Healthcare: doing the right thing and finding the right words to say it

Every now and then a conference – and I’m at one now – is enlivened by masterful presentation, brimming with insights on vital matters, the whole sharpened and enhanced by intelligent use of humour.

Such was the talk given by Walter Ricciardi, President of the Italian National Institute of Health. It was entitled From evidence to action in health policy making: a mission impossible? His subject was how senior clinicians concerned with the strategic direction of health, and convinced of the value of practising evidence-based medicine (the theme of the conference) could work with politicians in government to take the necessary decisions.

Walter Ricciardi
Witty, insightful and spot on about the need to get it right – and say it right

I’m keen on evidence-based medicine. That may sound like a trivial statement: who wouldn’t be? Well, you might be surprised how often medical decisions are taken on the basis of a clinician’s gut feel, or confidence that years of experience are enough, rather than evidence. Worse still, they’re often taken on the basis of politics: for instance, the UK government has made funds available to allow GP practices to stay open later, without putting in place any kind of process to check whether the move leads to any of the desired effects – most notably reducing attendances at Emergency Departments of hospitals.

The reason why Ricciardi feels this kind of discussion is vital now is the well-known observation that demand for healthcare seems to keep climbing uninterruptedly, as the population of the advanced economies ages and the technology available for care increases in sophistication (and cost). As he suggested, there has to be a limit to the amount society can sensibly be asked to invest in healthcare.

That reminded me of a presentation I attended some years ago, when one of the speakers pointed out that, on present trends, the USA would be spending 100% of its GDP on healthcare by the end of this century. That’s clearly impossible – something has to go into schools and roads and things, to say nothing (this is the USA we’re talking about, after all) about defence. So what is the maximum US citizens will accept? 50%? Surely that’s too high. 30%? It’s hard to imagine. 20%? If so, things are urgent indeed: they’re already spending 18%.

That’s without even providing full healthcare coverage for the whole population.

Limiting healthcare expenditure, wherever the limit lies, means that at some stage we’re going to have to start denying care. That’s where evidence-based medicine comes in. There are a great many treatments that could be denied without doing patients any harm – indeed, where the denial would do them good.

At one end of the scale, prescribing antibiotics for viral conditions harms us all and does no good to the patient.

At the other end, intense and highly expensive interventions for a patient with a fatal condition can wreck the end of a life and incur huge waste.

We have to start finding a way to avoid this kind of wasteful, if not downright harmful, way of practising medicine.

That’s where Ricciardi turned up the humour a notch or two. He suggested that the people who understand the issues have a vocabulary of 140,000 words; the general public, and he included politicians in that category, a mere 7000.

I don’t know where those numbers came from. Frankly I find them highly questionable. In fact, I’m inclined to ask, where’s the evidence? However, the underlying point is worth making: specialists in medical information need to find a way of communicating the case for some of these notions more effectively to the population. They need to persuade politicians of the need for action, and help the politicians find the words to express their decision in a way voters will accept.

At this point he made a point I found particularly amusing, though he may have meant it seriously. He referred to Jean-Claude Juncker, President of the European Commission, as intelligent and honest. It was wonderful to see how the English in the room all started in their seats and shuddered: Juncker is viewed as a figure of derision in England. He’s disliked in a great many countries, but it was striking how much stronger the English reaction was.

He went on to quote Juncker as saying, “we know what to do. We just don’t know how to get elected afterwards.”

Jean-Claude Juncker: a smart and honest politician?
Not according to the English, but are they right?

Now, that really is both honest and true. The things that need doing are tough to make popular. A politician that does them may indeed find it hard to win office again.

There’s an excellent example in Ricciardi’s own country, Italy: the Italian government has taken an extraordinarily courageous decision, to make childhood vaccinations compulsory. The anti-vax movement has reached dangerously high levels, with herd immunity being lost and long-vanished diseases like measles and mumps making an appearance again. The government took the action necessary, based on the mass of evidence available: the potential harms of the vaccinations are less serious and less common than those of the diseases they eradicate.

But will they have persuaded the voters that the decision was right? Popular anger in response to the measure was intense and widespread. We’ll see in next year’s elections how well the government has done in taking popular opinion with it.

It’s important to practise evidence-based medicine. But it’s just as important to find the words to explain what you’re doing. The former is what we have to do but, without the latter, the politicians who do it will be unable to stop their achievements being unravelled by their successors.

Medical Science: so hard to keep up with

It’s a lot of fun working for a company that has a product that actually does what it says. Sadly, rather a lot of people selling information technology to the National Health Service seem to regard it as a slightly dull but dependable, and above all uncritical, source of funding. You know, they’ll never make your fortune, but you can dump mediocre systems on them and they’ll buy them, not perhaps at the highest of prices but at a price that’s always paid, and with few questions asked.

Sadly, I’ve worked for a few of those companies. I remember being ambushed at one conference at which I was presenting, when a representative of a client hospital asked, in public, why on earth anyone should trust us, given how badly we’d let them down on another product?

Well, it’s a blessed relief to be away from all that unpleasantness. Today I’m working with an evidence-based medicine product that does exactly what it claims to do: provide rapid access to carefully evaluated, up-to-the-minute information reflecting the most recent understanding of medical knowledge.

To take them or not to take them?
The answer may depend on when you ask the question

It’s just as well it does so. One of my colleagues pointed out at a recent presentation that about 15% of all information affecting medical practice changes every year.

Fifteen per cent.

Every year.

That may seem extraordinary, but I have a personal anecdote which seems to confirm it.

A year or so ago, my general practitioner decided that it was time to have my blood tested and assess my level of risk of having a stroke or heart attack in the next ten years or so. You may well guess that at stake was whether or not I should be put on statins. I had wish to start taking those drugs but, then, I had even less wish of suffering a stroke or heart attack.

Well, the results were clear. My risk was above 10%. That was the threshold level. The doctor prescribed statins.

I didn’t take them for long. My digestion turned lousy, I started sleeping badly, I was getting headaches. Classic symptoms.

However, having looked into it a bit – well, to be honest, my wife did – I rather think the reaction was psychosomatic. I was, at the time, working for the worst of the purveyors of dire quality to the health service. My boss had cut me out from doing any actual work on the software, which was good for my conscience but lousy for my long-term employment prospects. It wasn’t a good time, which I think may have contributed to my poor reaction to the medication.

A year or so on, and in a satisfactory job at last, I felt I should take a look again at whether I ought to be taking statins after all. I made contact with the GP again. Once more, he had my blood tested. And, again, the risk of stroke or heart attack was above 10%.

But, lo and behold! Medical science had changed. As he explained to me.

“We used to think the threshold for statins was 20%. Then it was reduced to 10%. But now it’s back up to 20%. And your risk is under 20%.”

So? What did this mean? Could I still live statin-free?

“So,” he went on, “I’ll not be prescribing any medication for now.”

Wonderful! My conscience is clear. I did all that was necessary. And science made the decision for me.

Isn’t it great? But doesn’t it just underline the importance of keeping current? Because how serious your condition is doesn’t just depend on your health – it also, apparently, depends on when you ask the question.

Palliative care and the power of mind over matter

It was a pleasure to have a chat with a Palliative Care Consultant the other day.

Noble mission

A Consultant, in this context, and for those more used to American terms, is the equivalent of an Attending Physician. Or, for those not too familiar with either system, a senior hospital doctor. As for Palliative Care, it’s the field served by physicians who are not trying to cure, because the patient has a condition beyond the capacity of medicine to cure in its present state, so care is focused on eliminating pain and giving a patient the best possible conditions of life. 

In the circumstances.

Strangely, such care, rather like the hospices where it is often dispensed, is generally joyful. Hospices, housing dying patients, are places where the one great question has been answered. The reply – “you’re dying” – may not be the one we most want to hear, but it has been given, it is definitive and there’s no further point in tormenting oneself over it. Instead, both patients and carers can focus on making the last few months as pleasurable as possible.

“Yes,” said the Consultant who was talking to me, “but I deliver my care in this hospital. As soon as a patient moves from the curable to the non-curable category, but before they move to a hospice. And you’d be amazed at how much we can do.”

I nodded.

“There’s even good research evidence that well-delivered palliative care extends patients’ lives. I’m treating patients expected to survive ten years.”

“Perhaps the fact that they’re happy and free of pain explains their survival.”

“I’m sure it does. But isn’t it extraordinary? How does mood overcome pathology?”

“Do we perhaps underestimate the power of the mind over the body? Take the placebo effect: it can have immense impact.”

“It can,” she told me, ”placebos have been used as anaesthetics. And, you know, during the Second World War, when morphine stocks ran out, they called on it. They’d tell soldiers who’d lost limbs or had them smashed up, horrible injuries, men in agony, that new stocks of morphine had been received. And then inject them with saline. ‘Aah,’ they’d go,” and she opened her arms in the gesture of a man relieved of terrible pain, “thank God! At last.”

We really don’t take enough account of the effect the mind can have on physical suffering. It’s probably the main source of the efficacy of alternative medicine, in particular of homeopathy: it works because you believe it works. But, even if it’s based on belief alone, it really works.

A chastening thought for an over-materialistic age. But also a wonderful tribute to the admirable, joyous specialty of palliative medicine. I’m pleased to have met and had a conversation with one of its expert exponents, however briefly.

Hers are vital skills. Any one of us may some day call on them.

Healthcare: choice is what you really want. Or so the politicians assure you

For years now, British governments – sadly, Labour as well as Conservative – have attempted to convince us that what we really need in healthcare is free choice.

The argument goes like this. Everyone wants to be sure that the care they’re receiving is the best available. And they can only tell if they’re given the information they need; and once they know which the best choice is, they need the right to exercise it.

What this leaves out of account is that at the moment you need care, there’s every chance that you’re sick, which is hardly the best position to be in if you’re trying to make an informed choice. Why, you might even be unconscious. I’ve known people whose qualities of judgement wouldn’t be harmed by being unconscious – they vote UKIP, for instance – but usually, being out of it doesn’t make us more judicious.

Their relatives might be in a better position to take a decision, but if they’re worried, borderline panicky, they may not be the best judges either.

What about a GP? There’s someone who might be able to help. But one doesn’t always have the luxury of waiting to call between 8:30 and 9:00 the following day, only to be told that the first available appointment is on Thursday week.

The reality is that, faced with a medical emergency, we don’t waste a lot of time making a choice. Or rather, we make the choice on purely pragmatic grounds, without taking medical performance into account.

For instance, I’ve taken people into Accident and Emergency on several occasions. How did I choose the A&E department? Simple. It was the closest.

The L&D: unprepossessing entrance but a centre of excellence
And also my closest A&E department

As it happens, I’m proud of our local hospital, the Luton and Dunstable. It scores highly on most comparative reviews of quality. It’s launched some exciting and innovative initiatives, such as “silent wards”: instead of cutting back on expenditure on administrative staff, it’s taken on large numbers of ward clerks, so that nurses can be freed to concentrate on nursing. Phones and faxes, as well as printers, are looked after by the clerks, behind closed doors. Each nurse has an assigned nursing assistant and looks after ten patients, who don’t even have bells – since nurses are constantly moving round their ten beds, they get to patients more quickly than if bell pushes were in use.

The result? The elimination of bells, phones and faxes, means that wards have a quieter, more restful atmosphere. Restfulness is a major contributor to healing. That enhances the effect of more frequent contact with a nurse.

So I’m perfect happy with the L&D. But what if I’d been told that Milton Keynes (40 minutes away) was even better? Or the great university hospital at Addenbrooke’s in Cambridge (an hour and a quarter)? Would I really have taken a friend or relative in pain to one of those hospitals instead of getting them to hospital in under a quarter of an hour?

To ask the question is to answer it.

Many others answer it the same way. 95% of all hospital treatment for Luton residents is provided by the L&D. What really is the choice? Or more to the point, offered the choice, Luton residents choose to be treated at their local hospital. After all, where else is it as convenient for their friends and relatives to visit them?

It was fascinating to be given a striking illustration of these ideas at a seminar I attended last week, on Clinical Audit. Dr Kevin Stewart, Clinical Director of the Clinical Effectiveness and Evaluation Unit at the Royal College of Physicians, told the story of Bill Clinton’s heart attack.

The ex-President began to suffer severe mid-chest pain while walking in New York with Hillary Clinton who had to make a swift choice. Did she log on to the internet and check the published information on comparative performance of New York cardiologists? She did no such thing. She phoned one cardiologist – one who happened to be languishing in 137th place in the league tables.

On what basis did she pick that particular physician?

She knew him. Personally. His number was in her phone.

As we all know, he saved Bill Clinton, so he can’t have been that bad.

The essential point is that when we make choices of medical care, they’re as often as not arbitrary. So all that fuss about choice is just that: a lot froth, designed to whip up some support among certain voters who are currently in good health and lack the imagination to realise that, in an emergency, they wouldn’t exercise their right to choose anyway.

Choice is a lot cheaper than the real question. Which is care quality. If we could guarantee excellent care, in all hospitals, at all times, choice would be entirely irrelevant.

It’s a lot easier to pledge choice. Even if it would never be exercised.

Healthcare gatekeepers

Curious the similarities and dissimilarities between the US and Europe.

On both sides of the Atlantic, we live in societies that proclaim the sanctity of human rights, and which honour them except when some overriding factor, such as the race or creed of the individual, makes it more convenient to flout them.

Equally, our societies uphold the rule of law, except when governments feel that it’s too constricting and they think they can get away with circumventing it.

Finally, our nations are built on the principle that power is exercised by consent and that government can only rule with the support of the people, except on those occasions when ministers want, say, to wage a war and therefore need to ignore the pusillanimous refusal of voters to see that this is the right thing to do.

However, striking though the similarities are, there are also major transatlantic differences. For instance, a large majority in the US remains wedded to the retention of the death penalty, a view they apparently regard as justified by the astronomically high murder rate they enjoy.

Another significant difference is the approach to healthcare. A great many European nations feel that a person needing care should receive it without consideration of his or her ability to pay. Many in the US, on the other hand, see this idea as a dangerous concession to socialistic thinking, one that infringes the individual’s fundamental right to be kept waiting for treatment while finance staff check on insurance or, in the absence of cover, other means of paying for care.

It has to be said that the European model of treatment free, or nearly free, at the point of care, does make it difficult to limit demand on hospitals.

In Britain, the issue was addressed by asking General Practitioners to act as gatekeepers. Except for emergency patients, hospital care was only available on referral by a GP to a hospital physician.

That ‘except’ is the problem, of course. Because people who don’t want to go through their GP just recategorise themselves as emergencies and turn up at Accident and Emergency departments. A good article in today’s Guardian relates some horror stories from the Bradford Royal Infirmary: a patient in A&E to have a false nail removed, another for a pregnancy test she could have bought from a pharmacy…

But these are exceptional cases. What is clear is that there is mounting pressure on A&E departments, leaving them under a strain that is close to unbearable, and putting hospital budgets in jeopardy. There is, it seems, an increasing tendency in society to view a hospital A&E department as a first port of call in injury or sickness rather than a last; at the same time, in a society where more survive into frail old age, a greater number of people are showing up with serious problems requiring treatment.

A&E may sometimes look like a substitute for a GP surgery,
but it really, really isn't

Clearly the GP as gatekeeper system is failing. I saw this when I was working with my local hospital: A&E attendances were climbing inexorably, and emergency admissions growing with them, putting services under intolerable pressure. 

One attempt at a solution the hospital explored was to open a general practice inside the hospital, right by the main entrance. This seemed a good idea: patients would have the impression they were going to hospital but would be seen by general practice rather than far more expensive hospital staff. The sustained increase in A&E attendance showed, however, that it wasn’t working.

In my view, the scheme had one great flaw: the practice was to one side of the entrance to A&E.

What I’d like to see happen is the practice to be set up right in front of A&E so that only people arriving by ambulance would be able to access emergency services directly. Everybody else would have to pass through the GP practice, where they would be triaged: those absolutely requiring hospital services would be passed through, the others would be treated by practice staff.

That would make GPs truly gatekeepers to the service.

It strikes me that it’s an idea worth trying. Apart from anything else, it might help us preserve the specific characteristic of the British system, an idea I rather like, not just because I prefer not having to reach for a wallet at a time when I’m already seriously off colour, but because, funnily enough, our system costs little over half as much as the American model.

Which sounds like win-win to me.

Whistleblowing isn’t always good for your healthcare

‘The press lives by disclosure,’ wrote John Delane, iconic editor of the London Times in the nineteenth century. 

It isn’t even any old disclosure. News is something we all want to know and someone else wants to keep quiet. Publishing it is journalism at its most effective.

The whistleblower has a key role in making it happen.

Not the least shameful aspect of many recent scandals has been the attempt by people in authority to silence potential whistleblowers, and much of the outcry has been over the failure to listen to them in the past it time to correct problems: it’s often the people at the coalface who know what’s going wrong and who could launch action to correct it if only they could gain a hearing.

So I’m keen on a campaigning, disclosing press, and I’m keen on whistleblowers having the opportunity to make themselves heard.

However, there needs to be some intelligence in the way information is handled as well. Otherwise, as much damage can be done by irresponsible disclosure, as would have been done by unprincipled concealment.

My local hospital, the Luton and Dunstable, has in place a well-resourced discharge planning department, putting it at the cutting edge of health service management today because it embodies a goal pursued across the NHS, to encourage collaboration between social workers and district nurses as well as nurses and managerial staff from the hospital. 

The aim is to prepare for the earliest possible discharge of patients, under the best possible conditions: there is nothing to be said for keeping patients in hospital any longer than necessary, if only because hospitals are dangerous places (full of sick people) with a high chance of infection, patients recover better in their own beds, and beds are at a premium for others impatiently awaiting their turn.

Most discharges are uneventful. But sometimes discharge planning has to make sure that patients have district nurse or social care support in place, that their medication is ready, that they are going home to an environment in which they can continue to recover, and so forth. It’s hard work, under great pressure, involving the coordination of many different agencies and their staff.

Now it’s impossible to do good work without occasionally getting it wrong. The only people who never make mistakes are those who never make anything. The trick is not to be put off by fear of making errors, but to recognise them quickly, take action to correct them and learn the lessons.

So the Luton and Dunstable hospital is to be congratulated for carrying out regular audits of its discharge planning work. It’s entirely right that the department should understand its shortcomings and plan how to make sure they don’t occur again. Audit is a key way of providing information to support appropriate action.

So what a pity it is that a reporter on the Herald and Post, perhaps seeing himself as a latter-day Bob Woodward, got an article on the front page of the paper denouncing the cases that went wrong, such as the two patients discharged with cannulas still in place, or the dementia patient sent home with no-one ready to receive him. These are highly regrettable incidents, but the journalist might have mentioned that the problem discharges are a tiny proportion of the total, less than one in a hundred, and that the hospital has an exemplary record of handling discharges.

The press lives by disclosure.
But sometimes that’s less than helpful

The publicity won’t produce an improvement in service: the hospital was working on that already. Instead, what we’ll see is an increased reluctance to make information available if it can be abused. That can only increase the difficulty of achieving improvement.

Whistleblowers are essential in a healthy society. And the press does indeed owe it to itself, and to us, to live by disclosure. But it would be useful if the press learned that the disclosure of information is a right that comes with an obligation to exercise it intelligently.

Healthcare: they order these things better in the US

British doctors have set the alarm bells ringing again, over the government’s alleged drive to privatise more of the NHS.

Many fear that privatisation might make the NHS look more like US-style healthcare, with its strong and flourishing private sector. So it probably makes sense to take a look at what happens in the US and see whether its superior model isn’t one we could usefully emulate over here.

Time to revitalise the NHS with US healthcare dynamism?

Certainly, the US enjoys healthcare benefits that are denied to Britain. For instance, Kayser Permanente, one of the biggest health insurers, in its most recent report declared $1.6 billion of ‘income’ (it’s a ‘not-for-profit’ organisation), and that’s not the kind of thing we can point to in the UK. Blue Cross-Blue Shield, the biggest insurer of them all, with a monopoly presence in certain States, makes about 18 cents on every dollar of insurance it sells.

As well as the business benefits, some of the US healthcare performance figures are staggering too.

In Britain, we lose 4.56 children in their first year of life for every 1000 live births. The United States are well ahead, at 6.00.

On maternal mortality, the number of mothers lost in childbirth, Britain stands at 12 deaths per 100,000 pregnancies, but the US is achieving nearly twice that level: 21.

It’s true that life expectancy is very little different between the two nations, though here again Britain does on average impose around eighteen months longer in this vale of tears on its citizens (overall life expectancy stands at a little over 80), whereas the US releases them slightly earlier to travel to a better place (about 78.5).

The US also frees over 50 million of its citizens from the burden of carrying health insurance. Such people, unlike their British counterparts, don’t have to visit family practitioners when they are first ill (after all, they can’t pay for them); instead they have the luxury of waiting until they are really sick, at which point they will receive state-of-the-art treatment of their immediate symptoms in one of the world’s greatest hospitals, where no-one will waste their time trying to treat their underlying condition (for which they can’t pay either).

What’s most staggering of all is that the NHS costs Britain nearly 10% of its Gross Domestic Product, whereas the United States has so far limited expenditure on healthcare to less than 18%.

The poor old NHS clings on to outdated notions such as comprehensive healthcare, free to all at the point of care. In the light of the striking evidence assembled here, who still wants to protect it against the enlightened ideas our fine government wants to bring in from the US?

Healthcare: the kids are as bad as oldies

I was intrigued by an article I read recently by Denis Piveteau, a member of the French equivalent of the Supreme Court (the Conseil d’Etat) and also chair of the Commission into the future of health insurance in France.

We all know that one of the great issues of our time is the ageing population and the impact it has on health services. We all know that because it keeps being said. In the same collection as Piveteau’s paper, David Oliver from the Department of Health in England pointed out that ‘people over 65 account for 60 per cent of admissions, 70 per cent of bed days, 80 per cent of emergency readmissions or deaths in hospital and nearly 90 per cent of ‘delayed transfers of care’.’

But Piveteau recommends that we distrust simplistic soundbites. It isn’t just the old who consume healthcare services. He tells us that in France, at least, ‘people aged over 75 represent about a fifth of the total expenditure on healthcare of the population, or roughly the same as is consumed by people under 30, and those who are over 85 represent about the same as those who are under 10. And yet no one would ever think of claiming that people under 30 or under 10 are responsible for the deficit in health insurance in France’.

Now it’s true that the proportion of the population under 30 or under 10 isn’t growing, while the proportion over 75 or 85 certainly is. The ageing population is going to be a much bigger factor in determining the future of healthcare over the next few years than the younger age groups.

Even so, it’s great to have a little context, a little perspective. Expenditure on the very old is certainly high, but so is expenditure on the very young. We don’t resent the latter; it might not be a bad thing to be more tolerant of the former.

And that is the balanced view on an impartial observer of the human scene. Who, you may be surprised to learn, will be 60 next birthday.

You think we're the problem? Take a look at the kids.
And we don't make as much noise.

The path that leads to understanding healthcare

It's Sunday afternoon, which reminds me of how bad a time this was for one of my sons when he was a young child. His good cheer would start to dissipate from about lunchtime, to be replaced by something altogether much bleaker. As often as not, the evening would end with tears.

That was what the prospect of the coming week did for him. And yet, oddly, he enjoyed school.

I would try to comfort him by pointing out that this Sunday evening melancholy would probably only last until he was 65. Of course, I was wrong, but hey, I didn’t realise then that the retirement age would start to climb long before he reached it.

Still, it’s true that Monday morning syndrome is a pretty universal condition. Why, even Garfield the cat suffers from it, and what affects a cartoon cat must surely affect us all.

Funnily enough, it’s not a condition from which I suffer at the moment. This is because work has done something for me which hasn’t happened for a few years. It’s give me the opportunity to focus on a topic which is a hobby horse of mine – some might even say an obsession. Give me a podium and a projector these days and I’ll drone on about it endlessly. It probably doesn’t bore people who hear it for the first time, since the enthusiasm of a speaker tends to excite a reciprocal reaction in an audience, my poor colleagues must find it truly tedious.

The subject of my fixation? Pathways. Not the ones you cut through jungles or stroll along on country walks. Not the spiritual ones leading to moral high ground or low. I’m talking about pathways of care.


In healthcare as in life, you have to follow the pathway 

Over the last few years, it's becoming increasingly clear that we have to stop thinking of care in terms of events taking place at points of time. It's not easy to get away from those old habits of thought. In the general view of medicine, what matters is what happens at a particular moment, saving a patient in an emergency department or carrying out heroic surgery in the tense atmosphere of an operating theatre. Incidentally, it really is called ‘heroic’, usually because it stands little chance of success but will undoubtedly cause a great deal of suffering to the patient, which always makes me wonder whether the surgeon is the real hero of the story.

To doctors, too, what matters is what they’re doing right now to help the patient, and what happened before is only a source of information, what happens next a mere vague outline plan.

Increasingly, though, if you want to understand what is being done for patients and judge whether they’re receiving the most appropriate and effective care, you need to lift your eyes above this level. You need to understand what was done before the surgery and to follow it up afterwards. You need to compare all that with the treatment other people received. Did they perhaps not have surgery at all? Are they any the worse for it? Or are the results better if they have the operation?

As soon as you start asking that kind of question, you’re no longer talking about healthcare events but about pathways. The events are still there, of course, but strung together into pathways, like beads on a necklace. Taking the long view sees events only as components of something bigger, and that’s a much richer view.

One of the reasons why this is becoming more important is the sheer number of conditions that are the subject of chronic care, extended through time, as opposed to acute care, delivered over a relatively short period. Heart disease, diabetes, respiratory problems and many other medical conditions need treatment over a long time. That’s even truer of an area of illness we tend to talk about less, though it’s likely to affect one in three of us in our lifetimes: mental illness. Mental healthcare seldom takes less than a few months, often lasts a number of years, and can continue throughout life.

To think about healthcare in terms of extended pathways poses all sorts of new problems for information handling. In particular, it requires us to bring together items of information from many different areas and link them in a sensible way.

That’s what my present job has given me free rein to do. Since it’s something I’ve wanted to work on for years and have only touched on superficially in my previous roles, you can imagine the extraordinary (if slightly geeky) satisfaction it gave me recently to work with my colleagues to build views of events in care pathways. The other day, I scrolled through the records of care delivered to a patient who had suffered a stroke: not just the emergency attendances or the outpatient clinics and inpatient stays, but the time in care homes, the visits by district nurses, the physiotheraphy sessions either in or out of hospital.

For the first time, I was able to see a full pathway of care. I’m not a clinician so I can’t judge whether the care was the most appropriate. What I do know is, in that slowly scrolling list of records, I had all the information a clinician would need to make the judgement.

It gives me a buzz to know that, thanks to the outstanding support of highly proficient colleagues, I can now make a tool that powerful available to our clients.

Tomorrow's Monday. The prospect of a new week, of commuting back into the office, inspires no dread. Unlike my son in his childhood, I’m suffering from no Sunday evening blues at all.

Healthcare reform: confusion heaped on confusion

It's said often enough but that doesn't make it any less true: you really need to be careful what you wish for.

When David Cameron set up his nice new British government nearly a year ago, he equipped it with a Secretary of State for Health who had already spent five years as the opposition spokesman. Just what the doctor ordered, you’d think – someone with real understanding of his brief. Particularly as he’d been married to a GP. The opportunity, you’d think, for some good domestic debriefing.

Lansley: leaving us all bemused. Himself too, perhaps

But a year on, the gloss is coming off that shiny government. In particular, pretty well everyone is against the flagship reforms of the NHS that Lansley has championed. Most people oppose them because, quite frankly, they’re incomprehensible. Nobody, apparently least of all Lansley, has any idea what they’re intended to achieve. They ought to be good, because they’re going to cost about 12 billion pounds, but they’re so confused, it’s hard to judge.

The only people who seem to be in favour are a number of GPs. Of course, if the reforms go through, they may be able to triple their pay packets simply by denying hospital care to the rest of us. It’s a bit like farmers being paid not to grow crops. The differences is that we can all probably live with a bit less alfalfa, but being denied healthcare can have a limiting effect on career prospects. On any kind of prospect, actually.

So unclear are the benefits of the reform, that not just the Labour Opposition but their coalition poodle partners, the Liberal Democrats, are having second thoughts. Most telling of all, it looks as though David Cameron and other senior members of the government itself are seriously concerned. So a three-month moratorium has been imposed.

It’ll be interesting to see what happens next. Most of the people I meet from the health service are beginning to express a glimmer of optimism that the reforms might be dropped altogether and, ideally, Lansley and his team sacked. It seems that the early hopes conjured up by having a minister with experience of the field may have been misplaced.

As for the reforms themselves, we should perhaps have seen a hint of their inherent weakness in a simple linguistic flaw they contain.

The idea is that the bulk of the money spent by the health service would be handled by groupings of GPs. But just to call them ‘groups’ would of course be far too obvious and simple for the swanky lot that form our government. Instead they've gone for the much grander term ‘consortium’.

Unfortunately, ‘consortium’ is Latin and therefore behaves sneakily. What can you expect of words invented by the ancient Romans? These are the people who had gladiatorial combats, crucifixions and the inclination to invade other countries at the drop of hat. Not tolerant and civilised like us.

I spent yesterday with a bunch of NHS people. I heard the word pluralised correctly as ‘consortia’ though, inevitably, also as ‘consortiums’. Then there were those who thought that ‘consortia’ was itself a singular, as in ‘local GPs will have to form a consortia’, which naturally led to the creation of the curious plural ‘consortias’.

When we can't even agree on the words, what hope is there for the substance of the reforms?