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Richard Smith: Painfully slow progress improving health care

15 Sep, 08 | by BMJ Group

Richard Smith Are we making good progress with improving health care? If not, why not and how could we do better?

I tried to answer these questions as I spoke to a thousand enthusiasts for health care quality in Nijmegen at the launch of IQ Scientific Institute for Quality of Healthcare. There were probably 50 people in the room better qualified than me to answer the questions, but it’s the Promethean fate of ex-editors and roving pundits like me to sound off to people who know more than we do. The solution is to get out as fast as you can.


The first question is the easiest to answer. Despite 30 years of the quality movement health care is still unsafe (more so than bungee jumping), often ineffective, wasteful, inequitable, slow, and impersonal. It might be slightly better than it was 10 years ago, but a study in the BMJ three weeks ago and similar studies from the US (New England Journal of Medicine and Rand) the show health care providers achieve only about half of quality indicators.

And — very distressingly — it’s about 30% for the care of patients with “geriatric conditions” and less than 20% for end of life care.

So why aren’t we doing better? Firstly, improving health care is a hard problem, requiring complex and sustainable change on a huge scale. Secondly, there are no simple solutions. Accreditation, targets, markets, incentives, guidelines, pathways, information technology, and a dozen other interventions all have a place, but mostly they have small effects—and our understanding of how to make them work is primitive.

A bigger problem, I suggested in Nijmegen, is that quality improvement remains a minority sport. There may be thousands who attend the forums of quality improvement in health care and increasing numbers of clinicians trained in quality improvement, but improvement is still not the day to day business of most clinicians. They are busy treating patients and understandably may resent the constant refrain that they are not doing as well as they might. It’s uncomfortable for most to reflect on poor quality as they go about their daily work—and probably even more distressing for their patients.

And that’s another failing. Despite the Bristol scandal (and as I wrote these words I’m thinking that soon I will have to explain what I mean by “the Bristol scandal”) and hundreds of studies showing extreme variation in the quality of care, most patients assume, again understandably, that their doctors and hospitals are providing high quality care.

(Plus, suggesting to clinicians that their care is not high quality feels insulting. The day after my oration in Nijmegen I went to a clinic with my mother. I could see 20 ways in which the clinicians and hospital could have improved the quality of what they did, but it would have been rude and ungrateful to point them out. We smiled and said “thank you” repeatedly.)

So there is no great push for improvement from patients, and little appetite among clinicians for the permanent revolution that is needed to raise quality. Yet substantial improvement cannot happen without every part of the system changing.

How might we engage (an already tired word) clinicians and patients? Might we, one of the themes of my talk, be able to create an energised, effective social movement not only with evidence but with stories, campaigns, images, songs, marches, and passion? Such a movement abolished slavery in 20 years.

Could a social movement transform health care? Possibly, but my bias is that such a movement is much more likely to come from patients than clinicians.

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  • Chris Johnson

    There is a well known saying in quality circles that what gets measured gets done.

    I was led to this blog by a 2003 BMJ editorial on concordance – the shameful fact that 50% of prescribed medication is either not taken properly or not taken at all. This problem has been recognized for a long time but not much has been done.

    Today there are electronic recording devices that can be embedded into pharmaceutical packages to capture the time at which a pill is taken. The recorded data can be read back at the convenience of the patient, carer, pharmacist or doctor. I wonder why we still rely on a patient’s subjective impressions to check concordance, if we check at all.

  • Anne Savage

    The reason for the failure of the health services to improve can be summed up by ‘dereliction of duty’. Teachers have failed to teach. Fifty years ago graduates left medical school fully fledged and able to take on service jobs. Now they plead for more teaching. Those charged with the duty of maintaining standards have failed; the scandal of Bristol was that, when informed of the situation on several occasions, the PRCS and doctors at the Department of Health did nothing. Research has been infiltrated by drug firm influence, leading to inconclusive results and the inevitable plea for ‘more research’. ( And more funds) Journals are obsessed with their IFs;’cite this’ begs the BMJ on every page, and by insisting that they are too posh to open envelopes editors have restricted their sources of information to the academic departments. Goodness knows what academic departments do apart from their members flying as far and as often as they can with their Power Point Presentations

    Much has improved since I qualified; my joint replacements and revisions are testimony to that, but ‘ordinary’ care has got worse. Two patients I know of have had temporal arteritis missed with subsequent loss of sight, and I get regular reports of pressure sores making the last weeks of a life miserable. My personal encounter with ‘specialists’ when an allergy to spray propellant produced startling symptoms was depressing. Eosinophyllic alevolitis was diagosed as ‘one of those things’. Immune mediated vaso-constriction as ‘arthritis’ and cardiac irregularity as presaging fibrillation. Banishing sprays brought full recovery but I had to work it out myself with the help of my daughter-in-law. No. Doctors no longer know best. We need to put the baby back in the bathwater, that is, revive some old-fashioned practices and principles.

  • Peter Mahaffey

    I’m sure that Dr Smith, whose former publication, the BMJ, was so endemically anti-doctor, would choke if I suggested to him that the answer is more genuine, and I stress the word genuine, clinician control of the day to day NHS. The fact is that the health service that I started training in 30 yrs ago was INFINITELY more efficient than now. We worked all hours, we put through vast numbers of theatre cases and were proud to the point of competitiveness of how much we did. No-one knocked off until the job was done. Now corridors are empty by 5pm. Those most urgently in need of treatment always got it fast, not because of targets but because professional pride, decisions and responsibilities demanded it. The cost of the entire system when I finished training in 1988 was £40billion. Now its £100billion+ . The ‘social movement’ he proposes will make that £200billion because the ‘movers’wont have the faintest idea why patients take so long to get to theatre or that c.diff spreads mainly because of the crazy insistence on 100% bed occupancy and the total denial that diarrhoea in elderly patients on 20 bedded wards at night needs more than 2 staff at work to stop infection spreading. Its maniac proposals like this that turn off the real workers in the NHS. Let Dr Smith take over. I’m off home to my family where I get appreciated.

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