Intended for healthcare professionals

Making A Difference

Making a difference: running the gauntlet to improve health care

BMJ 2008; 336 doi: (Published 24 April 2008) Cite this as: BMJ 2008;336:947
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}

This supplement is the result of a gauntlet thrown down, and picked up, during a dinner in London just over a year ago. The gauntlet thrower was Don Berwick, president of the Institute for Healthcare Improvement in Boston. What, he asked, was the BMJ Publishing Group really for? What were we trying to achieve? In reply, I and our chief executive, Stella Dutton, were quick to quote the group’s mission, which ends with the crucial words “to improve outcomes for patients.” Fine, said Don, but how about being more specific: which outcomes, what patients, by how much?

We took his suggestion seriously. Why not target a few important healthcare problems, taking a quality improvement approach and focusing on the evidence on how to make a difference in these areas? But how to choose which issues to tackle among the many millions of pressing healthcare challenges facing the world? We turned in the first instance to BMJ readers. In May 2007 we asked you to tell us what information was most needed to improve the quality of care of patients in clinical practice. From your many rapid responses we harvested more than 200 ideas. After categorising these and matching them against the priorities of national and international bodies, we created a shortlist of 12. With the help of an expert panel (see box) we cut these down to six.

Inevitably the choice of topics is subjective rather than scientific, but the six we have ended up with are interesting. Several turn the spotlight on areas that are less than glamorous and are perhaps all too often passed over, even as their impact on individual lives and society increases. Two topics deal with problems of old age: multiple illness and adverse drug reactions. Two deal with palliation: of chronic pain and in dying from non-malignant disease. The remaining topics deal with two very different but serious and growing public health challenges: drug resistant infections in the developing world and excessive drinking in young women. You will no doubt find important gaps in what we have chosen. But if this initiative proves useful we can expand it further.

On each of the six topics we’ve invited leading commentators to write the pairs of articles that make up this supplement. One article in each pair aims to describe the importance of the problem in terms of its health and societal impact. The other looks at the available evidence on quality improvement initiatives to tackle the problem. Perhaps inevitably, in each case several of the quality improvement articles conclude that the evidence is inadequate and more research is needed, but the authors do lay out what they think are the priorities for future research. One key priority is to develop new and better research methodologies for evaluating quality improvement initiatives.

In her article on multiple health problems in elderly people, Iona Heath questions whether primary care can really meet the needs of older patients (doi: 10.1136/bmj.39532.671319.94), while John Wasson suggests that doctors focus on what matters to elderly patients rather than on what is the matter with them (doi: 10.1136/bmj.39532.671597.94). Jerry Avorn and William Shrank document ample evidence of the clinical burden of iatrogenic illness in older people but also highlight the “silent epidemic” of non-compliance and misplaced therapeutic nihilism that prevents many elderly people receiving effective treatments (doi: 10.1136/bmj.39520.671053.94). Anne Spinewine describes several evidence based initiatives for improving the quality of prescribing but says that most are not widely implemented. Shared decision making and better training for prescribers are part of her prescription, along with more clinical trials that enrol frail elderly people (doi: 10.1136/bmj.39520.686458.94).

“Chronic pain is common—but it isn’t sexy,” says Henry McQuay at the start of his article (doi: 10.1136/bmj.39520.699190.94). He makes an impassioned plea for more and better basic research to develop new painkillers, clinical research to evaluate them, and improvements in the provision of care for the large numbers of people who are too often at the bottom of the healthcare pile. Dawn Stacey and colleagues focus on pain in chronic osteoarthritis and on the role of decision aids in improving shared decision making (doi: 10.1136/bmj.39520.701748.94). Scott Murray and Aziz Sheikh (doi: 10.1136/bmj.39535.491238.94) and Joanne Lynn (doi: 10.1136/bmj.39535.656319.94) explore how the lessons learnt from cancer can be adapted for people with fatal non-malignant conditions such as heart failure and dementia. Murray and Sheikh conclude that “facilitating a good death should be recognised as a core clinical proficiency, as basic as diagnosis and treatment.”

It’s hard to equate “a good death” with the estimated 10 million children under 5 years old who die each year, mostly from preventable and treatable infections and an increasing number as a result of drug resistance. Zulfiqar Bhutta explains that better information and training could help to balance antibiotic “access” and “excess” (doi: 10.1136/bmj.39520.680718.94), while Ralph Gonzales and colleagues call for stronger regulation of antibiotic prescribing and better education of prescribers and the public (doi: 10.1136/bmj.39534.553044.94).

Ian Gilmore catalogues the growing problem of binge drinking by young women and says we shouldn’t dismiss it as an individual lifestyle choice that has nothing to do with the state (doi: 10.1136/bmj.39520.716863.94). He calls for higher prices and less availability—evidence based tools that have been shown to work internationally. In the companion piece, Brenda Reiss-Brennan and colleagues say that harm reduction is also possible at an individual level (doi: 10.1136/bmj.39520.730370.94). Drawing on their experience of providing primary care to adolescents, they say that processes need to be re-engineered to make care less fragmented and more accessible.

We need to choose one or two of these topics to focus on over the next year, on which we will create and compile content across the BMJ Group’s portfolio of products: the BMJ, BMJ Journals, Clinical Evidence, Best Treatments, and BMJ Learning. We are asking BMJ readers to help us choose which topics we should focus on first by voting online at, where you will also find podcasts by some of the authors.

How will we know whether we have made a difference? We probably won’t in any scientific sense. But we will be looking for ways to evaluate the effect of the initiative. On this, as well as on the topics themselves, we would welcome your thoughts.

Members of our expert panel

  • Zulfiqar Bhutta—professor and chairman, Department of Paediatrics and Child Health, Aga Khan University, Karachi

  • Angela Coulter—chief executive, Picker Institute Europe, Oxford

  • Sally Davies—director of research and development, Department of Health, London

  • Martin Marshall—director of clinical quality, Health Foundation, London

  • Chris van Weel—professor and head of Department of General Practice, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands

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