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They emphasised that evidence alone was not enough if the clinical skills were not of a high order. So much for recent medical history. Where are we now? Shaw's dilemma of demand exceeding the ability to provide remains a major challenge, probably the major challenge for modern healthcare. The dilemmas highlighted by Cochrane of the need to make health services effective and efficient remain timely.

The NHS has had unprecedented funding in the past ten years, but evidence of commensurate improvement is difficult to find. The American plan was to find cures for the major forms of cancer by the bicentenary of the state in Nixon called for the same kind of effort that split the atom and sent a man to the moon. It might have been good short term politics, but was poor science. Despite massive expenditure, no cure was found, indeed no significant advance was made in cancer management.

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Our own UK cancer plan 12 promised survival rates to match the best in Europe by Like the American plan it has absorbed huge resources and been associated with a massive bureaucracy. We can only hope that the similarities with the Nixon plan end there and that it will produce benefit. However, it must be said that the evidence of its effectiveness, never mind cost-effectiveness, is slow in coming.

Much has been spoken and written about efficiency recently; it's the obvious easy answer to the conflict between demand and supply. Unfortunately, most of the measures taken to achieve it have had little or no basis in evidence, or even in common sense, but were driven by crude arbitrary targets. It's hardly surprising that these have resulted in some poor quality care.

As a result of the drive for efficiency, management imperatives have become the major force in healthcare.

Autonomy and Trust in Bioethics (Gifford Lectures, ) by O'Neill, Onora

He described how the fads of business management had been transferred to healthcare despite important differences. There was no managerial panacea; it was a complex business, balancing upsides and downsides. Mindless attempts at cost control may, in fact incur costs and reduce the morale of both patients and healthcare professionals.

We cannot, of course, have clinical anarchy. There must be rules, but we should remember that compliance is likely to be inversely proportional to their number and complexity. Thus we come to the nub of the problem of how to achieve effectiveness and efficiency - managerialism versus professionalism, rigid rules versus culture and values.

They never should have been in conflict: properly implemented they would have been complementary. Griffiths envisaged that a balance between managers and doctors in management would produce a balance between clinical quality and cost. But increasingly, cost pressures became predominant. The clinical directorate system, despite its theoretical strengths, fails to solve even the simplest issues in service improvement and efficiency.

And, why should our patients trust us with decisions about their lives and health if we cannot even organise their appointments reliably? Governance which was intended to assure professionalism and quality has become an instrument of enforcement, too often of measures which have undermined quality. This would not only be a misuse of evidence-based medicine but suggests a fundamental misunderstanding of its financial consequences.

These problems of how to ensure quality and efficiency are not confined to this country. Dr Jerome Groopman, a professor of medicine at Harvard Medical School, in a paper in the New York Review 14 earlier this year, described the conflicting advice given to President Obama from his health advisers. One group advised coercive legislation, aggressively pushing doctors and patients to do what the government defined as best whilst another recommended greater clinical freedom.

So, the dilemma remains, but I am not pessimistic. Good ideas come to the surface, eventually.

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The concepts of EBM and clinical governance are intrinsically sound and should promote the best aspects of professionalism. They have been antipathetic only because they have been misused. Medicine can learn from business, but cannot be run as a business. That clinical excellence and financial control can be reconciled is well demonstrated at the Mayo Clinic.

The central tenet of the practice at Mayo is that the needs of the patient come first. It hardly needs to be said for it is evident that the concept pervades all levels of the organisation. A recent book, Management Lessons from the Mayo Clinic 15 describes the management structure and processes. The currency of respect is clinical excellence.

Physicians have as much at stake as do managers to ensure the financial viability of the institution. Managers have at much at stake as physicians to ensure good patient care. Leaders are invited; physicians who appear conspicuously ambitious for leadership have a high chance of rejection. The committee system works to achieve consensus which is easier where there is mutual respect and shared objectives.

None of this is new. Peter Drucker, the management academic wrote more than 20 years ago about the need for organisations to have values and pointed out the differences between businesses and not-for-profit organisations. King is well-placed to combine the business and professional, having been a former Judge of the High Court in South Africa and chairman and director of several companies. Good Governance involves fairness, accountability, responsibility and transparency on a foundation of intellectual honesty. It was gratifying to see, in a business journal, recognition of the primacy of clinical care and outcome, and powerful advocacy of the view that leadership should be clinical.

And so I come back to the new students. You have chosen one of the most fascinating, challenging and rewarding occupations anyone could have. You are living in interesting times. In my working lifetime, we have seen the failure of both socialist and free market ideologies in handling public services. We now hear public discussion of the need to find new ways in which society might organise its affairs better — how much the state should intervene in people's lives, what services it should, and should not, provide, and how it should deliver them effectively and efficiently.

The health service is a paradigm for these larger political issues. Many of the answers are already available in the medical and management literature. If I have encouraged at least some of you to become interested in these wider aspects of healthcare, I shall be well satisfied. National Center for Biotechnology Information , U. Journal List Ulster Med J v. Ulster Med J. Roy Maxwell. Author information Copyright and License information Disclaimer. Correspondence to: ten.

Clinical governance was to be achieved by: Application of evidence-based care Use of clinical guidelines Clinical audit Professional education Research Risk management Individual appraisal and re-validation All of these are worthy objectives, but could deliver only if implemented effectively. Shaw B. The doctor's dilemma. Harlow, Essex: Penguin Books; Great Britain.


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