Editor's Choice Editor's choice

Dealing in extremes

BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39266.573056.47 (Published 05 July 2007) Cite this as: BMJ 2007;335:0
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}bmj.com

    In Michael Moore's film Sicko, reviewed this week (doi: 10.1136/bmj.39262.638588.59), a woman in Britain is surprised to be asked how much the birth of her baby cost. She has no idea. Meanwhile, the threat of a $60 000 bill forces a man in America to choose which of his severed fingers will be reattached. Moore wants the US to have a single payer system, and the response to his film (doi: 10.1136/bmj.39258.421111.DB) shows that he is far from alone. His polemic exposes the damage to individuals and society that is caused by a system in which competing insurance companies have no reason to care what happens to unprofitable patients.

    The film may prove to be a tipping point for US health care in the dog days of the Bush regime. But Moore's rose tinted portrayal of Europe's health systems will raise a hollow laugh from anyone devilling with the detail of the NHS. At a recent King's Fund meeting on “the patient of the future” we heard that centrally funded systems reduce patients' engagement—shown by the woman with the baby in Moore's film. Why should this matter? Because hard cash is involved. According to the 2002 Wanless report on NHS funding, engaged patients are cheaper.

    Angela Coulter and Jo Ellins agree (doi: 10.1136/bmj.39246.581169.80). Their systematic overview concludes that patient centred care is about far more than being politically correct. Where patients are empowered—which is best achieved through a mix of oral and written information, with active support from clinicians—outcomes improve and use of health services may fall.

    Calls for greater empowerment of health professionals probably can't be equally evidence based, but at least these calls are now coming from groups other than the professionals themselves. As Nick Timmins explains (doi: 10.1136/bmj.39261.449097.AD), we don't yet know what Gordon Brown is planning for the NHS. But a report from the Cabinet Office on the Department of Health should be a priority for the attention for Alan Johnson, the new health secretary, says Rudolf Klein (doi: 10.1136/bmj.39262.746238.47). The report acknowledges that morale within the NHS is low and that the pace of change has disempowered staff. It warns that the department now needs to lead the shift from top-down targets to locally driven healthcare systems. The crucial question, says Klein, is whether Alan Johnson will translate the political rhetoric into reality.

    Michael Moore deals in extremes. So does the BMJ. Melita Gordon gives her own take on targets after six years spent in Malawi (p 45; doi: 10.1136/bmj.39255.551458.94). After a gruelling but highly efficient ward round—seeing 56 patients sharing 32 beds in three hours—she is humbled by a patient's offer to share his meagre meal. “If our clinical targets crowd out what our patients can teach us about humanity, we are missing the most important lessons of all.”

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