LETTER : Pressures and fallacies that shape London's health service

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The Independent Online
From Mr P. D. O. Davies

Sir: You rightly point out that the King's Fund has made a basic miscalculation in its recommendation that primary care be expanded at the expense of hospital beds ("Untried cure kills hospitals", 6 March). What you did not add was that the changes being implemented in the health service over the past four years are, like this last error, based on a misconception about the nature of hospital medicine. This misconception can be simplified to the following statement:

Specialised (hospital) medicine is about cold or urgent surgery. It is quantifiable in terms of time and money, relatively straightforward and facilities for its practice available in most hospitals around the country. Patients requiring this service need only be admitted, have the surgery performed, and be discharged in the shortest possible time.

From this basic misconception flow a number of fallacies, the principal ones to date being that contracting of such services between purchaser and provider can be carried out relatively easily, and that competition between providers enables efficiency to improve and costs to fall. There are also secondary fallacies, such as the hope that less invasive techniques of surgery such as "keyhole surgery" will reduce the need for beds, and (the latest) that better primary care, including day surgery in the community, will reduce the need for hospital beds.

As anyone with a grasp of medicine knows, the cold or urgent surgical case represents a small minority of the hospital in-patient and out-patient population. The great majority suffer from chronic illness for which there is no instant cure. The bulk of medical practice, in whatever speciality, is in helping those with ongoing illness to live qualitatively and quantitatively better lives. The treatment of these illnesses is not easily contracted or competed for and accounts for the great majority of the 25 per cent increase in emergency admissions hospitals have experienced in the last few years.

The popular media, particularly television, which thrives on the quick cure usually obtainable through surgery, rather than the slow relief that characterises most of medicine, has played a major role in promoting this misconception. As a result we have a reorganised health service which is trying to fit a very square peg into a very round hole. The sooner we realise this and alter health service changes accordingly, the more comfortable we will all be.

Yours sincerely,


Consultant Physician



6 March