Editor's Choice

Room 101: where services go to die

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c1523 (Published 18 March 2010) Cite this as: BMJ 2010;340:c1523
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}bmj.com

    Room 101—the torture chamber in George Orwell’s novel 1984—was named after a meeting room at the BBC where Orwell endured long and tedious management meetings. It has since come to mean a dumping ground for things we hate or don’t want anymore. Such a facility could be exactly what’s needed for health systems facing financial crisis, a virtual place to dump interventions and services we should stop providing in order to save money and improve care.

    The British Society of Gastroenterology has a Room 101 on its website (http://www.bsg.org.uk/). Only two things are in it at the moment, but society president Chris Hawkey has additional suggestions (doi:10.1136/bmj.c1281). They include an embargo on measuring C reactive protein except in defined circumstances, and stopping endoscopy in people with trivial gastrointestinal bleeds.

    Other specialists offer items for disinvestment (doi:10.1136/bmj.c1281): revascularisation in people with stable angina before they’ve been given optimal drug treatment; resection of pulmonary metastases in advanced colorectal cancer; ordering of routine “panels” of laboratory tests; topical antibiotic-corticosteroid combinations for eczema; caesarean section without medical indication; the “improving access to psychological services” programme; radiography for low back pain; and inhaled corticosteroids for mild or moderate chronic obstructive pulmonary disease.

    Some ideas fall into the realms of “investing to disinvest.” Wider provision of phototherapy for moderate to severe psoriasis would reduce the number of patients needing more costly biological treatments, says Alex Anstey. Jane Dacre says that early intensive treatment for inflammatory arthritis would save money in the longer term. Irene Gray and Carl Heneghan both call for stronger community services to maintain patients at home. And Charles Warlow suggests moving some of our scarce neurologists from outpatient departments to medical admitting units so that more patients can be promptly assessed and discharged.

    Also up for a severe trim are branded prescriptions. As Margaret McCartney reports (doi:10.1136/bmj.c1514), the Department of Health is proposing an automatic generic substitution scheme by which pharmacists would switch certain branded drugs for generic versions. Except in people stabilised on specific treatments, such as lithium and antiepileptic drugs, this tactic seems a good idea. But a letter in the Times last week said doctors’ choices about branded medicines should to be paramount. Should we mind, asks McCartney, that the letter was coordinated by a public relations firm working for a pharmaceutical company? “If freedom to prescribe less cost effective medicines is of such importance to grassroots doctors and patients,” says McCartney, “it does beg the question of why an anti-generics campaign has to be coordinated by a pharmaceutical company.”

    Will the NHS really be able to cut £15-20bn this year without catastrophic effects on patient care? Graham Rich (doi:10.1136/bmj.c1251) and Phil Leonard (doi:10.1136/bmj.c1258) both think it can. But Yair Zalmanovitch and Dana Vashdi say there will inevitably be a trade off between money, coverage, and quality (doi:10.1136/bmj.c1259). “Blinding the public with simplicities is neither fair nor wise,” they say. Yet the NHS Quality, Innovation, Productivity, and Prevention (QIPP) challenge is unbowed. It aims to help clinicians promote high quality care in a tight economic climate, and is now presenting success stories where teams have improved care and saved money (http://bit.ly/bN9mLb). The BMJ would like to help. Send us your accounts of money saving and quality improving efforts, and we will publish the best of them.


    Cite this as: BMJ 2010;340:c1523


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