On being scientific about organising care

Good care poorly delivered is diminished. Doctors, trained primarily in tending for individual patients, might like to think that care can be organised by a few “administrators” without anybody needing to think too hard. But it can't. Organisation is often difficult, and, as this issue of the journal illustrates, it needs to be based on evidence.

For starters, should patients be operated on by surgeons who do more than a certain number of operations a year? It seems likely that surgeons who do more operations may be better than those who do fewer, and increasingly the organisation of surgical services is predicated on this assumption being true. Yet it's annoyingly difficult to prove. A study of patients with colorectal cancer could not find any effect of a surgeon's caseload on survival, after adjustment for many factors(p 1381). And hospitals that had a medium number of cases had poorer survival among their patients than hospitals that managed fewer cases. The authors can't explain this finding and think that the “volume-outcome” debate may be a side issue and that other aspects of the organisation of services may be more important.

Another question: how long should patients with serious mental illness stay in hospital? Do short stays result in readmissions? Paul Johnstone and Gabriella Zolese have looked systematically at the evidence and find most of it to be poor (p 1387). The best evidence suggests, however, that patients who have planned short stays have as good outcomes as those who stay longer. Or, how can we best organise services for patients with severe personality disorders? Steve Kisely again finds the evidence inadequate (p 1410).

Yet these surgical and psychiatric services are costing large sums of money in most countries. It seems sensible to spend what are small amounts to conduct good studies that will allow confident conclusions on the optimum ways of organising services. (The same incidentally goes for education, criminal justice, military activity, social work, and—I must confess—publishing. Evidence based health care may be in its infancy, but most of its potential brothers and sisters are yet to be born.)

Finally, a farewell and a welcome. Jack Warden has stepped down after 12 years as our parliamentary correspondent. Jack understands parliament far better than many of its members and has an unfailing nose for what's coming, what's important, and what's tittle tattle. An admirer of Margaret Thatcher, he always delivered his accurate copy on time through some turbulent years. Now he's heading home to Scotland to report on its new parliament. His place is taken by Annabel Ferriman, a former correspondent of both the Times and the Observer.