Muir Gray: The need for systems

Muir Gray“All of a sudden a big mealie pudden came flying through the air.” This is the opening line of a Glaswegian song, which only gets worse, about an assault by a mealie pudden, a sort of second class black pudding with the blood removed. 

On the 24 November at 11 o’clock, I experienced severe central chest pain and after what I believed to be the usual assumption of indigestion, asked my wife to drive me to a cardiac centre, fortunately only four miles away, where I had a single stent inserted in the left anterior descending very quickly. 

The next morning I received a visit from a cardiac rehabilitation nurse with advice on walking, an appointment to see an exercise physiologist in a week’s time, and an appointment at the gym two weeks later—systems, systems, systems: a little later of course the Duke of Edinburgh followed my example.

By coincidence, we had just delivered the second NHS atlas of variation to the printers. Map 28 of the atlas shows that when the five primary care trusts with the highest percentages of primary angioplasty for STEMI (ST segment elevation myocardial infarction) and the five lowest rates were excluded, there was still an eightfold variation between populations. I am fortunate to live in a population in the top quintile with many primary care trusts achieving 100% primary angioplasty, but there are 21 primary care trusts achieving less than 50% primary angioplasty. Of course in some parts of the country travel times are much longer, but it is obvious when someone looks at the map that the longer travel times cannot explain all the variation. 

The data are 2010 data so the situation has probably improved for 2011. What can be done to improve the situation: more bureaucracy, or a more aggressive market? Neither in my view. Professional pride linked to transparency of reporting will do the job.

The technology of stenting is amazing, but without the system, the value of the technology is not fully realised.

Muir Gray is visiting professor of knowledge management, Nuffield Department of Surgery, University of Oxford.