Routine reporting

UK health care is suffering from what Will Hutton calls the “delivery paradox” (doi: 10.1136/bmj.39080.574699.47). Although standards of care are improving, public satisfaction is falling. This is important, says Hutton, because public dissatisfaction threatens could support for the universal public delivery of health care, which is fundamental to the NHS.

What's to be done? Hutton's solution won't suit everyone. It's called distributive democracy and goes completely counter to the current tide in the UK towards ever greater centralisation (despite the government's rhetoric of decentralisation). Hutton argues that general elections and party democracy can't respond to users' needs at a local level or on a day to day basis. Instead he advocates making our public institutions as responsive to citizens as the best private companies are to their customers. Health care should, he says, follow the BBC's lead in applying a “public value” test for everything it does. Clinical judgments about best value won't always coincide with public preferences—the furores over Herceptin and treatments for Alzheimer's disease demonstrated that. But Hutton argues that these tensions exist anyway and are better confronted in open debate.

I hope Brown and Cameron are listening. One or other of them will be in charge quite soon, and this sounds better than the current way of doing things, even if the practicalities have yet to be worked out. A draft report says that a further 37 000 jobs will go in the NHS in the next two years in an attempt to stem the financial crisis (doi: 10.1136/bmj.39090.709803.4E). Cuts on this scale and at this pace cannot possibly respond to strategic or local need. Nor can it be good for patient safety. Katherine Teale reports a crisis of care on the wards caused by lack of trained staff and continuity of care (doi: 10.1136/bmj.39063.450243.47).

Sadly, money spent on trying to improve patient safety by encouraging people to report potentially harmful incidents may have been wasted. Sari and colleagues (doi: 10.1136/bmj.39031.507153.AE) found that routine incident reporting performed poorly compared with case note review. Time constraints and fear of shame, blame, or litigation are likely contributors, they say. Charles Vincent (doi: 10.1136/bmj.39071.441609.80) urges greater clarity about the purpose of voluntary reporting. It must be to learn from mistakes and can tell us nothing about how often mistakes occur.

The BMJ's routine reporting system suffers from the same flaws. It can't tell us how many readers approve of the new look BMJ and how many don't, but it is giving us a fair idea. And the verdict (via rapid responses and emails direct to the BMJ's offices) has been overwhelmingly positive. Many readers have told us that they read more of the first new issue than they had ever done before, which is what we had hoped for. Even Richard Lehman, who was less than complimentary about the last redesign, expresses modified rapture in his journal blog (http://blogs.bmj.com/category/comment/medical-journals-review). (You might also like to read about his “Nightmare on NEJM Street” in this week's BMJ doi: (10.1136/bmj.39091.590093.47)). We haven't pleased everyone. Some readers preferred it the way it was, especially those who still hanker after the old blue cover with the contents on it. I have to say, though, that the BMJ won′t be returning to that any time soon. But please keep the feedback coming.