Intended for healthcare professionals

Editor's Choice

Trust and demand

BMJ 2006; 332 doi: (Published 06 April 2006) Cite this as: BMJ 2006;332:0-f
  1. Jane Smith, deputy editor (jsmith{at}

    Last week's Editor's Choice argued that health care was too important to be left to politicians and that Britain's National Health Service should be made independent of government. This week 900 British doctors have written to politicians to argue that the NHS is unsustainable and that it is time to look at new ways of delivering health care in the UK (p 813). What prompts this demand for new thinking is the service's financial crisis, which is seeing pay awards staged and jobs cut (p 813). Yet I wonder how apparent the crisis is to patients: several recent exposures to the NHS, through friends and family in different parts of the country, have shown exemplary service.

    Nevertheless, the sense of crisis and of unstoppable demand persists. Doctors for Reform argue that the NHS is simply too monolithic, and that a mixed economy might better manage demand, improve choice, and allow professionals to “retain the essential bond of trust with their patients.”

    The same tension between trust and demand emerges in an examination of referral management centres by Myfanwy Davies and Glyn Elwyn (p 844). The concept arose in the mid 1990s in the US, when insurance companies introduced referral management to sanction (or otherwise) referrals from generalists for specialist care. In the UK referral management centres seem to have sprung up quickly—seemingly in response to the current financial crisis as primary care trusts try to curb their spending by questioning and delaying referrals. Davies and Elwyn examine the evidence for the effectiveness of referral management systems—and fail to find any. In her commentary on the article Iona Heath sees referral management as a further stage in the “relentless commodification of health care,” weakening relationships of trust. She points out that any barrier to easy referral between generalists and specialists risks the safety of patients and the cost effectiveness of the generalist-specialist system. James Owen Drife agrees: “The reasons behind [this proposal] are desire for managerial control and ignorance of how efficient the system already is.”

    The sort of knowledge of patients that Heath talks about is also at the heart of Bassem Saab and Jumana Antoun's personal view (p 860). They ask doctors to be responsible for the consequences of their decisions on patients' healthcare costs and poverty—and not be influenced by the seductions of drug companies or new technologies. They want doctors to realise that the difference between a branded and a generic version of atenolol is 1.5 days' pay for a lowly paid Lebanese government worker and that they shouldn't suggest magnetic resonance imaging just because the technology is available. “As health professionals we may not have the power to change political regimes or put an end to wars and disease. But we can ensure that we are in charge of what we do.” As William Blake said, “He who would do good to another, must do it in minute particulars.”

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