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‘Consumption of health services is a peculiar business’ writes Jane Farmer (page 225). Quite so. This is an exploration of a survey's finding — described as counter-intuitive — that patients in the remotest parts of Scotland were most satisfied with the health services. The paper draws on research in the business arena to repeat the lesson, once again, that long-term relationships matter so much to patients. Like me, readers who have had direct experience of being a customer in the UK might express some surprise that business research supports such ideas (in another laconic phrase, Jane Farmer writes ‘…it is perhaps salutary to briefly consider how the matter of customer relationships have been handled there.’), but it is encouraging to find the central ideas of general practice confirmed from another sphere.
One doesn't have to look very far to find such conclusions echoed in the pages of the BJGP. In a study of primary care mental health workers the extra service was associated with better satisfaction with the services (page 196); the accompanying qualitative paper stresses the value of extra time and good listening (page 204). It's odd that such statements still need to be made, or that they should elicit any surprise. One can almost hear the rumble of readers' responses: ‘We know that. Why are you giving space in the journal to tell us that?’ The case for the importance of long-term relationships was also made in his book The Doctor. Father Figure or Plumber by James McCormick, who died earlier this year (page 249).
The difficulty is that the weight of research undertaken and evidence being published, the changes in work patterns and the health policy wonks are all pulling in the opposite direction. For instance, recent changes for out-of-hours care in the UK may be jeopardising good palliative care (page 247), with continuity from both doctors and district nurses, the latter rightly recognised as the real heroes of home palliative care, threatened. There's another illustration on p231, with the suggestion that behavioural therapies for headaches may work well, but less research has been done to support such approaches than on pharmacological remedies. So far, so good. But in the mental health study the conclusions are clear: better satisfaction but no difference in mental health symptom scores (page 196). So how, in a system where everyone genuinely wants to promote the most effective use of limited resources, do we value outcomes such as better satisfaction, or better continuity in palliative care? Similarly the guidelines for urgent referrals of patients suspected of having cancer, where the urgent referral for most of the cancers examined didn't seem to improve prognosis, but where, the authors suggest, the psychological outcomes may be improved (page 212). Or perhaps the question doesn't matter.
On page 250 there is a chilling account of the House of Commons Health Committee's report on Independent Sector Treatment Centres. The story is an all too familiar one, of an idea pursued on a hunch, that may be undermining the local NHS resources, and whose cost the Committee found itself unable to ascertain. Without the figures it becomes impossible to test the claims for efficiency made on behalf of the private providers and the lack of transparency is depressing.
At a conference on Open Access publishing held at the Royal College of Physicians last month, one speaker (not me, I hasten to add) talked about GPs as the group of doctors with the reputation of not reading anything. Here we like to feel that isn't correct, although in truth we don't know. The same person then suggested that doctors can be encouraged to read more by getting them to write. That might work. If everyone approached the BJGP with the intention of firing off an email when they come across something they agree or disagree with, they might read more actively. The last time I wrote asking the readers to send us more letters we got two saying how awful the BJGP is, which wasn't quite what I was after. But we would always welcome more correspondence.