of ineffective medication had spawned a mushrooming industry of hospital outpatient services, whose knock-on effects included “… the increased size of outpatient buildings and the increased staff required to run them; the increased ambulance services for the patients; the increased parking space around hospitals; the increased travelling for elderly ill patients; and the increased loss of time from work by otherwise fit patients.”
Effectiveness (whether treatments work—a dimension we now call efficacy) and efficiency (optimal use of resources) were, Cochrane said, two fundamental pillars on which the NHS ought to be run. He added a third—equality of provision across socioeconomic groups (which we now call equity), and called for better data, better training, more systematic reflection on practice, greater use of computers, and the setting up of independent watchdogs to monitor standards in the NHS. As Cochrane recognised in the book, efficacy, efficiency, and equity are not exhaustive dimensions of quality. Along with acceptability, access, and relevance, they became the “Maxwell Six” (Quality in Health Care 1992;1: 177-9), which inspired the first attempt at a national performance framework for the NHS, published on the delinquent child's 50th birthday, and to which the contemporary quality connoisseur would now add risk management, cultural congruence, partnership, and probably several more besides.
Cochrane was pilloried by colleagues for appearing on television to promote abortion and to claim (rightly, at the time) that there was no evidence of benefit from routine cervical smears. He thumbed his nose at “expert opinion” and denounced the Medical Research Council for its snobbery towards applied and occupational research (“the MRC investigated God-made diseases while others could investigate man-made diseases”). He delighted in the results of a randomised trial, published in the wake of a high profile American campaign to build a state-of-the-art coronary care unit in every hospital, which showed that heart attack patients might just as well stay at home (BMJ 1972;3: 334-7).
Cochrane's raw moral courage, his indefatigable pursuit of the truth, and his irreverence towards the scientific establishment remain an inspiration to those of us whose research time is increasingly spent in petty correspondence with ethical committees, grant giving bodies, and journal editors. His predictions about the lack of efficacy of treatments (for example, his hypothesis that thrombolysis would not influence outcome in myocardial infarction) were wrong as often as they were right. But he taught us to question practice systematically, and as such prepared the ground for both applied research and quality improvement in the NHS.
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