How should we fund our healthcare system?, asks Keith Taylor on page 765. We have all been following, more with a sense of wonder than anything else, the rising temperature of debates in the US on Obama's campaign to reform the healthcare system there, while the distant sound of the next election campaign here in the UK is giving us advanced warning that healthcare costs are likely to be an election issue. George Lundberg, the doyen of medical editors, has posted a blog listing seven steps that could, he estimates, save $750 billion annually.1 We might not be looking to make savings on such a scale here (although some of Lundberg's steps are ones that we should certainly be considering all the time). However many of us think we know some of the areas where costs could be cut. There is widespread disgust among NHS staff for the substantial sums of money paid to private sector suppliers for surgical procedures that never took place; there are the untold millions spent on private management consultants; and in an article full of righteous indignation on page 782, Edin Lakasing reminds us of the flea bite of £8 million ‘squandered on the populist nonsense of the patient access survey.’ Allyson Pollock's team has tried to find out about the cost of APMS contracts across the whole country (page 750). Here the results were all too familiarly depressing: incomplete information, despite using the Freedom of Information Act; substantial contracts awarded, although often without any competitive element in the tendering process; and above all an inability to work out the overall cost with a lot of data withheld. We simply don't know whether there are savings to be made here or not.
Lundberg's recipe involves stopping, or at least drastically cutting down on, a number of familiar practices, and we all know how difficult that is to do. GPs find it difficult enough to stop prescribing antibiotics, despite years of exhortation and research. Using a large database to compare trends in the UK and in the US, the study on page 735 did find a reduction both in the absolute numbers of antibiotic prescriptions and in the rate of prescribing for each episode. But the figures — antibiotics prescribed in 59% of adult respiratory infections and 31% of children's infections — seem to me to remain very high. Two more papers this month look at one possible consequence beyond the immediate ones. The Southampton group, in a follow-up study from their RCT of delayed antibiotics prescription for LRTI, concluded that a delayed prescription strategy probably did result in reduced reconsultation rates, but only in those who had received antibiotic prescriptions in the past (page 728). A study from the Netherlands (page 761), looking more widely at determinants of reconsultation found no association with antibiotic prescription. Here the predictors were dyspnoea and ongoing concerns remaining after the first consultation. Interesting too that a raised CRP level predicted reconsultation, suggesting that this is an indicator of more serious illness that is being perceived by the patients. The challenge with respiratory infections is the same as it has been for some years: treating the small number who need antibiotics while persuading the majority who don't (as well as ourselves) that they will be fine without them. Some more help comes from the paper on page 742, identifying a new set of conditions that carry an increased risk of developing pneumonia. None are that startling, but they do add up to quite a few patients. Ongoing concern as a predictor is a reminder of the need to check patients' understanding, which raises the emerging importance of health literacy (page 721). The authors of this editorial argue that achieving better health literacy will be essential if we are to encourage widespread patient participation, and that without major improvement major inequalities will persist. Which brings us right back to Lakasing's blast on page 782.