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Logo of brjgenpracRCGP homepageJ R Coll Gen Pract at PubMed CentralBJGP at RCGPBJGP at RCGP
Br J Gen Pract. 2006 October 1; 56(531): 809.
PMCID: PMC1920739


There is no perfect health system. All over the world, politicians struggle to make the best of a bad job that gets worse as we become able to do more. Should health care be funded from general taxation? Hypothecated tax? Social insurance? A mixed model? Would charging to visit the doctor help? Look in any general medical journal, or keep an eye on the serious media: these ideas are discussed at length. The evidence of cost-effectiveness of the various models is infinitely interpretable, and no two countries can be properly compared. It is unlikely that we will ever have properly evidence-based health management.

But if you're trying to design a health system it is important that you start off with the right information. You may not need to know which drugs are recommended for hypertension, you can leave that to the clinicians, but you need to have some idea of what sort of a health problem hypertension is: how many people have it; what sort of people have it; whether it is worth treating.

Orthopaedic surgeons have come in for a lot of stick while the NHS has been lurching around for a direction. They have an easily measurable index in the number of people awaiting joint replacement, and there is a perception that by encouraging NHS waiting lists they were feeding their private practices. Joint replacement lists are growing because patients now live long enough to need revisions. During that time they have accumulated enough comorbidities to make the operation a challenge not just for the surgeon. The patients are often ill enough that they would not have been given the primary replacement had they been that ill at that time, but willingness to treat difficult patients has moved on. That doesn't help the growing lists of primary replacements, now also being done in younger patients who previously would have been left until the joint was worse — but prostheses have moved on too. The government is impatient to get all these patients treated, and impatient with the surgeons, who they don't think are working hard enough.

What has this got to do with having the right information to design a health service? One reason the surgeons do too few elective operations is that they are heavily involved with trauma. The surgeon I work with is often in theatre all day screwing smashed pelvises back together. The Department of Health, so I was told, did not realise that orthopaedic surgeons did trauma; they thought it was done by A&E doctors. I wonder under what other misapprehensions the Department is busily reorganising the NHS?

Articles from The British Journal of General Practice are provided here courtesy of Royal College of General Practitioners