Groundwork for change
Authors: F. Millard
Journal: BMJ (1990)

If many British doctors currently feel beleaguered as they face local ward closures or new terms of contract, or contemplate pending government legislation to change the NHS, perhaps Michael Ryan's new book might cheer them up. At least they do not have to cope with the formidable array of problems faced by their Soviet counterparts. On the other hand, they might also find themselves miserably depressed at the catalogue of systemic shortcomings of the Soviet health service. Chronic underfunding of a service historically seen as unproductive; the pre? dominance of quantitative, rather than qualitative indices of performance and h progress; organisational < fragmentation, lack of w management skills, exces ? sive bureaucratisation g entailing mountains of | directives and paperwork; | hopelessly inadequate o resources, compounded by Maternity hospital, Ulan Ude, Siberia, their maldistribution; poor October 1989 quality accommodation, often with lack of basic sanitary facilities?these are some of the major factors explaining the lamentable conditions in which Soviet doctors work. In Britain there are areas or sectors where certain of these factors also exist. In the Soviet Union they are systemic features characteristic of the whole; exceptions shine precisely because they are exceptions. Neither does the medical profession itself emerge well from Ryan's analysis. Doctors' educational standards and thus their competence are low. Their miserable remuneration diminishes their social status and encourages corruption. Excessive, narrow specialisation generates a mechanistic view of medicine. Their lack of professional cohesion renders them passive participants in the processes affecting them and their patients. At last, however, the problems are being recognised, discussed, and publicised. Indeed, the old official portrayals of grandiose successes and achievements have rapidly receded in the era of glasnost to the point where it is difficult to find anything at all positive being said about the health service. Changes are promised in the values, structures, funding, and resourcing of the health service under the vigorous, dynamic leadership of the new minister of health, Dr Yevgeni Chazov.* Chazov has already succeeded in laying the groundwork for change in a number of vital areas. As Ryan rightly notes, vast additional sums are indeed now being found, or have been promised, in order to achieve amelioration on a heroic scale (p 61). Great attention is also being paid to developing a strong foundation of primary care, with emphasis on general practitioners (or family doctors) as the new linchpin of the system and provision for patient choice of primary care doctor rather than assignation by place of residence. None the less, the obstacles to genuine transformation, at least in the short to medium term, are formidable. Three points will indicate these. Firstly, the Ministry of Health lacks sanctions, whether carrot or stick, to ensure that its needs are met by industry. Whether in the construction of hospitals or the provision of medical equip? ment and spare parts, the performance of Soviet industry has been long weighed and found wanting. With isolated exceptions peres troika is not succeeding in making industry responsive to the needs of its customers, and in many spheres output is falling, not rising. Secondly, the promises of increased finance may easily be withdrawn