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xvii+510pp Price £14.99 ISBN 0-09-188377-6 (p/b)
London: Vermillion, 2002 .
If a physician had been asked in 1992 to predict how healthcare in the UK would change in the following decade his or her thoughts would have most likely turned to the impact of new pharmaceuticals and medical technology. Some might have identified the potential of advances in genetics. Few, I suspect, would have predicted the enormous change in the public scrutiny applied to the practice of healthcare.
Of course healthcare is not unique in this respect. The whole country has been subjected to a vast natural experiment in which successive governments have sought to measure everything that moves or, as often in the case of railways, does not move. We are bombarded with data on the performance of schools, public utilities, and police forces, though not yet of government ministers. Information-gathering on this scale has few precedents, except possibly for the activities of the State Statistical Committee in the Soviet Union, and it is noteworthy that our European neighbours have not gone down this road. The challenges identified by Soviet state planners are surprisingly relevant to our present situation in which patients are ‘lost’ from waiting lists, children of borderline ability are prevented from taking exams, and the scheduled journey times of trains are extended to avoid the risk that they will ever be ‘late’. They too identified concerns about falsification of data and a focus on achieving official targets by any means, regardless of whether they actually did any good.
For these reasons I approached the Good Hospital Guide with some reservations. If I want basic information on choosing a hospital I can look at the published star ratings, telling me something about waiting times and similar measures (conveniently ignoring the fact that they will be out of date by the time they are published). If I have sufficient time on my hands I can read some of the growing number of reports from the Commission for Health Improvement. Yet neither is particularly helpful for a prospective patient. Does Dr Foster do any better?
On balance the answer is yes, but what I found most helpful was the text, rather than the tables. The first 70 pages are used to explain the patient pathway through the healthcare system. In the next 150 pages it examines different aspects of hospital care, such as heart disease, cancer care and care of older people. Each is illustrated by brief case studies telling the stories of ordinary people. The content is accurate and accessible. Unlike some politicians, it recognises that the UK already has extensive private healthcare provision, providing a useful guide to what it offers and how to access it.
It is, however, the information on individual hospitals that fills most of the book. Each contains a brief narrative description and a table of performance data. I immediately looked for the account of my local hospital. The description was upbeat and certainly did not capture my personal experiences of being in a surgical ward without a functioning bath or shower, or in a emergency department cubicle with congealed blood on the walls. Turning to the data for further enlightenment, I admired Dr Foster's ability to obtain the information that is presented, when I find this so difficult as a researcher, but was puzzled as to what it meant. Some hospitals have more doctors and nurses per bed than others. Of course they do; with the vastly expanded range of treatment modalities, such as ambulatory surgery, rehabilitation and high and low dependency units, each involving objects we call beds, but with very different uses, this is what one would expect. The estimation of mortality is similarly problematic. Although the authors have been as rigorous as they could in adjusting for comorbidity, our own analyses indicated that secondary diagnosis coding in England was so variable as to be meaningless.
I do feel that this book will help patients (and, I suspect, many health professionals) to find a way through an increasingly complex healthcare system. It may also stimulate some hospitals to reassess what they offer in those areas where they are judged, such as provision of 24-hour CT scanning. However, I doubt if it will fix the shower in my local hospital.