On a recent inpatient stay, I was asked to select my dietary requirements by completing an optical character recognition card, not unlike a National Lottery card. For breakfast, I opted for Weetabix and wholemeal bread in "standard" portions. I got one Weetabix and two slices of bread. That was more than I needed in the circumstances, so next day I opted for the same in "small" portions. I got two slices of bread and two Weetabix.
This may not be of great clinical or economic significance, but it made me think whether we all had the same interpretation of "small", "standard" and "large", and what other frequently used words are often interpreted in different ways.
It is - and long has been - the objective of successive Governments to "even up" the quality of and access to health care throughout the United Kingdom. The term "equity" is used because there are significant variations in health need and priorities, whether arising from local demographic or population differences, or from local employment changes which may give rise to special mental health challenges. Local opinion is important, with many patients rating convenient local access more highly than better quality and more efficient service at a health centre often miles from their homes and difficult, time consuming and expensive for them or their relatives to attend.
For these reasons, it is important to allow some local variation in priorities as well as progressing towards common national health gain targets. On the other hand, the media delight in highlighting examples of variation, whether so called "post code prescribing" or access to specialist services. That sells newspapers and is an embarrassment to any government, not least because the health service is of great importance to the public and therefore to votes. The basis for these comparisons is usually equality, which is often all that can be easily measured or understood.
In many ways, the Government "league tables" of performance do not help - all such data require careful interpretation and the highest (or lowest) values are not necessarily the best. The same goes for comparisons with the health services of other countries. Is it right, for example, to have short hospital waiting lists achieved through overprovision and underuse of scarce and expensive resources? And do these comparisons take account of the strong primary care system in the UK?
We must be clear that equity is not the same as equality - and it is often very difficult to make true comparisons.
When it comes to the means of health care delivery, then, again, central advice leans towards equality. The recommendations of the National Institute for Clinical Excellence (NICE) will be used as the "yardstick" for performance measurement. Yet there must be some recognition of local variation in resources - and also it must not stifle development. The current arrangement in clinical audit is that an alternative to the "standard" is acceptable provided that similar quality and performance can be demonstrated.
Perhaps that is not a bad principle and could better recognise local resources and the need to stimulate development and refinement.
On a more mundane level, what do we understand by a "dry dressing"? It is a term used in many wound management protocols, yet recently I have seen considerable variation in interpretation between NHS trusts, within a single trust and even within a single clinic.
The simplest (and cheapest) interpretation is a plain gauze swab. A common alternative is the low adherent dressing. Sometimes, the two are combined into a single proprietary product, where a semipermeable, low-adherent surface is backed by an absorbent pad. It may be fixed by a tubular bandage or by a plain conforming bandage.
Sometimes a proprietary "Mepore" dressing has been used. This combines the "Melolin" style dressing with a non-allergenic adhesive surround, which certainly saves nursing time in application, but it adheres directly to the skin. This is generally considered poor practice when applied to damaged or fragile skin.
There needs to be a common understanding, at least locally, and I suggest that a clear definition is best included in a wound management policy common to primary and secondary care.
"Formularies" originated in early hospital practice, both as statements of what products were available and as an aid to the prescribing of complex local nostrums. They were essentially local, so that, for example, "Ointment No 6" might mean something quite different in one hospital to the one just down the road. Often the formularies of that time were expensively bound and did not lend themselves to frequent updating and revision - that was not a priority in the relatively stable days before the "therapeutic revolution". The British National Formulary was an important step in achieving a common understanding.
Now things have changed, and presentation is simpler and more easily updated. Formulary content is determined by an expert drug and therapeutics committee. Increasingly, the information is available to prescribers on line, further easing revision. It is also backed up by clinical pharmacist participation in prescribing decisions and by clinical governance.
Even then, there are different interpretations of the standing of the formulary, from those rigidly applied and where the procedure for obtaining a non-formulary item is complex and difficult, to those where it is relatively easy, for example, to continue the treatment of a patient who is already stabilised on a non-formulary product in primary care. Nothing shakes the confidence of a patient or annoys a general practitioner more than to experience an arbitrary change to a hospital-preferred alternative.
The same goes for general practice.
When the concept of a formulary was first introduced as one of the Government proposals to improve the quality and cost-effectiveness of prescribing, the intention was to stimulate practice-based review and agreement of prescribing policy. However, this did not go ahead as quickly or effectively as any of us would have liked, particularly since with the arrival of pharmacist prescribing advisers and the greater focus of their role, the trend has been towards district-wide formularies. Now we are seeing primary care group formularies. All are increasingly influenced by central guidance, which minimises repetition of effort. Although, despite active encouragement, the uptake has so far disappointed the NHS Executive, Prodigy (the computer-based prescribing support system) delivers strong central guidance direct to the prescriber.
Certainly, an early objective was to contain and reduce costs, as well as to improve effectiveness and quality. In many (perhaps most) primary care groups, cost reduction remains the primary objective.
Although implementation depends largely on peer review, prescribing adviser influence and incentives in the absence of effective sanctions, there is a widespread and developing view, particularly by the pharmaceutical industry, that compliance with the district formulary is mandatory.
Are committee-developed formularies binding on all GP prescribers, or are they a guide to good practice and an influence on practice prescribing policies? We need to be clear.
To quote the very old story, are we being asked to send "reinforcements to support the advance" or to send "three-and-fourpence to go to a dance"? There needs to be clear and unambiguous communication fully understood by the sender and by the recipient alike.