This recent article in the New England medical Journal about the future of medical education has caught my eye.  The authors quote from another article entitled  

Cottage Industry to Postindustrial Care — The Revolution in Health Care Delivery' which appeared in an earlier edition of the NEJM  -   doctors  must shift from viewing themselves as 'nonintegrated, dedicated artisans who eschew standardization'  to become leaders of a system that values 'wise standardization, meaningful measurement, and respectful reporting'.   Aren't wise, meaningful and respectful useful adjectives!

 As a practising doctor in the UK, two thoughts occur to me -  In the US,  patient autonomy and influence is increasingly viewed by those on the left as a liability and one of the major drivers of the huge cost of healthcare. In the UK.  one of the stated aims of the impending NHS reforms is to increase patient autonomy and influence - the 'Nothing about me without me' philosophy. Maybe even more 'local cottage industry' and less Stalinist centralisation.  In view of the American experience, does this mean costs will be driven upwards at a time when we are supposed to save £20 billion?

The second thought relates to the first article on medical education mentioned above - what kind of hospital doctors do we need in the future and how should the medical training system be altered to acheive this?  The British consultant position, especially in the surgical specialities,  has been more 'dedicated independant sometimes nonintegrated highly trained artisan' and less,  small compliant cog in the giant wheel of healthcare delivery.   Are we seeing the beginning of the end of the traditional system that will be replaced by one that sees the service run by a number of semi experienced doctors (subconsultants maybe!!) led by one compliant individual with shiny new MBA in medical leadership? 

The fact is that patients want to be treated and managed by individuals not systems. This tension, that is becoming increasingly apparent to me in the new NHS is unsustainable and something will have to give. I predict that cost containment will trump patient satisfaction .