Better care before and after surgery improves patient safety while saving money for the NHS

SIR – Professor Sir Bruce Keogh is right to emphasise the importance of adopting innovative technologies to improve patient safety in NHS hospitals (report, October 29).

However, improving the existing way of doing things can be just as transformative. Focusing on patient care before, during and after surgery – the perioperative pathway – can improve patient safety and the quality of care received. Perioperative medicine is not a new concept and many of the necessary resources already exist in NHS hospitals, but a comprehensive perioperative care package requires integration with services outside the hospital walls.

Investment in local public health services, such as smoking cessation, and more funding for social care are needed to ensure that patients undergoing surgery can access both the “prehab” and the rehab needed to guarantee the best possible outcomes.

Dr Liam Brennan

President, Royal College of Anaesthetists London WC1

SIR – Everything Professor Sir Bruce Keogh says about the safety crisis is obvious, except that it apparently hasn’t been a priority inside the NHS.

NHS litigation costs are double what they were in 2008, now close to £2billion a year. If these costs came out of managers’ budgets, bad departments would either vanish or improve. In other areas of life, insured individuals pay the premiums and the excesses themselves, and this motivates them to be safer. Prioritising quality improvement, training, and decent IT are other ideas.

There is no shortage of ways to make the NHS safer and more efficient. The NHS needs a structure that allows safety to flourish; it needs a systemic cure – and behind that, the will to think about a cure and the will to resource one.

Professor Harold Thimbleby

University of Swansea

SIR – In 1920 Lord Dawson was asked to recommend a system to provide medical care and allied services for the “inhabitants of a given area”. The report described a system of health care for the country as a whole but did not detail how its recommendations would be paid for, as this was outside its remit.

In 1948 the minister of health, Aneurin Bevan, introduced a system of funding which would be “free at the point of contact” – although this principle was quickly eroded. This system of central funding by the Treasury, admirable at the time, took no account of the demands which would fall upon the health service as huge changes in scientific medicine came about.

In 2012 a former health secretary, Stephen Dorrell, put it thus: “The institutions of 1948 are not appropriate to today’s patients … [They are] the result of a deal Nye Bevan struck in 1948, and every single person involved in that deal is now dead.”

When will this flawed structure be replaced?

Charles Gallannaugh FRCS

Waldron, East Sussex

SIR – Any attempt to “fix” the NHS must be justified by a credible belief that the attempt will improve overall health outcomes, efficiency, and preferably both.

We should also remember that there is much to lose if we get this wrong, not least because our starting point is quite good. Despite the shortcomings of the present NHS, we rank high on virtually all international efficiency comparisons. A recent Bloomberg analysis, for example, puts us in 10th position in a global ranking of 51 countries. The other countries cited in your editorial (Switzerland and Germany) rank 16th and 23rd respectively. The ranking evaluated health care costs as a share of GDP and per capita, as well as life expectancy and improvements from the previous year.

No one should pretend that any of this is easy – but, as always, we should look before we leap.

Professor John Cunningham

Centre for Nephrology UCL Medical School London NW3