Intended for healthcare professionals

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Analysis Essay

Reform reform: an essay by John Oldham

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f6716 (Published 20 November 2013) Cite this as: BMJ 2013;347:f6716

Rapid Response:

Re: Reform reform: an essay by John Oldham

Why aren't patients at the centre of health care?

A theme running through the print edition of the BMJ of 23rd November was how patients are not, despite the rhetoric, at the centre of health care. In addition to the professional factors,including those described by Oldham(1), three powerful trends in the last thirty years have made this less, not more, likely.

The first is the neo-liberal ideology of competition, that health systems will work best if made to behave like competing businesses. A major fallacy in this is that to a business, customer service is a means to the end of profit, not, as it should be in a health system, the end in itself. Businesses cannot be expected to do things that do not contribute, directly or indirectly, to profit. If healthcare organizations are to behave like businesses, they too will first look after their own interests, not necessarily those of patients.

The second is the cult of management that has dominated us since the 1980s, entering the National Health Service with the Griffiths Report, with its creed that all problems have generic managerial solutions. This has given us our never-ending stream of reorganizations: to a man with a hammer, every problem looks like a nail.

The third is the abuse of industrial analogies for health care. While industrial models of defined processes can be applied to some healthcare activities such as elective surgery in fit people, such processes depend on standardized and quality-controlled raw materials- the very reverse of the raw material of medical care, people in all their variety and increasing complexity as they age, with freewill and feelings of their own.

Reference: Oldham J. How NHS reforms go round in circles. BMJ 2013:347;f6716

Competing interests: No competing interests

25 November 2013
Edmund J Dunstan
Locum Consultant Physician
Royal Orthopaedic Hospital, Birmingham
Bristol Road South, Northfield, Birmingham B31 2AP