Skip to main content
NCBI home page
The BMJ logoLink to The BMJ
. 2001 Oct 6;323(7316):804.

Redesigning health care

Editorial was uncritical regurgitation of NHS Plan

Paul Meadows 1
PMCID: PMC1121344  PMID: 11642252

Editor—The BMJ seems to have become an organ of government spin. There is little evidence to justify giving space to Smith's editorial on redesigning health care.1 The editorial starts by drawing an analogy with “just in time” manufacturing methods. The closest general practice would come to this is by having open access to investigations and ready access to early outpatient appointments. I am sure that hospital colleagues would love to be in a position to offer this. There is no evidence I am aware of suggesting that delays in primary care are an appreciable factor in treatment time when patients are referred to secondary services.

Smith points out that in the United States “some practices” taking part in the “idealised design” project increased the proportion of their diabetic patients who had their glycated haemoglobin measured from 47% to 80%. It is laughable to suggest that we need to redesign general practice on such evidence. In my practice, which I am sure is not exceptional, 75% of diabetic patients have had glycated haemoglobin checked in the past year. As the initial figure from the United States was only 47%, the redesign suggested should be to base the system in the United States on general practice in the United Kingdom.

There is no over-riding case for speeding up appointments in general practice. The American experience of waiting times for general practice appointments may not be readily transferable to the United Kingdom. Seven English practices doesn't seem a firm foundation to justify redesigning appointments. Prebooked appointments can be more convenient for many patients and do not just represent a backlog of work. The suggestion of Mark Murray from the American project—that we should match capacity to demand and try to do more in each consultation1—was probably closer to the reason why any system would cope with more work.

Other measures to reduce visits to general practitioners included using the telephone. This is probably not a new idea to many general practitioners in the United Kingdom: many are likely to be doing this already. The availability of appointments on the day is not likely to reduce overall demand on general practitioners: in my practice patients have not turned up for appointments booked as urgent on the same day.

References

BMJ. 2001 Oct 6;323(7316):804.

Steady state demand is myth

James Cave 1

Editor—When the MGF motor car came on to the market in the mid-1990s one of the motoring journalists warned that because the market for soft top cars was only 2.5% it would not sell. Now, less than 10 years later, sales of soft top cars make up 15% of all new car sales.

What, readers may ask, has this to do with Smith's editorial?1-1 A market changes not just because of demands put on it but because of what it offers. Everybody knows this—except, apparently, our own boffins. The steady state so fundamental to the access plan of “doing today's work tomorrow” is a myth for three reasons.

Firstly, it does not allow for leakage of demand elsewhere in the system. Patients may well be seeing health visitors/casualty doctors/osteopaths or calling NHS Direct rather than seeing their own general practitioner because of the wait. Removing the wait will see demand rise; how else do fast food chains work?

Secondly, it does not allow for changes in doctors' working practice. A doctor might be content to see a patient only once a year as a compromise between demands on him or her and the care the patient needs. Any change in that doctor's perceived level of demand will shift the consultation frequency, either increasing the workload or reducing patient care.

Thirdly, there is the United Kingdom context in all this. Fewer general practitioners than the European average doing twice as much work with 5% less of the total health budget must mean that doctors in the United Kingdom start from a different position than do doctors in the United States or the rest of Europe.

Smith talks of leadership. Leadership is possible only when you believe in not only the mission but also the method. Many of us jobbing general practitioners are not sceptics at heart; we just do not believe the method.

References

BMJ. 2001 Oct 6;323(7316):804.

Practices in UK are working harder, not more efficiently

Iain B Craighead 1

Editor—While participating in the United Kingdom Primary Healthcare Collaborative my practice has seen an improvement in patient access.2-1 This has been achieved by increasing the number of appointments. Information about consultation rates has not been collected by the collaborative project, and to display information about improved access in the absence of this information is worthless.

At the last national meeting of the Primary Care Collaborative in Leicester it was evident that many of the practices were simply working harder, with longer surgery times, and in a way that would be difficult to sustain in the long term.

References

Articles from BMJ : British Medical Journal are provided here courtesy of BMJ Publishing Group

RESOURCES