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Editor's Choice

What counts?

BMJ 2008; 336 doi: (Published 31 January 2008) Cite this as: BMJ 2008;336:0

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  1. Tony Delamothe, deputy editor
  1. tdelamothe{at}

    Dutch obstetric outcomes topped the league tables two decades ago (about the time my wife was beginning her obstetric training). Home births were foisted on the rest of the developed world largely because they seemed to underpin the Dutch success. Yet something unexpected has happened: the Netherlands now has the second highest rate of perinatal deaths in Europe (doi: 10.1136/bmj.39472.657384.DB). It turns out that half the women who choose home births are transferred to hospital during labour because of unexpected problems. Delivering in hospital out of hours increases the risk of intrapartum and neonatal deaths by nearly a quarter.

    While deaths are an unambiguous end point, Nigel Hawkes reminds us that there are usually not enough of them to use as reliable measures of the quality of care provided by individual doctors or hospitals (doi: 10.1136/bmj.39470.702627.59). So, what about less catastrophic outcomes? Hawkes quotes Richard Lilford’s opinion that outcomes can’t be adequately corrected for confounders: you’re better off measuring adherence to processes known to produce better outcomes (BMJ 2007:335:648-70; doi: 10.1136/bmj.39317.641296.AD). Hawkes also considers canvassing patients’ rather than doctors’ opinions of the quality of care, which is what the government recently announced with its patient reported outcome measures (PROMs) scheme.

    If process measures and patient reported outcomes are the future, then the NHS’s Healthcare Commission is definitely ahead of the pack. Its report on England’s maternity services ranked 148 trusts by 25 mainly process measures derived from hospital statistics and questionnaires from mothers (doi: 10.1136/bmj.39475.348218.DB). Hardly any measures related directly to the outcome that presumably matters most to parents: healthy babes in prams (with a healthy mother in sight).

    While silent on maternity services, Laurent Degos and colleagues cover a lot of ground in their description of France’s healthcare system (doi: 10.1136/bmj.39451.406123.AD), the first in an occasional series on what countries across Europe can learn from each other. Ranked first among 191 countries in quality of health care (by WHO in 2000), France presumably doesn’t think it has much to learn from the UK. But Des Spence thinks that developing countries have: they should adopt the principles of the NHS to save themselves from descent into “health consumerism hell”—presumably a road paved with questionnaires (doi: 10.1136/bmj.39475.465926.59).

    He’s been surprised to discover among new economic migrants “strong, health seeking behaviour and doctor dependence.” He’s offended by “their looks of consternation at the paracetamol for a cold, the huff at the lack of investigation, goggle-eyed head spinning at having to wait to see a specialist.” The NHS could teach them stoicism; it may be gruff, offhand, and have poor table manners, but it is a diamond, he says.

    They may not regard the NHS as a diamond, but Americans are increasingly accepting it may be good in parts. Last week the US Institute of Medicine recommended an independent programme to evaluate “which diagnostic, treatment, and prevention services work best for various patients and circumstances.” A single entity would provide “credible, unbiased information”: its scope seems similar to NICE, writes journalist Janice Hopkins Tanne (doi: 10.1136/bmj.39475.341296.DB)

    NICE’s current role could expand further. In this week’s journal Karl Claxton and colleagues argue the case for value based pricing for NHS drugs (doi: 10.1136/bmj.39434.500185.25) This would mean that a drug would be approved for use only at a price that ensured that its expected health benefits exceeded the health forgone as other NHS treatments are displaced by its additional cost. NICE could play an important part in these calculations.