Too Little Quality; Too Many Doctors
Authors: Kamran Abbasi
Journal: Journal of the Royal Society of Medicine (2006)

What does it take for the Archbishop of Canterbury to pontificate on the nation's health? JRSM readers with an interest in medical history—and I know there are many—could probably catalogue centuries of religious interference in matters of public health. The Archbishop of Canterbury is now only a commentator on health unlike the Pope who is a policymaker instructing us on the benefits of chastity or the evil of condoms. But you suspect that when England's Primate offers an observation on the health service something must be bothering him.

In early May, Dr Rowan Williams articulated concerns for the quality of patient care and wondered aloud about the wisdom of economic expediency, number crunching, and target setting. What about quality, dignity, and equity, was his message at the annual Florence Nightingale commemoration? Dr Williams touched on a debate that is being rehearsed daily in the UK's hospitals and general practices. Where does efficiency end and quality begin? Can we devise a system that delivers the efficiencies demanded by managers and politicians but also offers the quality of care that clinicians cherish? Is the marriage of efficiency and quality a flimsy romance worthy of Barbara Cartland?

It did not require divine intervention for Dr Williams to identify a problem with the National Health Service. The media and the annual nurses' conference have seen to that. The government wants us to believe that the current financial cuts, organisational changes, and service reforms have generated a creative tension—a kind of big bang—that will catalyse the creation of a shining new health service. When the dust settles we will be shiny healthy people at no extra cost to the taxpayer. Sceptics, and there are many, believe that the only meltdown nearly as alarming as the polar ice caps is that of our beloved NHS. Others, who have never loved a tax-based system, are smiling I told-you-so smiles at the prospect of the private market that might be about to erupt.

John Wright and colleagues invoke Florence Nightingale to begin their description of a series of hospital quality improvement interventions that reduced mortality at Bradford Royal Infirmary (p. 303). Their study is a quality improvement report, otherwise known as a `closed loop' audit or a `before and after' study. These studies account for much of the research output in today's NHS. Purists shun quality improvement reports but it is a type of study that the JRSM will publish. Quality matters. The key to a good quality improvement report is a valuable narrative account of the strategies for change. These strategies should be supported by research evidence. The learning point in a quality improvement report is about the implementation rather than its statistical sophistication or the magnitude of the effect.

One measure of the quality of a health service might be the number of doctors and nurses per head of population. But where do you stop? Does the United Kingdom need 100 000 doctors or 1 million? Karen Bloor and her fellow health economists argue that we might have reached the point where the number of doctors is sufficient to meet the demands of our population (p. 281). Indeed, we might be in a state of overprovision, which would help to explain the government's and the GMC's sudden demand for overseas graduates to have a work permit. Arun Natarajan and Balasubramanian Ravikumar compose a requiem for international medical graduates. `Lives and livelihoods will be ruined,' they predict (p. 272).

Another method of reducing the number of doctors would be to have them struck off. Robin Ferner and Sarah McDowell highlight an alarming rise in the number of doctors charged with manslaughter since 1990, a rise that cannot be explained by the recent increase in the number of doctors (p. 309). This fashion for retribution, they conclude, is not the way to foster an open culture that is required to deliver the quality of care that the Archbishop of Canterbury is demanding.