June Focus

David Jewell

‘Book burning and the imprisonment of editors will not join the repertoire just yet’, writes Theophrastus on page 475. That's a relief, particularly as this issue of the BJGP finds itself straying into mildly controversial territory. Many readers will remember the BMJ paper published in 2002 claiming that the Kaiser Permanente Health Maintenance Organisation in the United States was much better value for money than the National Health Service. The paper on page 415 echoes the vigorous correspondence that followed the original BMJ paper, pointing out dubious assumptions and concluding that the claims simply don't stand up to critical scrutiny, and that to base UK policy on them is misguided. Not so, reply the authors of the original article on page 422. They stand by their conclusions and quote two later studies in support. However, in the editorial on page 410, Trevor Sheldon sides with the critics. He too feels that the original comparison was flawed, but also implies that the very attempt to make such international comparisons is always going to be difficult. The UK's Department of Health is charged with looking for easy solutions from abroad, rather than trying to draw on good innovative practice at home. The words of HL Mencken come to mind: ‘To every complex problem there is a solution that is simple, straightforward, … and wrong.’ On page 482, from across the Channel comes a distant echo in support of Trevor Sheldon's argument. For many years, critics of the UK's NHS have pointed to the wonderful French system to show us all what we should be doing. However, all is not well in France, with doctors disillusioned and planning early retirement. Heard that somewhere before? Or, as the Guardian put it after the last French elections: ‘The French healthcare system may be the best in the world, but the French cannot afford it.’ Paul Hodgkin on page 479 argues that there is something fundamentally wrong with our current methods of examining healthcare systems. For better understanding we should see them as gift economies, and stop trying use market models. His illustrations will be eerily familiar to many UK general practitioners.

Numerous papers over the years have raised worrying doubts about the equity of access for patients with heart disease, specifically whether women and ethnic minorities are being discriminated against when it comes to angiography and coronary artery bypass surgery. The study from the East End of London on page 423 comes to encouraging conclusions, with neither ethnicity nor deprivation appearing to influence access to angiography services. The study on page 442, using data from surveys across the whole of England, also showed that there was no influence from ethnicity in the prescription of lipid-lowering drugs. However there may be some influence both from deprivation and from age. The commentary on page 427 is a reminder of the problems of ecological studies, while Julia Hippisley-Cox's leader on page 411 points out that potential ageism in this particular field could be made worse by the existing public policies.

As in the May BJGP, considerations of access surface again in Mike Fitzpatrick's column on page 485. In this commendably Luddite scepticism towards technologically driven solutions for old problems (Mencken again) he is joined by Hay and colleagues on page 448, inviting us to be as wary of infrared thermometers as the BJGP previously warned we should be of electronic sphygmomanometers and weighing machines. James Willis weighs in on page 488 with concerns about confidentiality and electronic records — this one will run and run. Amid such outbursts it is good to be reminded that ‘Music has charms to sooth a savage breast’ (Theophrastus again). There is the photograph of the President of the RCGP and friends playing in Bournemouth (page 476), and the prospect of the European Doctors' Orchestra in Blackheath later this year (page 475). Like Theophrastus, I can only imagine how awful to be tone deaf, or, thinking of Beethoven at a concert of two of his late string quartets, completely deaf.