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CONTENTS

World Hospitals and Health Services

2004 Volume 40 Number 3

The Official Journal of the International Hospital Federation

Contents

03

Editorial Professor Per-Gunnar Svensson

IHF IHF NEWSLETTER Newsletter

04 International Hospital Federation news

06

07

Dates for your diary

International news round up

COUNTRY PROFILE

10 The development of the Greek health care system Professor

Theodoros Syrakos and Dr Sophia Chatzicocoli

ARTICLES

12 Population health in Europe: how much is attributable to health

care? Ellen Nolte and Martin McKee

16

18

23

29

33

37

40

41

44

47

Management

Health care governance in the UK National Health Service

Jo H Wilson

Special feature

The National Programme for IT in the UK National Health

Service Dr Richard Granger

Infrastructure

Planning and design for a culture of safety in Thessaloniki’s

Hospitals Dr Sophia Chatzicocoli-Syrakou

eHealth

Implementing telemedicine technology: lessons from India

Sanjay P Sood

Are Spanish physicians ready to take advantage of the Internet?

Susana Lorenzo and José J Mira

Clinical care

The global challenge of diabetes Professor Pierre Lefébvre and

Anne Pierson

REFERENCE

Résumés en Français

Resumen en Español

Directory of IHF professional and industry members

OPINION MATTERS

Musings on the future of health care systems Ferdinand Siem

Tjam

Editorial Staff

Executive Editor:

Professor Per-Gunnar Svensson

Desk Editor:

Sheila Anazonwu, BA (Hons), Msc

Editorial Office

Immeuble JB SAY

13 Chemin du Levant,

01210 Ferney Voltaire,

France

Email: info@ihf-fih.org;

Internet: www.hospitalmanagement.net

Subscription Office

International Hospital Federation

c/o M.B. Associates

52 Bow Lane, London EC4M 9ET, UK

Telephone: +44 (0) 20 7236 0845

Fax: +44 (0) 20 7236 0848

ISSN: 0512-3135

Published by Pro-Brook Publishing Limited

for the International Hospital Federation

Alpha House,

100 Borough High Street,

London SE1 1LB, UK

Telephone: +44 (0) 20 7863 3350

Fax: +44 (0) 20 7863 3351

Internet: www.pro-brook.com

For advertising enquiries contact

Pro-Brook Publishing Limited

on +44 (0) 20 7863 3350

World Hospitals and Health Services is

published quarterly. All subscribers

automatically receive a copy of the IHF

yearbooks: Hospital Management International

and New World Health. The annual

subscription to non-members for 2004

costs £125 or US$175.

World Hospitals and Health Services is listed in Hospital Literature

Index, the single most comprehensive index to English language

articles on health care policy, planning and administration.

The index is produced by the American Hospital Association

in co-operation with the National Library of Medicine. Articles

published in World Hospitals and Health Services are selectively

indexed in Health Care Literature Information Network.

The International Hospital Federation is an independent,

non-political body whose aims are to promote improvements

in the planning and management of hospitals and health services.

The opinions expressed in this journal are not necessarily those

of the Federation or Pro-Brook Publishing Limited.

Vol. 40 No. 3 WORLD | World hospitals Hospitals and and health Health services Services | 13| 01


EDITORIAL

Is there anything like

a ‘Smart’ Hospital?

PROFESSOR PER GUNNAR SVENSSON

DIRECTOR GENERAL, INTERNATIONAL HOSPITAL FEDERATION

The IHF Pan-Regional Conference of 4-7 November

2004 in Thessaloniki, Greece, has the title The Smart

Hospital (for details visit www.ihf.smarthospital.gr; or

contact dwight@ihf-fih.org). At this Conference, the

concept of the ‘smart hospital’ will be carefully discussed.

The base for scrutinising this idea will be laid by addressing

the historical and cultural coordinates of the hospital.

The Conference is organised by the IHF in collaboration

with the Faculty of Medicine and the School of Architecture

at the Aristotle University of Thessaloniki.

The idea of the ‘smart hopsital’ is associated primarily with

a more general trend in hospital management and

architecture, which seeks to create buildings more adaptable

to changes in environmental conditions and more flexible in

meeting the varying functions required of the building; such

an approach inevitably leads to a greater degree of

automation in all the various systems operating within the

building.

There are, of course, many aspects of the hospital

technology that may be linked to the ‘smart’ hospital. One

such aspect is the hospital’s ehealth strategy. Our own

ehealth survey, in the previous edition of World Hosptials and

Health Services, demonstrated that hospitals are actively

planning for implementation of ehealth in their systems.

Almost two-thirds of the responding hospitals already have

ehealth strategies in place.

The concept of the smart hospital also embraces the whole

system of medical and nursing services, as well as the

organisation and management of the hospital. In these areas,

the idea of the ‘smart’ building is usually understood to be

synonymous with administrative efficiency and the flexibility

of the organisational system.

What we shall be seeking at Thessaloniki’s Conference to

investigate the latest trends in these systems, and

particularly on the way in which they can be reconciled with

the demand for ‘smarter’ structural shells. The Conference

will also give the chance for delegates from around the world

to exchange views on substantial health issues.

New ehealth section for Journal

As part of the IHF’s ongoing commitment to eheath, a new

section of the journal will look specifically at this area. In this

edition, we have two articles from India and Spain. In future

editions, this section will also include information on latest

developments provided by the International eHealth

Association, who we welcome into partnership for this

particular initiative. ❑

Professor Per-Gunnar Svensson

Director General

International Hospital Federation

Vol. 40 No. 3 WORLD | World hospitals Hospitals and and health Health services Services | 13| 03


IHF NEWSLETTER

International hospital

Federation news

IHF Berlin conference explores strategic options for the Hospital market

SPEAKERS FROM THE FIELD OF HOSPITAL MANAGEMENT, consulting, health care policy and economics provoked a lively

discussion amongst the 100 international attendees at MCC Hospital World 2004 held in Berlin in 28-30 June 2004.

Hospital privatisation was one of the most discussed topics at the meeting. Dr Rainer Salfeld from McKinsey in Munich said

that private hospitals will be leading health care institutions in Europe in the future as health care expenditures are rising faster

than GNP and patients are becoming more demanding. The importance of the private hospital was also emphasized by Dr Axel

Paeger from Ameos Holding AG in Zurich, who told the audience that the private hospital market is currently expanding by

16% annually to reach a value of €14 billion by 2007.

Other contribution came from Pascal Garel of HOPE on the question of patient mobility and Cecilia Schelin Seidgard, CEO

of the famous Karolinksa Hospital in Stockholm on the hospital’s merge with the Huddinge University Hospital. Dr Richard

Friedland of the private South African company, Netcare, described his experiences providing ambulatory ophthalmologic

procedures for the UK NHS. Specifically on hospital management, Steven J Thompson, CEO of Johns Hopkins International

presented a survey report on the globalization of the health care sector and Dr William Ho from the Hong Kong Hospital

Authority presented a view of the impact of SARS on Hong Kong.

The conference was widely enjoyed by the attendees and in an unusual step they were asked to cast their votes for the venue

of next conference.

JCI opens new European office in IHF Secretariat

THE INTERNATIONAL HOSPITAL FEDERATION welcomes

the Joint Commission International (JCI) to Ferney-Voltaire

in France, where they have established a new

European office at the IHF headquarters.

The JCI offers the international health care community

accreditation services for hospitals, medical transport, home

care, laboratories and other health care organisations. The

organisation also provides consulting services, as well as

products and services designed and developed by

international health care experts.

Dr Paul Van Ostenberg, former Executive Director of Joint

Commission Accreditation, and a leader in promoting health

care quality and safety throughout the world, is the

Managing Director of the new office.

For more information about JCI contact gdeegan

@jcrinc.com or visit the website at www.jcrinc.com

/international

Pro-Brook Publishing to be sole IHF publisher

PRO-BROOK PUBLISHING LIMITED, the publisher of

this journal, has taken over publishing the IHF yearbooks

from SPG Media Group PLC (formerly Sterling

Publications Limited) and has been charged with

initiating an exciting programme of annual publications

and directories that will reflect the IHF’s diverse agenda.

This arrangement will make Pro-Brook Publishing the

sole publisher of the IHF’s printed publications.

Pro-Brook is based in London and publishes for the

Commonwealth Secretariat, the Global Forum for Health

Research and the International eHealth Association, as

well as the IHF. The publishers hope that IHF members

and those involved in the health care community will

help shape the programme and contribute to the

publications.

Contract Pro-Brook Publishing on

info@pro-brook.com

News from the Projects and Events office

The next event for the IHF, the Pan-

Regional Conference ‘Towards the

Smart Hospital’, is coming up soon in

Thessalonica, Greece from 4-7 November

2005.

The idea of the ‘smart’ hospital is

associated primarily with a more general trend in

contemporary architecture which seeks to create buildings

with a higher level of adaptability to changes in

environmental conditions, in which the structural shell is

more flexible in meeting the changing functions of the

building, and in which there is a greater degree of

automation in all the various systems operating within the

building. This trend is of particular importance in the case of

04 | 12 World | WORLD Hospitals hospitals and Health and health Services services | Vol. 40 No. 3


IHF NEWSLETTER

large-scale, elaborate building complexes like hospitals. Of

course, the trend for smarter buildings must be combined

with the current demand for hospital architecture to

incorporate recent developments in architectural theory and

aesthetics; the design of a hospital should not deal any more

only with functional requirements and criteria.

The concept of the ‘smart’ hospital goes beyond the

structural shell of the building to embrace the whole system

of medical and nursing services, as well as the organisation

and management of the hospital. In these areas the idea of

the ‘smart’ building is usually understood to be synonymous

with the concepts of administrative efficiency and the

flexibility of the organisational system.

For more information and registration details I encourage

you to visit the website at www.ihf.smarthospital.gr and take

a look. As well, if you are unable to attend or if this does not

fit into your particular areas of interest I urge you to pass the

word to any of your colleagues or associates who might be

interested in attending.

Planning is also moving ahead swiftly for the 34th IHF

World Hospital Congress ‘Hospitals and their Challenges’ in

Nice, France from 20-22 September 2005. There are three

broad themes for the conference – ‘skills and competencies’,

‘quality’ and ‘research’. The work of the scientific committee

is nearly completed in choosing the topics for the breakout

sessions and the associated speakers. Please be sure to note

the dates down in your agenda and to make plans to attend.

The associated web site will shortly be up and running.

Check the IHF events web page for updates.

On the project side of things we are making steady

progress towards launching a pilot test of IPSI – The

International Patient Satisfaction Index. We will share more

information about these developments as it becomes

available. We have also begun a relationship with RL Europe.

This is an organisation that promotes tools that enable

tracking and monitoring in the field of social responsibility;

specifically in the areas of ethics, the environment, health

and safety and quality assurance.

Finally, I have a challenge for you as members of the

International Hospital Federation. We at the Secretariat need

to hear from you what we can do to better serve your needs.

Our organisation exists to serve you and your interests.

Please contact me with thoughts and suggestions about how

we can improve the IHF. I can be reached at dwight@ihffih.org.

Dwight Moe

Project and Event Manager, IHF

News from the Membership office

New members are always welcome

and there are many benefits which

are worth restating. Joining the

international health care fraternity is, of

course, the most important one. However,

new members will also have access to:

➜ the international network of health

services management and policy makers;

➜ the exciting international flow of ideas on health service

management and organisation;

➜ IHF’s many and varied education programmes around

the world;

➜ the opportunity to influence IHF discussions on health

care issues with WHO and other world bodies;

➜ the opportunity to influence national and international

organisations in their health policy development.

In addition, further benefits include:

➜ all members are entitled to receive free of charge our

official journal World Hospitals and Health Services and the

IHF Yearbook;

➜ members can benefit from reduced fees on all scientific

and educational events;

➜ our extensive knowledge and network of contacts in the

health care field may be utilised by our members in the

pursuance of professional interests;

➜ researchers and those involved in business can benefit

from our database of hospitals and health care

organisations around the world. An invaluable tool for

international networking, this database is available to

members at a reduced rate.

➜ Take advantage of a work desk at the Secretariat in

Ferney-Voltaire, next to Geneva, in France; with prior

appointment, this facility will be made available to our

members;

➜ Retirees and students benefit from a discount on their

individual membership fee.

Who are our members?

The IHF has four main membership categories:

A The primary membership of the Federation is open to

national hospital associations or ministries of health of

the countries concerned.

Payment information: Minimum €852/$921 Maximum

€14,320/$15,038

B Other organisations concerned with hospitals and

other institutions directly connected with the provision

of health care.

Payment information: €334/$464

C Individuals in the health care profession.

Payment information: €100/$122

D Corporate entities engaged in supplying goods and

services to the health care industry.

Payment information: €537/$679

For details on how to join the IHF contact me at marylene

@ihf-fih.org

Marylene Ballestero

Membership Services Coordinator

Vol. 40 No. WORLD 3 | World hospitals Hospitals and and health Health services Services | 13| 05


IHF NEWSLETTER

Conference and

events calendar

2004

4-7 November IHF Pan-Regional Conference

The Smart Hospital

Thessaloniki,Greece

dwight@ihf-fih.org/thesis@thesis-pr.com

www.ihf.smarthospital.gr

2005

20-22 September 34th International Hospital Congress *

Nice, France

Dwight@ihf-fih.org

htmlwww.nice2005-ihf.fhf.fr

2007

5-9 November 35th International Hospital Congress *

Seoul, Korea

www.hospitalmanagement.net/ihf/events.html

2004 Collaborative Events:

27-29 October Medic Africa

Africa Regional Leadership Management Workshop

Hospital Management in Difficult Times

Dar es Salaam, Tanzania

sheila@ihf-fih.org or info@fsg.co.uk

http://www.hospitalmanagement.net/ihf/events.html

www.medicafrica.com/fsg_medic_africa.htm

Events marked * are interpreted into English, French and Spanish. All other events will be in English/

host country language only. IHF members will automatically receive brochures and registration forms on

all the above events approximately 6 months before the start date. IHF members will be entitled to a

discount on IHF Congresses, pan-regional conferences and field study courses.

For further details contact the:

IHF Project & Event Manager, International Hospital Federation

Immeuble JB Say, 13 Chemin du Levant, 01210 Ferney, France

E-Mail: dwight@ihf-fih.org

Or visit the IHF website: www.hospitalmanagement.net/ihf/events.html

06 | World Hospitals and Health Services | Vol. 40 No. 3


IHF NEWSLETTER

International news round up

WORLD

Piot issues call to action at AIDS summit in Bangkok

AT THE XV INTERNATIONAL AIDS CONFERENCE in Bangkok, held between 11-16 July

2004 and organized by the International AIDS Society and the Thai Ministry of Health,

UNAIDS Executive Director, Dr Peter Piot, told the closing session that he truly believed

that for the first time there was a real chance that to get ahead of the AIDS epidemic.

He attributed this momentum to both science and activism and the fact that the last

decade had seen an unprecedented combination of the two. However, he warned that

challenges still needed to be met and he called for three things. The first is ownership. The

time for strategies imposed from the outside is over. There is a requirement to address

locally-defined needs and allow staff to do their work. Dr Piot condemned the on-going

scores of AIDS donor missions and rival coordination mechanisms.

Secondly, he called for more capacity to be built to deliver treatments and prevention over

the enext ten to twenty years. And thirdly, he stressed the need to expand the prevention

effort to ensure that treatment remained sustainable.

He called for crisis management to be combined with long-term investment and appealed

to all donor nations to contribute their share, including to the Global Fund – and to all

developing nations to give priority to AIDS in their budget allocations. Sustaining the

billions will require results, support from mainstream public opinion in rich countries and

recognition of the need to maintain special AIDS funding for many years. As part of this

effort he called for the conversion of Africa’s crippling debt to be relieved – ‘the $15 billion

annually that disappears down the money pit. That is four times more than is spent on

health and education – the building blocks of the AIDS response.’

Dr Piot said there was a need to accept ‘the exceptionalism of AIDS’. He called on ‘every

community to rewrite the rules of how it deals with those sensitive issues at the heart of

the epidemic – sex, homosexuality, commercial sex, drug use, rape, stigma, gender, and

masculinity.

For further information see: www.aids2004.org

WHO Ministerial

Summit on Health

Research to take

place in Mexico

THE WORLD HEALTH

ORGANIZATION (WHO) has

organized a summit for

member-country ministers to

set the technical agenda for

global health research. The

Summit, to take place in

Mexico City between 16 and

20 November 2004, is

organised in conjunction with

and co-joined to the Global

Forum for Health Research’s

conference, Forum 8, which

this year focuses on the health

research needs required to

achieve the UN Millennium

Development Goals. Forum 8

is open for all to attend.

For further information

and details of how to attend

see: www.globalforumhealth

.org.

AFRICA

Darfur faces high levels of disease and death

INCREASED FUNDS, PEOPLE AND SUPPLIES are critical

now in the Darfur region of Sudan to prevent a major

health catastrophe. Cholera, dysentery and malaria

threaten the survival of hundreds of thousands of internally

displaced people. However, risks to people’s health can be

reduced through effective health interventions within an

intensified relief programme. This was the conclusion of

two top leaders of the World Health Organization (WHO)

as they visited camps and hospitals in South and West

Darfur in July 2004.

Dr Lee and Dr Hussein Gezairy, Regional Director of

WHO’s Eastern Mediterranean Region, also noted that

even in the June 2004, joint action by the Federal Ministry

of Health, non-governmental organisations, UNICEF and

other international humanitarian agencies had resulted in

important improvements for health.

They noted good use is being made of the funds

available, though logistic challenges still beset major relief

operations. More people in more camps have clean water,

adequate food, primary health care and proper sanitation.

More therapeutic feeding centres are being opened and

hospital services in Darfur are being improved.

But the gap between needs and available relief are still all

too evident. Beyond communicable disease, the physical

and mental health of women who have been subjected to

sexual violence, and the longer term health needs for

children are additional concerns.

Overall, the UN estimates the costs of humanitarian

relief at US$ 240 million. To date, less than half of that has

been pledged. WHO requires about US$ 1.2 million per

month to carry out its operations in the three Darfur states.

WHO is working closely with the Sudan Ministry of Health

and other partners to coordinate the health response,

prevent communicable disease outbreaks, and rehabilitate

hospitals.

For more information contact: Yvette Bivigou -

Communications officer, WHO/Sudan at

bivigouy@sud.emro.who.int

Vol. 40 No. 3 WORLD | World hospitals Hospitals and and health Health services Services | 13| 07


IHF NEWSLETTER

AFRICA

Dr Sambo nominated as WHO Regional Director for Africa

DR LUIS GOMES SAMBO was nominated on the 2 September 2004 by the WHO Regional Committee

for Africa for the post of WHO Regional Director for Africa.

Dr Sambo, 52, of Angolan nationality, is currently the Director of Programme Management at the WHO

Regional Office for Africa (AFRO), where he is responsible for the management and operation of WHO

programmes in the African region.

The Regional Director-elect will succeed Dr Ebrahim Malick Samba who retires in January 2005 after

serving two terms (1994 to 2004).

For more information contact: Samuel T. Ajibola at ajibolas@afro.who.int

Dr Luis Gomes

Sambo

AMERICA

PAHO aids relief efforts in storm-struck Caribbean

DISASTER EXPERTS from the Pan American Health

Organization (PAHO) are working with other international

and local agencies to carry out relief efforts in nine Caribbean

countries affected by hurricanes and tropical storms that

swept through the region in August and September 2004.

A record-setting North Atlantic hurricane season so far has

left more than 500 dead and tens of thousands affected

throughout the region.

In the neighboring Dominican Republic, a PAHO team is

evaluating health conditions and procuring medicines and

supplies for some 12,000 people living in emergency shelters

following Tropical Storm Jeanne.

In Panama, PAHO disaster experts have been working

closely with local health officials and UN personnel to carry

out on-the-ground assessments of damage from mudslides

and flooding. At least 10 people were killed and more than

1,405 left homeless. According to the National System of Civil

Protection, 12,891 people were affected by the flooding, with

2,744 houses damaged and 281 destroyed.

In the aftermath of Hurricane Ivan, damage to water and

sanitation systems and large numbers of displaced people

have created an increased risk of communicable and vectorborne

diseases in Barbados, the Cayman Islands, Grenada and

Jamaica. PAHO’s Caribbean Epidemiology Centre (CAREC)

has coordinated much of the PAHO relief effort in these

countries.

In Jamaica, Ivan was responsible for the deaths of at least 12

people, including several residents of a fishing village who

were swept away in a tidal surge. Many health facilities are

facing shortages of power, water, supplies and personnel.

PAHO staff report that Grenada is still dealing with the

aftermath of Ivan, which blasted the island on 7 September

2004 and caused at least 37 deaths, 380 injuries and 42

hospitalisations. Winds blew the roof off a laboratory at St

George’s Hospital, and Princess Alice Hospital was left

nonfunctioning. In all, some 80% of the country’s health

facilities were damaged by the hurricane.

PAHO has joined with the British aid agency DfID to

provide emergency medical supplies to treat 20,000 people.

Cases of diarrhoea, fever and rashes have been reported at the

nearly 140 emergency shelters set up throughout Grenada.

For further information see: www.paho.org

NIH research plan targets US obesity

epidemic

NATIONAL INSTITUTES OF HEALTH released a strategic

plan on 24 August 2004 to guide its support for research

to prevent and treat the nation’s rising epidemic of obesity.

The plan, developed by a task force convened in spring

2003 to intensify and enhance coordination of obesity

research across the agency, outlines goals and strategies for

research to prevent and treat obesity through a

combination of behavioural, environmental and medical

approaches.

About 65% of US adults are overweight or obese, NIH

notes, conditions estimated to cost the nation $117 billion

in medical and indirect costs such as lost wages due to

illness. The agency plans to invest roughly $440.3 million

in obesity research in fiscal year 2005, up from $378.6

million in 2003.

For more on the research plan, visit

www.nih.gov/news/pr/aug2004/niddk-24.htm.

PAHO and University of Geneva to work

together on disaster relief

THE PAN AMERICAN HEALTH ORGANIZATION (PAHO)

and the University of Geneva have signed an agreement on

the 20 July 2004 to increase and facilitate cooperation on

emergency preparedness and disaster relief programmes. The

collaboration will directly involve PAHO’s Emergency

Preparedness and Disaster Relief Program and the University

of Geneva’s Multifaculty Program in Humanitarian Action.

The agreement, which will go into effect immediately and

last until April 2006, aims to improve professional

development needs, based on the understanding that

through synergy both organizations can have the greatest

impact. It allows for the humanitarian action programme to

undertake academic research and analysis on certain topics

and activities with PAHO.

Both organizations will cooperate in identifying

candidates for the Masters’ Programme in Geneva.

For further information see: www.pdho.org

08 | 12 World | WORLD Hospitals hospitals and Health and health Services services | Vol. 40 No. 3


IHF NEWSLETTER

ASIA

Outbreak of Avian Influenza in Viet Nam

IN THE PRESENT OUTBREAK in Viet Nam, first reported

on 12 August 2004, three fatal human cases of avian

influenza have now been laboratory confirmed, two in the

north and one in the south of the country. For two of these

cases, further testing has identified the H5N1 strain as the

causative agent. The most recent case died on 6 August

2004 and no new cases have been identified since then.

A WHO team is presently in Viet Nam to assist the

Ministry of Health in outbreak investigations. With support

from the Ministry of Health in Viet Nam, arrangements are

under way to send specimens to a laboratory in the WHO

Global Influenza Surveillance Network.

Studies will determine whether the virus responsible for

these cases has mutated. It is particularly important to learn

whether the H5N1 virus strain remains entirely of avian

origin.

Details of the outbreak are available at WPRO website,

http://www.wpro.who.int/news.asp or at WHO HQ

website http://www.who.int/csr/don/2004_08_13/en/

WHO urges ASEAN to strengthen, not

weaken, curbs on tobacco trade

THE WORLD HEALTH ORGANIZATION urged the

Association of South-East Asian Nations (ASEAN) to

carefully weigh the public health risks of liberalization of the

tobacco trade under the ASEAN Free Trade Agreement

(AFTA), and to take into account the established link

between tobacco and poverty in the region.

Tobacco kills one person in 10 globally, amounting to

approximately five million deaths a year. In the Western

Pacific Region, there are 3,000 deaths each day from

tobacco-related diseases

The call, from WHO’s Western Pacific Regional Office,

came as ASEAN officials prepared to meet in Penang,

Malaysia, on 23 and 24 August 2004 to discuss the wideranging

impact of AFTA on the tobacco trade and health.

For further information see: www.who.int

AMERICA

US delays new certification requirement for

foreign health workers

THE DEPARTMENT OF HOMELAND SECURITY, announced

on 19 July 2004 a one-year delay in a rule that will require

foreign health care professionals to obtain special certification

from a DSH-approved credentialing body to work in the US

on a non-immigrant visa. The department said it will delay the

rule for 12 months for workers employed in the US as of 23

September 2003. ‘Had DHS not delayed the regulation,

thousands of top-notch, U.S. licensed Canadian nurses and

other health care personnel who cross the border daily would

have been barred from providing care here,’ said AHA

Executive President Rick Pollack. The decision to delay the

rule follows months of strong opposition from within the

health care community.

EUROPE

New online human rights course for prison

doctors

DOCTORS WORKING IN PRISONS who detect signs of

torture or other degrading treatment and who face

dilemmas about their dual loyalty to the state and to their

professional ethical code now have a new web-based course

on human rights and ethics to help them.

The course, developed by the Norwegian Medical

Association and launched in Geneva by the World Medical

Association, is designed to assist doctors working in prisons

by raising their awareness of their role in identifying abuse

and torture, and by assisting them in dealing with human

rights violations. It is one of several WMA programmes to

assist and guide physicians and others in the appropriate

care of vulnerable populations.

Among the dilemmas addressed by the course are cases

where doctors:

• are asked to declare prisoners fit for punishment, such as

solitary confinement;

• are asked to examine shackled patients;

• are unsure whether and to whom to report cases of abuse

or torture in prison;

• are under pressure to witness restraint of violent

prisoners;

• are under pressure from the authorities not to refer

prisoners to clinics outside the prison;

• are under pressure to share prisoners’ medical records or

confidential health status with non medical staff;

The course, which is accessible from www.wma.net or

http://lupin-nma.net, addresses questions relating to

issues such as the responsibility to report and to whom,

hunger strikes and treatment of the mentally ill.

New EU research centre for Africa

THE EUROPEAN UNION (EU) has launched a research

center in South Africa to Help Africa fight the spread of

HIV/AIDS, TB and malaria. Piero Olliaro, Executive

Director of the European Developing Countries Clinical

Trials Partnership (EDCTP) has said that the group would

fund 18 clinical trials in Africa and nine in Europe over the

next three years. The EU has set aside $4.2 million for the

first year of the trials. ❑

For further information see: www.ihj.org.uk

The Editor would like to thank the World Health

Organization, the World Medical Association, the

International Healthcare Journal, Norwegian

Medical Association, the Amercian Hospital

Association and the Global Forum for Health

Research for their help in compiling the

International News. Should you have any suitable

news items, please email your information to

Sheila@ihf-fih.org.

Vol. 40 No. 3 | World Hospitals and Health Services | 09


COUNTRY PROFILE: GREECE

The development of the

Greek health care system

PROFESSOR THEODOROS SYRAKOS

MEDICAL SCHOOL, ARISTOTLE UNIVERSITY OF THESSALONIKI

DR SOPHIA CHATZICOCOLI

ARCHITECT, THESSALONKI

Historically, Greece is recognised as the origin of

western civilisation and the birth place of the arts

and sciences in general. In particular, Greece is

considered to be the birth place of medical science founded

by Hippocrates (460-370 BC). He is internationally

recognised as ‘the Father of Medicine’ and of health care

systems, originally initiated by the network of Asklepieia.

Asklepieia were cult-places of the divine physician and

healing god, Asklepios, the mythical son of God Apollo, who

was himself the physician of the Olympian Gods. In fact,

Asklepieia were the first hospitals (or health care campuses)

in Europe. The first Asklepieion was believed to have been

founded by Asklepios himself in Thessalia, in the central

mainland of Greece around the time of Trojan War, in which

Asklepios’ two sons are supposed to have participated.

Asklepieia flourished for many centuries, until approximately

the 6th century AD and only stopped functioning with the

prevalence of Christianity.

More than 500 Asklepieia have been found and/or

mentioned in literary sources in the then Hellenic territory.

A kind of holistic health care was offered in Asklepieia. This

arose from the concept of illness as a result of the interaction

of physical, psychological, social and environmental factors.

This understanding of holistic health care originated from

the Hellenic (Greek) Philosophy and Mythology.

During the Byzantine Empire the healthcare system was

mainly formed by a network of Xenones and Nosokomeia ,

hospitals supported by the state, the Orthodox Church and

the monasteries, offering healthcare services mostly

characterised by the Christian ideal of ‘philanthropy’.

During the dark ages of Ottoman occupation (from the fall

of Constantinoupolis in 1453 to the Greek revolution of

1821 and the final liberation of the present day Greek

territory at the beginning of the 20th century) numerous

physicians escaped abroad and the main sources for health

care support were offered by the Orthodox Church and the

local Greek authorities, both in a continual struggle to avoid

any controversies with the Ottoman ruler.

After the liberation, Greece attempted to recover and to

catch up with the developments of Western countries. The

main factors for the creation and direction of the modern

ENEGRO

MACEDONIA

ri

ia

a

A

Tirane

ALBANIA

GREECE

Xanthi

Aegean

Khania

Ionian Sea

Iraklion

Mediterranean Sea

Figure 1: Greece

Skopje

Patrai

Sofia

Athens

Burgas

Istanbul

Izmir

Greek health care system have been the achievements of

‘Western’ medical science, technology and health care

systems thinking, the structure of the socioeconomic life

influenced by the development of the newly established

Greek state and the workers, as well as the public demands

inspired by the Greek historical tradition and modern needs

and views.

The modern system

As early as 1836 the first health insurance funded services

started to appear and develop independently. In 1917 the

Ministry of Healthcare was established. Since then, almost

every new government has changed the organising plan of

that Ministry referring to notions such as health, social

welfare, social insurance, etc. In March 2004, the present

Ministry of Health and Welfare was formed. However, other

ministries have supplementary roles in health promotion

and health care planning such as the Ministry for the

Environment, Physical Planning and Public Works, the

Ministry of Education, etc.

The main steps towards social insurance relating to

employment date from the period 1932 to 1961 with the

establishment of the National Insurance Organisation (IKA)

Bu

10 | World Hospitals and Health Services | Vol. 40 No. 3


COUNTRY PROFILE: GREECE

and the Agricultural Insurance Organisation (OGA). The

hospital treatment system began in 1937 with public health

care institutions and the medical system function. In 1979,

a draft plan for a National Health Service (NHS) was

introduced and in 1983 the Greek NHS was established.

Nevertheless, many NHS practices were applied earlier, like

the establishment of the Central Council of Health (KESY)

in 1982. Later, regulations to update the NHS were passed

in 2001 and 2003.

Nowadays, Greece is divided into 17 Health Regions, each

one being managed by its own Regional Health Council

(PESYP). Health care is provided primarily by the NHS. It is

paid for by public insurance funds which provide their

members with free health care (supplemented by

prescription charges in some cases) and the state budget.

However, many people have additional health insurance to

pay for private care.

At the end of 1997, there were 350 hospitals operating

with 52,474 beds. Of these 140 hospitals with 37,047 beds

were public (Legal Entities of Public Law) and 210

hospitals, with 15,427 beds, were private (Legal Entities of

Private Law and Clinics). In total, 29.4% of hospital beds are

privately owned.

In 2000, there were 47,251 physicians in Greece. The

corresponding density was 232 inhabitants per physician,

among the lowest in Europe.

Challenges

One of the main challenges for the Greek healthcare system

is created by the geographic characteristics of the country

(see Figure 1). Greece covers a territory with great

geographical diversities and dominated by a mountainous

mainland and more than 3,000 islands resulting in a

coastline of more than 15,000 km. The 92 main Greek

islands are spread across both the Aegean and Ionian Seas.

The problem of accessibility to health care services by the

inhabitants of some remote locations in the high mountains

and many islands is a great challenge.

The demographic problem offers another challenge for the

Greek health care system. The continuous decrease in the

under 15s (from approximately 25% of the total population

in 1971 to 14% according to the 2001 census) and the

resulting increase in the over 65s from approximately 11%

of the total population in 1971 to 18.5% in the 2001 census

demands a reconsideration of orientation and planning.

Health statistics create the next challenge for the Greek

health care system. For example, the leading causes of death

following treatment are 35.5% due to circulatory system

diseases, 23% due to neoplasms and 22% due to injury and

poisoning. Furthermore, an analysis of the main causes of

death between 1971 and 1999, shows an increase of 121%

in heart diseases cases, 84% in neoplasms cases, 75% in

celebrovascular disease cases, 21% in respiratory system

disease cases and 16% in accident cases. Therefore,

‘developed world’ diseases and road accidents form the two

main increasing causes of death and require the further

development of the primary health care service.

Greece remains an attractive tourist destination and in

2000 the number of tourists visiting the country was

Greece: health statistics

Total population: 10,970,000

GDP per capita (2001): Intl $16,247

Life expectancy at birth (years):

75.8 (male); 81.1 (female)

Healthy life expectancy at birth (years):

69.1 (male); 72.9 (female)

Child mortality (per 1,000): 7 (male); 5 (female)

Adult mortality (per 1,000): 118 (male); 48 (female)

Total health expenditure per capita (2001): Intl $1,522

Total health expenditure as % of GDP (2001): 9.4

Total area: 131,957 sq.km.

Inhabitants per sq.km: 83.13

Source: WHO 2002

13,605,453. The need to cover a target population of more

than double the size of the inhabitants, mainly for the

summer months, forms a difficult task and a challenge to the

Greek health care system. In addition, another challenge

follows recent discussions concerning the development of

health tourism initiatives.

The eagerness to catch up with the developments of

Western countries, has led to an unquestioned acceptance

and over-estimation of foreign ‘authorites’ in every aspect of

health care planning and individual political obligations,

have sometimes been in opposition to the national interest

and have resulted in numerous problems. One problem has

been the importing of foreign hospital design without any

research on and adaptation to the local Greek characteristics

and requirements. This has produced adverse reaction from

the public and Greek professionals. Another problem is the

absence of a rational master plan of health care facilities on a

national level. That has resulted in uncontrolled

development and spasmodic actions to cover the resulting

inequalities. For example, the Greater Athens area has only

30% of the Greek population, but 46% of the hospital beds

(43% public and 53% private) and 54% of the physicians and

the 44% of the nursing staff. In addition, in central Athens,

an area of 5 sq.km., there are more than 20 of the biggest

hospitals in Greece causing additional traffic and access

problems. All these form a vital challenge concerning the

planning and design level for the Greek health care service.

Recent international forces aiming at a globalised health

care plan can form a challenge for the health care systems

worldwide. However, a globalised health care plan has met

scepticism in Greece. The strong traditional ‘sacred’ relation

between patient and physician tends to be weakened by the

interference from outside. The idea of passing the leading

role in health care from the idealistic and ‘close to the

patient’ medical approach to the rational and remote from

the patient economic management control is not in line with

the Greek health care tradition.

The great challenge to the Greek health care system lies on

the balanced combination between international

developments and the local cultural needs as well as the

heavy duty to be the guardian of the humanistic Greek

health care tradition. ❑

Vol. 40 No. 3 | World Hospitals and Health Services | 11


References

1

Chatzicocoli-Syrakou S, ‘The Asklepieion’s Healing Environment - Learning from

the Past’, World Hospitals and Health Services Vol. 33, No. 2, 1997, pp. 22-27.

2

Aravantinos AP, Asklepios and Asklepieia, 1st ed: 1906, 2nd ed: Leon ed. 1975(GR).

See also: Edelstein E & L, Asklepius. A collection and interpretation of the testimonies,

Baltimore, 1945.

3

Apollodoros, Mythologia, III, 118-120. See also: Hesiodos [Hesiod]*, Apospasmata,

Hoiai, 18 (51) **

4

Chatzicocoli - Syrakou S, Syrakoy AC, The Birth of the Healing Hospital in Ancient

Greece, 2004 International Conference and Exhibition on Health Facility PDC,

ASHE, American Hospital Association, Tampa, Florida, USA, March 15-17, 2004.

Pub. PDC 2004 Resource Manual, pp. 303-306.

5

Homeros [Homer]*, Ilias, B 731, D 194, L 518, etc. **

6

Chatzicocoli-Syrakou S, Syrakoy C, Asklepieian Ideas Supporting Contemporary

‘Holistic’ Healthcare Design, Chapter for Architecture, IHF Pan Regional Conference.

Bahrain, 6-8 November 2000

7

Marketos S, Illustrated History of Medicine, Zeta Med Ed., 2000 (GR).

8

Chatzicocoli-Syrakou S, Syrakou C, Syrakos T, The Hellenic Mythology. A Source of

Origin Research for the Philosophical and Ideological Foundations in Health Care,

Human Centred Design for Health Care Buildings, International Conference and

Workshop. 28-30 August 1997. Trondheim, Norway. Proceedings, Sintef, pp 107-

111.

9

Miller TS, The Birth of the Hospital in the Byzantine Empire, The Johns Hopkins

University Press, Greek ed: Trans. Kelermenos N, Hiera Metropolis of Thebes and

Levadia, 1998.

10

Georgakopoulos K, ‘Ancient Greek Physicians’, Iaso, 1998, pp 481-484 (GR).

11

Rutkow IM, Surgery. An Illustrated History, Mosby, 1993, pp 45-52.

12

Anapliotou-Vasaiou E, International standards in Health and National Systems, Athens,

p. 86 (GR).

13

National Statistical Service of Greece (NSSGr), Social Welfare and Health Statistics,

Athens, 2001, p.7.

14

Platon [Plato]*, Symposion [Symposium]*, 214b. **

15

NSSGr, Social Welfare and Health Statistics, Athens, 2001.

16

NSSGr, Greece through numbers, 2002, p. 18.

17

NSSGr, Statistical Yearbook of Greece, Athens 2002, p. 45.

18

Chatzicocoli-Syrakou S, ‘Healthcare in Greece’, Siokis Medical Editions, (to be

published).

*The terms in brackets [ ] state the Latinised or English version of the presiding

Greek term.

**The ancient texts are available in several editions in Greece e.g.: Prof. G.

Mistriotou, Athens 1880, 1895. Papyros, 1957, 1959. Zacharopoulos, 1939-1956.

Kaktos, 1993, 1994.


POLICY: POPULATION HEALTH

Population health in

Europe: how much is

attributable to health care?

ELLEN NOLTE

LECTURER IN PUBLIC HEALTH, LONDON SCHOOL OF HYGIENE & TROPICAL MEDICINE AND

RESEARCH FELLOW, EUROPEAN OBSERVATORY

MARTIN MCKEE

PROFESSOR OF PUBLIC HEALTH, LONDON SCHOOL OF HYGIENE & TROPICAL MEDICINE AND

RESEARCH DIRECTOR, EUROPEAN OBSERVATORY

Abstract

Does health care save lives? Commentators such as McKeown and Illich, 1,2 writing in the 1960s, argued that it

contributed very little to population health, and might even be harmful. However, they were writing about a period

when health care had relatively little to offer compared to today. More recent reviews of the contribution of health

care to health have led to a consensus that McKeown was correct to the extent that ‘curative medical measures

played little role in mortality decline prior to mid-20th century’. 3 But the rapidly changing scope and nature of health

care means it cannot be assumed that this is still the case. Thus, several writers have described often quite

substantial improvements in death rates from conditions for which effective interventions have been introduced. 4

Yet the debate continues, with some arguing that health care is making an increasingly important impact on overall

levels of health while others contend that it is in the realm of broader policies, such as education, transport and

housing that we should look to for future advances in health. Inevitably, this is to a considerable extent a false

dichotomy. Both are important. But how much does health care contribute to population health?

Voir page 40 le résumé en français. En la página 41 figura un resumen en español.

One way of thinking about this question is to look at

deaths that should not occur in the presence of

effective and timely health care. 5 This has given rise

to the development of a variety of terms including ‘avoidable

mortality’ and ‘mortality amenable to medical/health

care’. 4,6,7 However, much of this work was undertaken in the

1980s and early 1990s and it has received relatively little

attention more recently. Indeed, as the World Health Report

2000 shows, 8 the concept has been overlooked in some

influential recent studies. Furthermore, health care has

advanced considerably in the intervening period. Another

reason for revisiting this issue is that ‘avoidable’ deaths were

often limited to those under, for example, the age of 65, a

figure that seems inappropriately low in the light of life

expectancies that are now about 80 years in many countries.

So does ‘avoidable’ mortality still offer a means of assessing

health system performance and is the list of causes of death

previously deemed to be avoidable still valid?

Revisiting the concept of ‘avoidable mortality’

In a recent study we have undertaken a systematic review

tracing the evolution of the concept of ‘avoidable’ mortality

from its inception in the 1970s, subjecting it to a detailed

methodological critique and looking at how it has changed

over time. 9 To help future researchers we have produced a

comprehensive, annotated review of the work that has been

undertaken worldwide so far. Our review has shown that

‘avoidable’ mortality was never intended to be more than an

indicator of potential weaknesses in health care that can

then be investigated in more depth. We describe examples

of where this approach has been successful, drawing

attention to problems that might otherwise have been

missed.

In contrast, many of the critics of ‘avoidable’ mortality, or

more specifically, mortality amenable to health care

(amenable mortality), have asked that it do something it was

not intended to do, to be a definitive evaluation of the

effectiveness of health care. Thus, it is not surprising that

studies seeking to link amenable mortality with health care

resources have failed to do so, especially when undertaken

within countries, although it is notable that where gross

differences exist, as between western and eastern Europe,

the gap in amenable mortality is especially high. For these

reasons, it seems justifiable to extend the extensive body of

research that has already been undertaken to look at

‘avoidable’ mortality, updating the list of conditions

12 | World Hospitals and Health Services | Vol. 40 No. 3


POLICY: POPULATION HEALTH

(a) between 1980 and 1998

(b) contribution of amenable mortality to changes

Portugal

Austria

Finland

Germany West

France

Italy

UK

Denmark

Spain

Greece

Netherlands

Sweden

60 65 70

Portugal

Austria

Finland

Germany West

France

Italy

UK

Denmark

Spain

Greece

Netherlands

Sweden

-50 -25 0 25 50 75

Life expectancy in years

Percentage contribution of amenable mortality

LE 1980 1980-89 1989-98

1980-89 1990-98

Figure 1: Changes in male life expedancy (0-75) in selected EU countries

included to reflect the changing scope of health care and

extending the age limit to reflect increasing expectation of

life. However, it must be recognised that the concept of

‘avoidable’ mortality does have important limitations,

relating to comparability of data, attribution of causes, and

coverage of the range of health outcomes.

Comparisons of health system performance are now firmly

on the international policy agenda, especially since the

publication of the World Health Report 2000. It is our view

that incorporating the concept of ‘mortality amenable to

medical care’ into the methodology used to generate the

rankings of health systems in that report would be an

advance on the current methodology used. For example, we

have shown how, among OECD countries, this would lead

to different rankings from those based on overall disability

adjusted life expectancy used in the WHO current

rankings. 10

However, any approach based on aggregate data would

not address one of the major criticisms of such comparisons,

that they do not indicate what needs to be done when faced

with evidence of sub-optimal performance. This requires a

more detailed analysis and in our study we propose a new

method, in which analyses of amenable mortality identify

areas of potential concern that are then examined in more

detail by studying the processes and outcomes of care for

tracer conditions, selected on the basis of their ability to

assess a wide range of health system components.

Amenable mortality in the European Union

Our study builds on what has been done before, updating

the list of conditions considered amenable to health care in

the light of advances in medical knowledge and technology

and extending the age limit to age 75 to reflect increasing

expectation of life. We applied this revised concept to

routinely available data from selected countries in the

European Union to investigate the potential impact of

health care on changing life expectancy and mortality in the

1980s and 1990s.

The results show that all European countries have

experienced increases in life expectancy between birth and

age 75 since 1980 (see Figure 1a), when deaths that could

be prevented by timely and effective care were still relatively

common in many countries (see Figure 2). The pace of

change differed over time and between countries.

Reductions in amenable mortality made substantial positive

contributions in the 1980s in all countries except in Italy

(men) (see Figure 1b). The largest contribution was from

falling infant mortality but in some countries reductions in

deaths among the middle aged was equally or even more

important. These countries were Denmark, The

Netherlands, the United Kingdom, France (for men) and

Sweden (for women).

In many countries the pace of improvement slowed in the

1990s although not in Greece, Italy and Portugal, a finding

that would imply a continued catching up in the southern

European countries.

By the 1990s, differences in amenable mortality in the

European Union had narrowed (see Figure 2) although

standardized death rates from amenable causes among

Portuguese men remained three times higher than those

among Swedish men. Differences among women are less

pronounced; but again, in 1998, amenable mortality was

highest in Portugal (96.9/100,000) and lowest in Sweden

(51.9/100,000).

Vol. 40 No. 3 | World Hospitals and Health Services | 13


POLICY: POPULATION HEALTH

250

200

MEN 1980 1998

150

100

50

0

200

Portugal

Austria

Finland

Germany West

France

Italy

UK

Denmark

Spain

Greece

Netherlands

Sweden

150

WOMEN 1980 1998

100

50

0

Portugal

Austria

Finland

Germany West

France

Italy

UK

Denmark

Spain

Greece

Netherlands

Sweden

Figure 2: Age- standardized death rates (0-74) from causes amenable to health care in

selected EU countries, 1980 and 1998

These findings lend further support to the notion that

improvements in access to effective health care have had a

measurable impact in many countries during the 1980s and

1990s, in particular through reductions in infant mortality

and in deaths among the middle aged and elderly, especially

women. However, the gains achieved, to a considerable

extent, have reflected each country’s starting point. Thus,

those countries where infant mortality was relatively high at

the beginning of the 1980s, and which had the greatest

scope for improvement, such as Greece and Portugal,

unsurprisingly saw the greatest reductions in amenable

mortality in infancy. In contrast, in countries with infant

mortality rates that had already reached very low rates by the

beginning of the 1990s, such as Sweden, the scope for

further improvement was small.

Similarly, the scope for improvement in amenable deaths

in adulthood was greatest in those countries where initial

rates were highest. The corollary of this is that as rates fall in

all countries, the extent of variation decreases. As a

consequence, it seems likely that, in the 21st Century, the

ability to compare health system performance using

mortality data at the aggregate level is likely to be limited,

simply because the differences will be relatively small. This

does not, however, mean that there is not scope for analyses

that use amenable mortality rates to screen for potential

problems that can then be explored in more depth. It also

does not exclude the use of amenable mortality to gain new

insights into inequalities in access to care. ❑

References

1.

McKeown T. The Role of Medicine:Dream, Mirage or Nemesis? Oxford:

Blackwell, 1979.

2.

Illich I. Limits to Medicine. London: Marion Boyars, 1976.

3.

Colgrove J. The McKeown thesis: a historical controversy and its enduring

influence. Am J Public Health 2002;92:725–29.

4.

Mackenbach J.P., Looman C.W,N., Kunst A.E., Habbema J.F.D., van der Maas P.J.

Post-1950 mortality trends and medical care: gains in life expectancy due to

declines in mortality from conditions amenable to medical interventions in The

Netherlands. Soc Sci Med 1988;27:889–94.

5.

Rutstein D.D., Berenberg W., Chalmers T.C., Child C.G., Fishman A.P., Perrin

E.B. Measuring the quality of medical care. N Engl J Med 1976;294:582–88.

6.

Charlton J.R.H., Hartley R.M., Silver R., Holland W.W. Geographical variation in

mortality from conditions amenable to medical intervention in England and

Wales. Lancet 1983;i:691-6.

7.

Holland W.W. The ‘avoidable death’ guide to Europe. Health Policy

1986;6:115-7.

8.

World Health Organization. The World Health Report 2000. Health Systems:

Improving Performance. Geneva: WHO, 2000.

9.

Nolte E., McKee M. Does Health Care Save Lives? Avoidable Mortality Revisited.

London: The Nuffield Trust, (in press).

10.

Nolte E, McKee M. Measuring the health of nations: analysis of mortality

amenable to health care. BMJ 2003;327:1129–32.

14 | World Hospitals and Health Services | Vol. 40 No. 3


MANAGEMENT: GOVERNANCE

Health care governance

in the UK National

Health Service

JO H WILSON MSC (DIST), PG DIP, BSC (HONS), RGN, RM,

RSCN, FCIPD, AIRM, MIHM, MIOD,

LECTURER PRACTITIONER, NOTTINGHAM TRENT UNIVERSITY

Abstract

The NHS Plan sets out a challenging agenda for modernising the UK National Health Service (NHS), governing the

organisation's performance and improving and extending service provision. Good health care governance is an

essential prerequisite for all modernisation effort. This article will explore the responsibilities and implications for

health care boards, managers and clinical staff in providing assurances for health care governance.

Health care organisation directors, executive and non-executive, all share responsibility for the direction and

control of the organisation. They are required to act in the best interest of the patients, staff and the general public

and have statutory obligations to provide safe systems of work under the Health and Safety Regulations. Each

director has a role in ensuring openness, being honest and acting with integrity, taking responsibility for their own

personal learning and development, constructively challenge and develop strategy and ensuring the probity of the

organisation’s activities.

Voir page 40 le résumé en français. En la página 41 figura un resumen en español.

Senior health care managers have collective

responsibility for strategic planning, financial

management systems, risk management, clinical

governance, ensuring that the organisation has the necessary

capacity and capability to meet its objectives and for

reviewing the organisation’s performance. Senior managers

cannot micromanage and remain strategic so it is up to them

to ensure that they have processes, proper systems and

controls in place with an accountability framework to work

through others to meet the governance agenda and help the

organisation to meet its objectives.

The ever changing agenda for the delivery of high quality

patient care outcomes is being increasing assessed,

monitored and evaluating to increase the public confidence

in the service provision. Health care professionals are

striving towards meeting the challenges of regulatory

compliance, patient involvement in service decision making,

the establishment of Patient and Public Involvement Forums

(PPIF), improved patient safety and involvement of all staff

in systems analysis to find root causes of ‘near misses’ and

adverse health care events to ensure lessons can be learned

and practices changed accordingly. The focus within health

care is for risk management to be everybody's role and

responsibility in being more proactive than reactive.

Healthcare Trust Boards must be provided with assurances

that these challenges are being met and that all-key staff have

the skills, capabilities, leadership, coordination and

processes to stay abreast of these changes.

Health care organisational board responsibilities

Boards of directors within health care organisations have a

duty to ensure that the interests and well being of patients,

staff and visitors are being served through a strong system of

governance. They can only fulfil their responsibilities if they

have a sound understanding of the principal risks facing the

organisations. Health care boards are responsible for

ensuring that there are proper and independent assurances

given to them on the soundness and effectiveness of systems

and processes in place for meeting their objectives and

delivering appropriate outcomes. The whole process is

integral not only to the effective stewardship of public

money but to the complete assurance process that supports

the delivery of high quality health care. Boards have a key

role to play in modernising health care through ensuring

that their organisation is properly change managed, have the

right culture and staff feel accountable to meeting their

agenda for improving the performance.

Health care organisation boards should fully debate and

map the connections linking their organisational objectives,

risk, clinical governance and the range and effectiveness of

existing assurance reporting. Constructing an assurance

framework will effectively define the organisation’s approach

to reasonable assurance. The assurance framework provides

health care organisations with a simple but comprehensive

Vol. 40 No. 3 | WORLD World Hospitals hospitals and Health health Services services | 15 13


MANAGEMENT: GOVERNANCE

Health care Board Assurance

CEO

External

Audit

Audit

Committee

Independent Assurance

BOARD

‘Top-down’ population

Priority Setting & Assurance

(Clinical/Management)

6-12 current issues

Governance

Committee

Internal

Audit

RISK REGISTER

‘Bottom-up’ population

75-200 principal risks

Source: Marsh Ltd

Figure 1: The assurance framework for health care board assurance

method for the effective and focused management of the

principal risks to meeting their objectives.

The interests of patients are best served by strong systems

of good health care governance where health care boards can

enhance the care and wellbeing of patients and the staff who

look after them. An organisation that is not properly

governed and which is out of control will result in staff

wasting their time fire-fighting with inadequate plans and

resources, staff becoming stressed and demotivated with

wasted and inappropriate use of valuable resources. The

outcomes over time will suffer with the effect that the care

given to patients and their families inevitably causing

suffering and increasing complaints and clinical negligence

claims.

What health care organisational boards must do

In order to allow the health care board to strategically

manage (see Figure 1) through an assurance framework and

have the appropriate processes and systems in place for

senior managers to coordinate, control and have an effective

performance monitoring framework in place, the following

eight key tasks must be in place:

➜ Establishment of strategic and directorate principal

objectives which are crucial to the Trust’s organisational

goals and targets.

➜ Identification of the principal risks that may threaten

the achievement of the board’'s objectives these are

typically in the range of 75-200 with a prioritised 6-12

current issues which are on the board agenda.

➜ Identification and evaluation of the design of the key

controls intended to manage these principal risks which

are underpinned by the risk management and controls

assurance standards.

➜ Setting out the arrangements for obtaining regular

assurances on the effectiveness of the key controls for all

areas of principal risks.

➜ Evaluation of the assurances with appropriate

questioning and review of all areas of principal risk.

➜ Clear identification and analysis of positive assurances

and areas where there are gaps in controls and/or

assurance.

➜ Put in place plans to take corrective action where gaps

have been identified in relation to the principal risks.

➜ Maintaining dynamic risk management arrangements

within the Trust including monthly review of the risk

register and action plans for improvements in health

care governance.


Constructing an assurance

framework will effectively

define the organisation’s

approach to reasonable

assurance.


16 | World Hospitals and Health Services | Vol. 40 No. 3


MANAGEMENT: GOVERNANCE

Until recently, relatively little

attention has been given in

any country to trying to identify

the sources of risk in health

care and to finding ways to

reduce it in a planned and

organised way.



The assurance framework and risk register will form the

key documents for health care boards to implement,

monitor and control health care governance. This will link

into the financial management systems, all of which will

need to be examined regularly for their robustness in

financial and assurance planning and controls. These

assurances will provide health care boards with the

reassurances that they can provide and commission high

quality patient services with the guarantee of efficiency,

effectiveness and good clinical governance controls.

What does this mean to health care providers

The management of health care is a risky business as patient

care is delivered in a highly complex and pressured

environment, which requires good controls of processes and

systems to reduce the potential for clinical errors. Health

care is delivered to increasingly sick, vulnerable

people, with increasing technologies and changes in

interventions/treatment management. More than almost any

other industry in which risks occur, health care is highly

reliant on people, more often than machines, to make

decisions, exercise judgements and execute the techniques

which will determine the patient outcomes.

Until recently, relatively little attention has been given in

any country to trying to identify the sources of risk in health

care and to finding ways to reduce it in a planned and

organised way. A much higher level of error has been

tolerated in health care than has been acceptable in other

sectors. This is now changing and a much higher priority

has to be given to enhancing patient safety by being more

proactive in risk identification and management and having

systematic learning from what does go wrong.

All health care providers must work in collaborative way to

provide integrated patient-centred care through health care

governance and strategic and local controls. All staff have a

part to play in ensuring they manage risks by undertaking

individual patient and directorate risk reviews,

demonstrating continuous quality improvements and

maintaining safe systems of work for patients, colleagues and

visitors. Staff are accountable and responsible for the care

they deliver and must localise and demonstrate risk and

clinical governance agendas and provide information and

assurances that they are doing their reasonable best to the

board assurance programme.

Patient safety and welfare is a key component of health

care governance and in order to change the ingrained culture

and attitudes risk management processes and developments

must be firmly on the health care board agendas.

Mechanisms have also been put in place that will increase

lay involvement and internal and external reviews of service

provision. These include the Patient Advice and Liaison

Services (PALS), patient forums, overview and scrutiny

committees (OSCs) and at the centre, the Commission for

Patient and Public Involvement in Health (CPPIH). Matters

of health care governance concerns can be referred to these

patient/public forums and to the Commission for Healthcare

Audit and Inspection (CHAI), the National Patient Safety

Agency (NPSA) or to any other person or body the forums

deem appropriate including the media. The new systems of

Patient and Public Involvement (PPI) in the NHS hold a real

potential to effect positive changes and to democratise the

NHS in improved risk management, health care quality

policies and practices and thereby improve health care

governance.

Conclusion

Convergence of all systems of internal and external controls

which will demonstrate that health care boards are doing

their reasonable best to meet governance controls and

should form the health care governance assurance

framework. This system will bring together the coordination

and evaluation of the work of auditors, inspectors and

reviewers of good operational, corporate, educational and

financial risks which will bring increased benefits to both the

organisation and all of the review bodies. It will help

minimise the burden on the Trust by reducing overlaps and

allow potential gaps in assurance to be identified, assessed,

actioned locally and corporately and implemented and

evaluated to meet healthcare governance.

Internationally, health care risk and governance should be

given top priority by doctors, nurses, therapists, managers

and all staff to improve the quality of care to patients and

improve the risk adjusted outcomes. These priorities and

outcomes are crucial to the organisation in providing real

time evidence that they are meeting the corporate

requirements and safe systems of health care governance. ❑

Vol. 40 No. 3 | WORLD World Hospitals hospitals and health Health services Services | 17 13


SPECIAL FEATURE: INTERVIEW WITH RICHARD GRANGER

The National Programme

for IT in the UK National

Health Service

AN INTERVIEW WITH RICHARD GRANGER

DIRECTOR GENERAL, NHS IT

Richard Granger is the Director General of IT for

the NHS and is in charge of implementing the UK

national IT programme for the health service.

Prior to taking up this post in October 2002, he was a

partner at Deloitte Consulting. Before taking on the

challenge of modernising IT for the NHS he worked on

the successful procurement and delivery of a number of

large scale IT programmes, the most recent of which was

the Congestion Charging Scheme for London.

WHHS: What do you consider to be the key successes

in the procurement programme and why?

RG: This is an exciting and ground-breaking moment for the

National Health Service (NHS) as it takes the first steps

towards offering a truly 21st century service to its patients

and staff.

As the National Programme for IT in the NHS moves into

its implementation phase, systems and services are being

installed that will revolutionise the way the NHS works in

England, bringing benefits for patients and staff alike.

The world’s largest civil IT project, the National

Programme is aimed firmly at helping to deliver the vision of

‘a service designed around the patient’, as outlined in the

UK Government’s paper Delivering the NHS Plan. It is crucial

to the modernisation of the NHS. It is essential if the

increasing demand for care is to be met.

The procurement process itself set new standards, creating

a blueprint for others in the UK and beyond.

It was fast because so much of the modernisation of the

NHS depends on the delivery of excellent new IT systems

and services. It was different - because the programme has

contracted with suppliers who must only deploy solutions

for the NHS which have been proven to be safe, resilient and

fully functional.

It was complex because the programme brings together

different suppliers and different solutions which must be

integrated.

It was successful not least because of the major savings

Contracts Awarded

Choose & Book – Atos Origin – £65m

NHS Care Records Patient Record – Spine – BT - £620m

NHS Care Records Service – Local Service Providers:

➜ London – BT - £996m

➜ North East and Yorkshire – Accenture - £1099m

➜ North West and West Midlands – CSC - £973m

➜ Eastern England and East Midlands – Accenture – £934m

➜ Southern England – Fujitsu Alliance - £896m

New NHS Network – BT - £530m

Figure 1: NHS contracts awarded

achieved on hardware and software, compared to individual

procurements by trusts or strategic health authorities.

Contracts worth over £6bn (see Figure 1) have been

awarded to deliver the NHS Care Records Service, Choose

and Book (Electronic Booking Service) and the National

Network (N3).

Suppliers are now working in partnership with the

National Programme and the NHS to achieve a successful

implementation. At a local level, NHS IT professionals in

each of the five geographic clusters of strategic health

authorities are already working with local service providers

to ensure that local systems are compliant with national

standards and will facilitate data flow between local and

national systems.

WHHS: What is happening around implementation?

RG: As the programme moves into implementation,

engagement is increasing, both with the IT community and

with end users – NHS clinicians and frontline staff.

The recently established Care Record Development Board

(CRDB) will work on defining processes within care and

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SPECIAL FEATURE: INTERVIEW WITH RICHARD GRANGER

across the care boundaries that will be enabled through the

use of IT.

The CRDB will provide clinical and patient input into the

development of IT by the National Programme, bringing

together patients, public, social and health care

professionals in one body.

CRDB action teams will be commissioned to carry out

specific pieces of work making their recommendations to

the board. For example, an action team may be required to

address and define the care processes involved in electronic

prescribing. Each action team will be assembled based on

the expertise required for the particular work area.

The action team will consult with a wider network of

stakeholders including NHS bodies, patient and user

organisations and health and social care professions to

enable them to make their recommendations to the board.

These recommendations will inform the way that the IT is

developed to support improved patient care.

The work of these action teams will be based on

the priorities of the National Programme ensuring

recommendations are given at the appropriate time to

inform the development of the NHS Care Records Service.

Because of the sheer scale and complexity of the new IT

systems and services being delivered by the National

Programme across England, and the need for national and

local expertise, implementation through each cluster will be

phased, incremental and informed by the experiences of

early adopters.

It must be remembered that nothing on this scale has ever

been attempted before. It is an ambitious programme and,

although frontline NHS staff are anxious for delivery, the

National Programme, its suppliers and its NHS development

partners want to ensure that systems and services provide

appropriate clinical functionality and are tailored to local

needs. This will ensure that benefits for staff and patients

can be realised.

Implementation schedules will reflect local needs and

readiness. Basic processes that have underpinned working

for many years will change. There is much work to be done

in managing change as well as deploying new technology. To

be successful, process redesign must have input from

technologists, clinicians and managers. NHS IT and

informatics staff therefore have a major role to play.

WHHS: How do you plan to get the Clinicians on

board with your reforms?

RG: Deputy Chief Medical Officer Aidan Halligan, who was

appointed Joint Director General and senior responsible

owner for the National Programme in March, is now

spearheading clinical engagement and benefits realisation.

As part of increased local engagement, Aidan’s first few

months in post have included a series of roadshows, visiting

trusts and listening to local people.

Other recent moves have seen the programme launching

the Frontline Support Academy. This will utilise groundbreaking

simulators to mock-up realistic environments like

hospital wards and GPs’ surgeries where clinicians will learn

how best to use new systems, with actors playing the role of

patients.

Work continues apace with engagement, process redesign

and IT deployment. We all acknowledge that a modern

NHS cannot work effectively with a disparate collection of

paper and organisation-based information systems. Together

we can truly build a patient-centred NHS which benefits all

those who work in it and those who are cared for by it.

Creating a patient-focused NHS and empowering

individuals to make informed choices over their health and

care are cornerstones of the Government’s vision for the

NHS in the 21st century. Modern information and

communications technologies are crucial to achieving this

vision. The National Programme for IT has a key role in

helping to transform the vision into reality.

WHHS: What do you see as the key milestones?

RG: By 2010, the National Programme is tasked with

creating:

➜ a live, interactive electronic NHS Care Records Service to

ensure the right information about patients is available to

the right people whenever and wherever it is required,

including static and moving digital images, such as x-rays

and scans;

➜ an electronic booking service – Choose and Book – to

make it easier and faster for patients and their GPs to

book convenient appointments for patients;

➜ a system for the electronic transmission of prescriptions

from prescribers to pharmacies, to improve safety and

convenience for patients;

➜ a national network to provide modern IT infrastructure to

meet NHS needs now and into the future.

WHHS: What do you think patients will notice most

about the new reforms?

RG: This summer, patients in London and the North East

began to experience the first changes to be brought about by

NPfIT. Choose and Book, the National Programme’s

electronic booking service, is commencing its roll out in

these areas and will be delivered throughout England by the

end of 2005.

This will enable patients to book outpatient appointments

from their GP’s surgery, selecting a convenient appointment

time, date and hospital for treatment from a choice of those

available. This puts the patient rather than the hospital at

the centre of the booking process.

It enables patients to fit their appointment around their

life, not vice versa. And, if patients prefer to consult with

family, carers or colleagues before booking, they can choose

to phone a call centre later to make their appointment.

Underpinning the implementation of Choose and Book

and the other services to be delivered by the National

Programme, is the NHS’s National Network – N3. N3 will

eventually connect all 18,000 NHS locations and sites,

creating a single, secure, national system.

This will allow more than 100,000 doctors, 380,000

nurses and 50,000 other health professionals to send and

receive information – including voice and video, e-mails,

medical information and test results – in a secure manner.

The new network will facilitate the provision of the 24

hour a day, seven day a week, live, interactive NHS Care

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SPECIAL FEATURE: INTERVIEW WITH RICHARD GRANGER

Records Service (NHS CRS). By 2007 all England’s 50

million plus patients will have an electronic NHS Care

Record.

Detailed information will be stored locally, where the

majority of care is provided. In addition, a summary of a

patient’s essential health information will be accessible

whenever and wherever a patient seeks NHS care in

England, whether that treatment is planned or unexpected.

This will improve the speed, effectiveness and safety of

diagnosis and treatment. Authorised clinicians will have

secure access to potentially lifesaving information, such as

patient allergies, current medication, outcomes from

operations and test results.

In time, patients themselves will have easy, but secure,

access to their record, via the secure HealthSpace website,

which will also provide tools and information to help people

look after their own health.

In the future, patients will be able to use HealthSpace to

express their treatment preferences, organ donation wishes

and needs, such as wheelchair access or translation services.

Patients will have to weigh up the benefits of information

sharing between health organisations against the risks. A

major public information campaign is planned to ensure that

they are able to make an informed decision about whether to

opt out of allowing their electronic record to be shared with

health professionals involved in their care. Once the new

systems are complete, patients will also be able to request

that certain parts of their record are only shared in particular

circumstances, such as an emergency.

Whilst there are issues and risks with the new technology

that must be identified and minimised, there are huge

potential benefits. Patients will be able to gain a speedier

diagnosis when a specialist opinion is required. New Picture

Archiving and Communications Systems mean x-rays and

scans will be stored digitally on computer so they can be

sent instantly from a hospital where they were taken to a

specialist who may be many miles away.

In the future, patients in hospital could also begin to see

clinicians using wireless technology to call up their health

record at the bedside. As the patient’s NHS Care Record will

be automatically updated, GPs will be aware of all the

relevant details when a patient makes a follow up visit to the

surgery.

Prescribing will be safer and more convenient for patients

by the end of 2007 when the Electronic Transmission of

Prescriptions (ETP) is fully implemented. It will not always

be necessary to visit a GP’s surgery to collect repeat

prescriptions, as they will be sent electronically to

community pharmacists.

Safety will also be improved as, in most cases, prescription

information will not be handwritten or typed more than

once. ETP will, in addition, ensure that information about

medicines that have been prescribed and dispensed are

automatically added to a person’s NHS Care Record. This

will lead to better patient care as authorised clinicians and

associated health care professionals will have more

information about the medicine someone is taking.

In rural areas, telemedicine could in future take away the

need for patients to travel miles to hospital for a

consultation. Instead they could visit their GP’s surgery and

have the consultation via a video link with a specialist. In

some places this already happens.

The new technology could also assist patients with

chronic diseases, such as diabetes, to play a more active role

in the management of their condition. They could in future,

for example, ask for online information about managing

diabetes and store care plans and online diabetes

management courses. They could use HealthSpace to log

their weight and blood sugar level readings and organise

email reminders to book appointments to check their

eyesight.

Everyone providing care will have the essential

information they need to make safe decisions. Treatment

and prescribing errors that can harm patients will be

reduced. And patients will also have easier access to their

medical information and be able to play a more proactive

part in their own health and care.

WHHS: How does the UK national plan differ from

attempts by other countries?

RG: England is leading the world in developing an electronic

care record for every single patient – nothing has ever been

attempted anywhere else in the world on this scale so we are

leading from the front.

The National Programme for IT also has a larger functional

scope than other national strategies, seeking to cover the

whole range of services across primary and secondary care.

There is a strong history of electronic patient record

development across Europe over the years – to which the

NHS has made significant contributions – but they are

usually more on an institutional or regional basis, rather than

national.

It is testament to the exiting progress we are making that

other European countries such as France and Sweden have

been taking a very close interest in what the National

Programme is doing.

WHHS: What lessons can other countries learn from

your experiences?

RG: We have been able to start from a very solid base of ICT

experience, expertise and knowledge built up over many

years. The National Programme did not start from scratch,

but drew heavily on previous IT strategies dating back to

1992.

What the National Programme has done is to accelerate

the process, to have a clear focus on what needs to be done

and how to achieve it quickly, efficiently and cost effectively.

Do not underestimate the amount of effort required, it is

a huge task and one which can only be driven through with

hard work, commitment, enthusiasm and a passion to

succeed.

We have already begun to see the fruition of our

endeavours with the successful launch of Choose and Book

and within a short space of time many more patients and

NHS staff will see the benefits of what we are aiming to

achieve. ❑

22 | World Hospitals and Health Services | Vol. 40 No. 3


INFRASTRUCTURE: DESIGN

Planning and design for

a culture of safety in

Thessaloniki’s Hospitals

DR SOPHIA CHATZICOCOLI-SYRAKOU (LEFT)

ARCHITECT AND MEMBER, THE INTERNATIONAL UNION OF

ARCHITECTS – PUBLIC HEALTH GROUP

ATHENA-CHRISTINA SYRAKOY (RIGHT)

ARCHITECT

Abstract

Thessaloniki is the second capital of Greece, located in the region of Macedonia, in the northern part of the Greek

mainland. After the opening of the boarders of the former ‘Eastern Block’ countries and following their general

open-policy to the European Union, Thessaloniki became an important part of the Balkans Initiative, aiming at

attracting patients from abroad to Greece. Thus, some of the most modern hospitals in Greece are near

Thessaloniki. Patient safety forms an important issue of the policy attracting patients.

With this paper an attempt will be made to examine the characteristics of a culture of safety embodied in the

planning and design of two of Thessaloniki's hospitals. These characteristics are to be found in the health care

environment of the present clinical processes, on both, a quantitative and a qualitative basis, and finally,

suggestions for further development

Voir page 40 le résumé en français. En la página 41 figura un resumen en español.

Thessaloniki was founded by King Cassandros of

Macedonia in 315 BC and named after his wife. King

Cassandros’ wife, Thessaloniki, was the daughter of

the Great Macedonian King Philippos II and the sister of

Megas Alexandros (Alexander the Great). King Philippos II

B’ named his daughter, Thessaloniki (Thessalo+niki =

Victory against Thessaly), after his victory against the

Thessalians, the inhabitants of the neighbouring Hellenic

region of Thessaly.

After the opening of the borders of the former ‘Eastern

Block’ countries and their general open-policy to the

European Union, Thessaloniki became an important part of

the Balkans Initiative, aiming at attracting patients from

abroad to Greece. Therefore, some of the most modern

hospitals in Greece are near Thessaloniki, including the

recently constructed Papageorgiou, a public 600-bed general

hospital (architects: AN Tompazis, K Kyriakidis & Assoc.), as

well as the new Diabalkaniko’ (Interbalkan) private hospital

facility (architects Chasapi A, Sargentis A & Assoc.), located

next to the international airport, where many foreign

patients are being treated.

Patient safety

Patient safety forms an important issue in attracting patients.

However that is not an easy task as patient safety is

threatened globally by several factors, such as:

➜ terrorist actions;

➜ natural resources pollution;

➜ nosocomial or hospital acquired infections.

Trying to examine briefly the above factors in

Thessaloniki’s hospitals we have the following comments to

make.

Terrorist actions

Greece is a relatively safe country, at the moment, as it is:

➜ a small country;

➜ has a low profile foreign policy;

➜ a long tradition of democracy;

➜ a strong belief in social justice.

For the above reasons Greece, in general, and

Thessaloniki, in particular, do not seem to be strong targets

for terrorist actions.

Natural resources pollution

Greece is a favourite tourist destination mainly due to:

➜ the wonderful natural resources;

➜ the nice weather;

Vol. 40 No. 3 | World Hospitals and Health Services | 23


INFRASTRUCTURE: DESIGN

➜ the lack of heavily polluting industries.

For the above reasons the natural resources pollution does

not appear as a serious threat to patient safety in Greece and,

consequently, to Thessaloniki’s Hospitals in particular.

Nosocomial infections

The term ‘nosocomial’ derives from the Greek word

Nosocomeion for Hospital, a term combined by the Greek

words nosos and comeo meaning ‘illness’ and ‘care’

respectively. Nosocomial or hospital acquired infections are

one of the latest and of the most difficult international

challenges facing hospital planning and design.

International reports have stated that approximately one

in ten hospital patients, at any one time, acquire an infection

in hospital. Additionally, other reports insist that on average,

nosocomial airborne infections cause financial losses in the

European Union of over €7-8m for every 1,000 beds.

Despite the medical, scientific and technological

developments, or rather because of those, there has lately

been an increase in such infections. The main causes around

the world of this re-emerging problem seems to be:

➜ the growth in the number of more severely ill patients in

hospitals (aged, immunosupressed, etc);

➜ the increasingly polluted natural environment has

weakened patients’ immune systems;

➜ the heavy and inappropriate use of advanced generation

drugs, which caused the development of bacteria

resistant to antibiotics.

The evolution of bacteria resistant to antibiotics has been

one of the most serious problems facing the global health

care community.

Of these pathogens the most prevalent seems to be:

➜ Methicillin Resistant Staphylococcus Aureus – MRSA;

➜ Vancomycin Resistant Enterococci – VRE.

There have been several reports of outbreaks concerning

infections caused by MRSA and VRE alone, which account

for nearly 10% of the workload of the bacteriology labs in

busy hospitals.

The question then emerges: how can the planning and

design of the health care environment and facilities

contribute to the nosocomial infection control?

Approaching the answer, we could refer to the possible

alternatives offered by the planning and design of the health

care facilities, of eliminating the basic conditions for the

environmental transmission of the pathogens. These basic

conditions for the transmission of pathogens are recognised

to be the following:

➜ the presence of the pathogen;

➜ sufficient virulence and relatively high concentration of

the pathogen;

➜ a mechanism of transmission from environment to host;

➜ a portal of entry;

➜ a receptive host.

The absence of any of these elements prevents

environmental transmission from occurring.

Hence, the environmental planning and design

contribution to nosocomial infection control is formed by

targeting one or more of the above basic conditions for the

transmission of pathogens. The quantitative characteristics of

a planning and design strategy for nosocomial infection

control, target mainly the first of the above elements and its

qualitative characteristics primarily the last component.

The culture of safety in Thessaloniki’s hospitals

There is an attempt to determine the characteristics of a

culture of safety, concerning the infection control

programme in Thessaloniki’s hospitals planning and design.

The quantitative characteristics

The quantitative characteristics in Thessaloniki’s hospitals

planning and design are based on the planning and design

laws and regulations aiming, intentionally or not, at

infection control issues. In official design regulations in

Greece, there are endless quantitative descriptions

concerning the various specialised hospital rooms and clinic

departments, as well as the hospital in its entirety. Those

regulations are not limited to descriptions of rooms but they

also provide diagrams and functional flows. They may also

offer a more detailed description concerning design.

The following are the diagrams of operating departments

showing flow of patients (see Figure 1), operating team, staff

and supplies following an infection control orientation by

departmental planning and a diagram showing the staff

changing accommodation (see Figure 2), where step by step

spatial procedures lead from the septic to the aseptic areas.

The qualitative characteristics

The qualitative characteristics in Thessaloniki’s hospitals

planning and design aim at the qualitative issues of the

hospital infection control programme, such as the

strengthening of the patients’ immune system, and

consequently their resistance to an infection. That is

achieved through focusing on improvements of a more

relaxed kind and with a highly aesthetic quality health care

environment based on the Greek tradition, philosophy and

mythology and mainly on the characteristics of Asklepios.

The worship of Asklepios (Asklepius or Aesclepius, etc, as

his name appeared later in the Latin language), was first

spread as that of a hero of the prehistoric era, who lived and

served as a physician, in the region of Thessalia (Thessaly)

on the central Hellenic mainland. His prehistoric existence

is linked with the Trojan War, the Argonauts and Hermes

Trismegistos. The disagreement among the historians and

archaeologists, about the chronology of the existence of

Asklepios, is connected with the long lasting debate

concerning the dating of these major events in the

prehistoric Hellenic world.

The ideas of the healing art, deriving from Asklepios’

philosophical presence, were applied in the healing

environment of Asklepieia. Asklepieia were centres of worship

for the hero, divine physician and healing god, Asklepios.

Asklepieia were the health centres of Ancient Greece and in

fact, they were the first hospitals (or, better, health care

campuses) and medical schools in Europe. Almost every

Greek city had its own Asklepieion in its centre or in its

24 | World Hospitals and Health Services | Vol. 40 No. 3


INFRASTRUCTURE: DESIGN

vicinity and some of them became famous Pan-Hellenic

healing centres and medical schools. Their name derives

from their founder Asklepios and offered therapeutic

treatment for many centuries in the then Hellenic territory,

from the Trojan War, where Asklepios’ two sons, Machaon

and Podaleirios, are mentioned by Homer, to have

participated both as physicians and leaders of the forces of

Trikki, Ithomi and Oihalia, cities of Thessaly, thoughout

Classical, Hellenistic and Roman times to the early-

Byzantine times (approximately the 6th century AD) and the

Christian era.

Asklepieia even survived, for approximately a century, after

Emperor Theodosios’ persecution of what they called the

‘idolatrous’ world, as opposed to Christianity, in 392 AD.

Emperor Theodosios was the one who abolished the

Olympic Games. Furthermore, upon his order one of the

‘seven wonders of the world’, the statue of the Olympian

Zeus in Olympia was destroyed.

Asklepieia and the qualitative characteristics

Asklepieia consisted of buildings of different and

complementary functions, avoiding complex planning and

letting nature take part in the healing process. Below we can

see, in one of the reconstructions of the Asklepieion of

Epidauros, the Tholos, which was the surgical suite

building, and the intensive therapy unit called Kataclinterio.

Both separate buildings but in close proximity, a very strong

evidence of shallow planning.

The philosophy of qualitative characteristics of Asklepieia

were expressed by and embodied mainly in the properties of

God Apollon, mythical father of Asklepios from where his

healing art mainly derived. God Apollon represented,

mythologically and philosophically, the general and abstract

idea of the divine healing powers. For example, Apollon was

the physician of the gods. That means as philosophical

characteristic of the notion of healing environment: respect

to the natural healing powers. Statues of Apollon show him

as a handsome young man with eternal youth, health and

graceful strength. He usually holds a snake, a symbol of

medicine, or lyre, a symbol of music, peace and harmony, or

even a bow and arrows, symbols of punishment to the

unfaithful.

In interpreting Apollon’s symbols, we can recognise as

health care qualitative characteristics the proposition that:

the healing environment should accommodate the medical

(health care) activities and should stress, symbolically, the

medical achievements in order to strengthen the people’s

belief in the final, positive results. The healing environment

should also be reinforced by music, creating a peaceful

atmosphere, and a sense of harmony. Finally, the

punishment to the unfaithful of the above rules should be

symbolically reminded to maintain the healing environment

conditions.

Apollon was the god of sun. He represented the life-giving

sunlight and warmth. That means as healing environment

qualitative characteristics: natural and spiritual light,

meaning good environmental conditions as well as concern

about spiritual welfare. He was also the god of natural

beauty of the countryside and its divine strengths. That also

Figure 1: Diagram of operating departments

Figure 2: Staff changing accomodation

could be regarded as a qualitative characteristic for the

healing environment: preservation of the natural beauty.

Apollon was considered to be the leader of the Nymphs,

beautiful virgins, spirits of wild forests, rivers, lakes and

mountains, who represented the natural harmony and were

often nurses of gods and heroes. He was also the leader of

the three Charities (Graces), who represented the

delightfulness of art. There could be interpreted as

qualitative characteristic proposals: the healing environment

should also show respect to the spirits of wild nature and

natural harmony (running waters, plants, etc) and moreover,

should be supported by art works, art performances and art

facilities.

The qualitative characteristics in Thessaloniki’s

hospitals

In Modern Greece, the conscious or unconscious use of

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INFRASTRUCTURE: DESIGN

Above left: A piano in the Diavalkaniko

Hospital entrance lobby

Left: Greenry at the Papageorgiou

Hospital

Above: The Diavalkasiko Hospital

qualitative characteristics for creating a healing environment,

as in Asklepieia is evident; it is seen in various

interpretations. We will notice such interpretations in the

mentioned two Thessaloniki’s hospitals, the Papageorgiou

General, State Hospital and the Diabalkaniko (Interbalkan)

Private Hospital.

The presence of nature and natural resourses

The plan of the Papageorgiou Hospital in Thessaloniki where

the abstract, embodied in the God Appolon’s properties, the

philosophical characteristic of the notion of a healing

environment: respect for the natural healing powers, is

applied with plants and court spaces that are used for the

creation of not only an immediate contact with nature, but

also for an energy efficient design. Here the tallest plants will

grow up to a grid protecting patients and staff from the strong

Greek summer sun. During the winter, their leaves will fall

off, allowing the sun to warm up the interior spaces.

At the Diabalkaniko Hospital in Thessaloniki, the

restriction of the site did not provide a clear base for the full

use of surrounding nature in the healing process. However,

internal openings with the roof natural lighting prevent the

creation of deep planning, opening the space to the eye for

the better understanding of the building.

The contribution of the arts

Considering art as a means for upgrading the health care

facilities environment, as it was also proposed by the

philosophical characteristic of the notion of a healing

environment derived from God Appolon’s properties, seems

simple and obvious.

The visual arts contribution in Papageorgiou Hospital,

includes painting and metal net structures perceived as

modern sculptures

However, in contemporary health care environment, the

visual arts are given the highest priority while some other art

expressions have been occasionally and unsystematically

mentioned; it is the piano in the entrance lobby of

Diavalkaniko Hospital, which has a symbolic presence.

However, in Asklepieia, everybody, patients, visitors and staff

used the theatre. The piano performances were perceived as

a means for the therapy of the soul and the mind in the

context of a ‘holistic’ approach to health care. Now, the

theatre facilities in modern Greek hospitals are convention

spaces used mainly for medical scientific purposes.

However, discussions are on-going for its use by the patients

and visitors as well.

The social environment

In modern Greek hospital regulations, the understanding of

the strong social need of an average Greek for special

attention but at the same time not depriving him/her from

their social, mainly family, context, is observed. Rooms with

more than four beds are not recommended by the

‘governmental order 202/91’, which combined with the

elasticity concerning visiting hours in hospitals, creates a

strong social environment. The preferred hospital room

space is where the patient enjoys both exclusive attention by

26 | World Hospitals and Health Services | Vol. 40 No. 3


INFRASTRUCTURE: DESIGN

the staff and on at the same time the exclusive and constant

attention of the family and friends all day long. Thus,

hospitals, especially the ones that have been recently

established, are trying to adjust a small sitting area in the

patient room with armchairs, which can be turned into

beds. In Asklepieia this was recognised. On a ancient stone

carving it is possible to see a patient with his family and his

favourite pet being welcomed by a priest-doctor and a snake

symbolising a welcome from the god Asklepios himself. The

family, friends and pets could stay at the Xenon, meaning

hotel, which was provided on the Asklepieion campus. The

patient, depending on the gravity of its situation, would stay

for the first stages of his diagnosis and general support of his

health, with them in this hotel.

Conclusion

The achievement of a culture of safety seems to be at the

centre of the current interest of the health industry

professionals. This effort requires the contribution of every

component of health care industry. One of those

components is recognized to be the planning and design of

health care facilities. The purpose of this study was to

understand the planning and design of health care facilities

contribution to the achievement of a culture of safety, in

general, and in two of Thessaloniki’s Hospitals, in particular.

Patient safety is threatened globally by several factors, such

as those related to terrorist actions, the natural resources

pollution and the nosocomial or hospital acquired infections.

Out of them the nosocomial infections seem the most likely

to threaten patient safety in Thessaloniki’s Hospitals.

The method used was developed in two ways concerning

the analysis of the quantitative and qualitative roles of the

planning and design of health care facilities. The results have

shown that the quantitative role of the planning and design’s

contribution is extremely important in quantitative issues of

the hospital infection control programme, such as the

elimination of the possible relatively high concentration of

the pathogens.

Additionally, the qualitative role of the planning and

design contribution has a major influence on the qualitative

issues of the hospital infection control programme, such as

the strengthening of the patients’ immune system, and

consequently their resistance to an infection, through

focusing on improvements of a more relaxed and with a high

aesthetic quality health care environment. This is supported

by the reassurance provided by the contribution of the local

cultural identity.

Finally, we may conclude that the achievement of a

culture of safety requires not only projects and studies

aiming to re-design clinical processes but also to the

building of a safer health care environment, which can

properly accommodate and support both quantitatively and

qualitatively those clinical processes reinforced by the

lessons derived by the experience of historical examples,

such as the Asklepieia.

However, with the known attachment of our current

civilization to the direct, preferably, economic benefit we are

going away from the humanistic example of Asklepios and

Asklepieia. Nowadays, the patient is characterized as a

‘client’ or ‘consumer’ and the planning and design as ‘cost’

or ‘investment’. What do we observe here? All the terms

used are economic. Does this imply that perhaps the future

aim, as far as health care is concerned, is simply profit? For

strengthening the immune system of the patients one

should not forget Hippokrates position, when he insisted

that ‘it is not beneficial to count everything in money’.

Otherwise the whole system could turn from humanoriented

to profit-oriented and thus be inhuman. ❑

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28 | World Hospitals and Health Services | Vol. 40 No. 3


SPECIAL FEATURE: INTERVIEW WITH RICHARD GRANGER

The National Programme

for IT in the UK National

Health Service

AN INTERVIEW WITH RICHARD GRANGER

DIRECTOR GENERAL, NHS IT

Richard Granger is the Director General of IT for

the NHS and is in charge of implementing the UK

national IT programme for the health service.

Prior to taking up this post in October 2002, he was a

partner at Deloitte Consulting. Before taking on the

challenge of modernising IT for the NHS he worked on

the successful procurement and delivery of a number of

large scale IT programmes, the most recent of which was

the Congestion Charging Scheme for London.

WHHS: What do you consider to be the key successes

in the procurement programme and why?

RG: This is an exciting and ground-breaking moment for the

National Health Service (NHS) as it takes the first steps

towards offering a truly 21st century service to its patients

and staff.

As the National Programme for IT in the NHS moves into

its implementation phase, systems and services are being

installed that will revolutionise the way the NHS works in

England, bringing benefits for patients and staff alike.

The world’s largest civil IT project, the National

Programme is aimed firmly at helping to deliver the vision of

‘a service designed around the patient’, as outlined in the

UK Government’s paper Delivering the NHS Plan. It is crucial

to the modernisation of the NHS. It is essential if the

increasing demand for care is to be met.

The procurement process itself set new standards, creating

a blueprint for others in the UK and beyond.

It was fast because so much of the modernisation of the

NHS depends on the delivery of excellent new IT systems

and services. It was different - because the programme has

contracted with suppliers who must only deploy solutions

for the NHS which have been proven to be safe, resilient and

fully functional.

It was complex because the programme brings together

different suppliers and different solutions which must be

integrated.

It was successful not least because of the major savings

Contracts Awarded

Choose & Book – Atos Origin – £65m

NHS Care Records Patient Record – Spine – BT - £620m

NHS Care Records Service – Local Service Providers:

➜ London – BT - £996m

➜ North East and Yorkshire – Accenture - £1099m

➜ North West and West Midlands – CSC - £973m

➜ Eastern England and East Midlands – Accenture – £934m

➜ Southern England – Fujitsu Alliance - £896m

New NHS Network – BT - £530m

Figure 1: NHS contracts awarded

achieved on hardware and software, compared to individual

procurements by trusts or strategic health authorities.

Contracts worth over £6bn (see Figure 1) have been

awarded to deliver the NHS Care Records Service, Choose

and Book (Electronic Booking Service) and the National

Network (N3).

Suppliers are now working in partnership with the

National Programme and the NHS to achieve a successful

implementation. At a local level, NHS IT professionals in

each of the five geographic clusters of strategic health

authorities are already working with local service providers

to ensure that local systems are compliant with national

standards and will facilitate data flow between local and

national systems.

WHHS: What is happening around implementation?

RG: As the programme moves into implementation,

engagement is increasing, both with the IT community and

with end users – NHS clinicians and frontline staff.

The recently established Care Record Development Board

(CRDB) will work on defining processes within care and

18 | World Hospitals and Health Services | Vol. 40 No. 3


SPECIAL FEATURE: INTERVIEW WITH RICHARD GRANGER

across the care boundaries that will be enabled through the

use of IT.

The CRDB will provide clinical and patient input into the

development of IT by the National Programme, bringing

together patients, public, social and health care

professionals in one body.

CRDB action teams will be commissioned to carry out

specific pieces of work making their recommendations to

the board. For example, an action team may be required to

address and define the care processes involved in electronic

prescribing. Each action team will be assembled based on

the expertise required for the particular work area.

The action team will consult with a wider network of

stakeholders including NHS bodies, patient and user

organisations and health and social care professions to

enable them to make their recommendations to the board.

These recommendations will inform the way that the IT is

developed to support improved patient care.

The work of these action teams will be based on

the priorities of the National Programme ensuring

recommendations are given at the appropriate time to

inform the development of the NHS Care Records Service.

Because of the sheer scale and complexity of the new IT

systems and services being delivered by the National

Programme across England, and the need for national and

local expertise, implementation through each cluster will be

phased, incremental and informed by the experiences of

early adopters.

It must be remembered that nothing on this scale has ever

been attempted before. It is an ambitious programme and,

although frontline NHS staff are anxious for delivery, the

National Programme, its suppliers and its NHS development

partners want to ensure that systems and services provide

appropriate clinical functionality and are tailored to local

needs. This will ensure that benefits for staff and patients

can be realised.

Implementation schedules will reflect local needs and

readiness. Basic processes that have underpinned working

for many years will change. There is much work to be done

in managing change as well as deploying new technology. To

be successful, process redesign must have input from

technologists, clinicians and managers. NHS IT and

informatics staff therefore have a major role to play.

WHHS: How do you plan to get the Clinicians on

board with your reforms?

RG: Deputy Chief Medical Officer Aidan Halligan, who was

appointed Joint Director General and senior responsible

owner for the National Programme in March, is now

spearheading clinical engagement and benefits realisation.

As part of increased local engagement, Aidan’s first few

months in post have included a series of roadshows, visiting

trusts and listening to local people.

Other recent moves have seen the programme launching

the Frontline Support Academy. This will utilise groundbreaking

simulators to mock-up realistic environments like

hospital wards and GPs’ surgeries where clinicians will learn

how best to use new systems, with actors playing the role of

patients.

Work continues apace with engagement, process redesign

and IT deployment. We all acknowledge that a modern

NHS cannot work effectively with a disparate collection of

paper and organisation-based information systems. Together

we can truly build a patient-centred NHS which benefits all

those who work in it and those who are cared for by it.

Creating a patient-focused NHS and empowering

individuals to make informed choices over their health and

care are cornerstones of the Government’s vision for the

NHS in the 21st century. Modern information and

communications technologies are crucial to achieving this

vision. The National Programme for IT has a key role in

helping to transform the vision into reality.

WHHS: What do you see as the key milestones?

RG: By 2010, the National Programme is tasked with

creating:

➜ a live, interactive electronic NHS Care Records Service to

ensure the right information about patients is available to

the right people whenever and wherever it is required,

including static and moving digital images, such as x-rays

and scans;

➜ an electronic booking service – Choose and Book – to

make it easier and faster for patients and their GPs to

book convenient appointments for patients;

➜ a system for the electronic transmission of prescriptions

from prescribers to pharmacies, to improve safety and

convenience for patients;

➜ a national network to provide modern IT infrastructure to

meet NHS needs now and into the future.

WHHS: What do you think patients will notice most

about the new reforms?

RG: This summer, patients in London and the North East

began to experience the first changes to be brought about by

NPfIT. Choose and Book, the National Programme’s

electronic booking service, is commencing its roll out in

these areas and will be delivered throughout England by the

end of 2005.

This will enable patients to book outpatient appointments

from their GP’s surgery, selecting a convenient appointment

time, date and hospital for treatment from a choice of those

available. This puts the patient rather than the hospital at

the centre of the booking process.

It enables patients to fit their appointment around their

life, not vice versa. And, if patients prefer to consult with

family, carers or colleagues before booking, they can choose

to phone a call centre later to make their appointment.

Underpinning the implementation of Choose and Book

and the other services to be delivered by the National

Programme, is the NHS’s National Network – N3. N3 will

eventually connect all 18,000 NHS locations and sites,

creating a single, secure, national system.

This will allow more than 100,000 doctors, 380,000

nurses and 50,000 other health professionals to send and

receive information – including voice and video, e-mails,

medical information and test results – in a secure manner.

The new network will facilitate the provision of the 24

hour a day, seven day a week, live, interactive NHS Care

20 | World Hospitals and Health Services | Vol. 40 No. 3


SPECIAL FEATURE: INTERVIEW WITH RICHARD GRANGER

Records Service (NHS CRS). By 2007 all England’s 50

million plus patients will have an electronic NHS Care

Record.

Detailed information will be stored locally, where the

majority of care is provided. In addition, a summary of a

patient’s essential health information will be accessible

whenever and wherever a patient seeks NHS care in

England, whether that treatment is planned or unexpected.

This will improve the speed, effectiveness and safety of

diagnosis and treatment. Authorised clinicians will have

secure access to potentially lifesaving information, such as

patient allergies, current medication, outcomes from

operations and test results.

In time, patients themselves will have easy, but secure,

access to their record, via the secure HealthSpace website,

which will also provide tools and information to help people

look after their own health.

In the future, patients will be able to use HealthSpace to

express their treatment preferences, organ donation wishes

and needs, such as wheelchair access or translation services.

Patients will have to weigh up the benefits of information

sharing between health organisations against the risks. A

major public information campaign is planned to ensure that

they are able to make an informed decision about whether to

opt out of allowing their electronic record to be shared with

health professionals involved in their care. Once the new

systems are complete, patients will also be able to request

that certain parts of their record are only shared in particular

circumstances, such as an emergency.

Whilst there are issues and risks with the new technology

that must be identified and minimised, there are huge

potential benefits. Patients will be able to gain a speedier

diagnosis when a specialist opinion is required. New Picture

Archiving and Communications Systems mean x-rays and

scans will be stored digitally on computer so they can be

sent instantly from a hospital where they were taken to a

specialist who may be many miles away.

In the future, patients in hospital could also begin to see

clinicians using wireless technology to call up their health

record at the bedside. As the patient’s NHS Care Record will

be automatically updated, GPs will be aware of all the

relevant details when a patient makes a follow up visit to the

surgery.

Prescribing will be safer and more convenient for patients

by the end of 2007 when the Electronic Transmission of

Prescriptions (ETP) is fully implemented. It will not always

be necessary to visit a GP’s surgery to collect repeat

prescriptions, as they will be sent electronically to

community pharmacists.

Safety will also be improved as, in most cases, prescription

information will not be handwritten or typed more than

once. ETP will, in addition, ensure that information about

medicines that have been prescribed and dispensed are

automatically added to a person’s NHS Care Record. This

will lead to better patient care as authorised clinicians and

associated health care professionals will have more

information about the medicine someone is taking.

In rural areas, telemedicine could in future take away the

need for patients to travel miles to hospital for a

consultation. Instead they could visit their GP’s surgery and

have the consultation via a video link with a specialist. In

some places this already happens.

The new technology could also assist patients with

chronic diseases, such as diabetes, to play a more active role

in the management of their condition. They could in future,

for example, ask for online information about managing

diabetes and store care plans and online diabetes

management courses. They could use HealthSpace to log

their weight and blood sugar level readings and organise

email reminders to book appointments to check their

eyesight.

Everyone providing care will have the essential

information they need to make safe decisions. Treatment

and prescribing errors that can harm patients will be

reduced. And patients will also have easier access to their

medical information and be able to play a more proactive

part in their own health and care.

WHHS: How does the UK national plan differ from

attempts by other countries?

RG: England is leading the world in developing an electronic

care record for every single patient – nothing has ever been

attempted anywhere else in the world on this scale so we are

leading from the front.

The National Programme for IT also has a larger functional

scope than other national strategies, seeking to cover the

whole range of services across primary and secondary care.

There is a strong history of electronic patient record

development across Europe over the years – to which the

NHS has made significant contributions – but they are

usually more on an institutional or regional basis, rather than

national.

It is testament to the exiting progress we are making that

other European countries such as France and Sweden have

been taking a very close interest in what the National

Programme is doing.

WHHS: What lessons can other countries learn from

your experiences?

RG: We have been able to start from a very solid base of ICT

experience, expertise and knowledge built up over many

years. The National Programme did not start from scratch,

but drew heavily on previous IT strategies dating back to

1992.

What the National Programme has done is to accelerate

the process, to have a clear focus on what needs to be done

and how to achieve it quickly, efficiently and cost effectively.

Do not underestimate the amount of effort required, it is

a huge task and one which can only be driven through with

hard work, commitment, enthusiasm and a passion to

succeed.

We have already begun to see the fruition of our

endeavours with the successful launch of Choose and Book

and within a short space of time many more patients and

NHS staff will see the benefits of what we are aiming to

achieve. ❑

22 | World Hospitals and Health Services | Vol. 40 No. 3


EHEALTH: SPAIN

Are Spanish physicians ready to

take advantage of the Internet?

SUSANA LORENZO,

FUNDACIÓN HOSPITAL ALCORCÓN, MADRID

JOSÉ J MIRA,

UNIVERSIDAD MIGUEL HERNÁNDEZ DE ELCHE

Abstract

Objective: To analyse specialist doctors’ opinions, attitudes and habits with respect to e-health, and the

repercussions of these factors on doctor/patient relations.

Methodology: Use of a survey to analyse attitudes, Internet use, habits and opinions about the advantages and

disadvantages of the Internet among 302 doctors in eight Spanish hospitals.

Results: Of the doctors surveyed, 80% have access to and use the Internet. Almost 40% use the Internet for less

than one hour a day; doctors in smaller hospitals spend more time on the Internet and men spend more time than

women. The most frequently visited websites are PubMed (11%) and Google (22%); when choosing a website,

periodical updating and prestige are important to 78% and 69%, respectively; 37% have taken a course through the

Internet; 35% consult electronic journals systematically; 16% regularly collaborate with, or write materials for

healthcare websites; 12% receive electronic mail from their patients.

Three clusters of information were generated in this study to classify the participating hospital doctors: the

different types of information the doctors consulted, the way the Internet enhances doctor/patient relations and the

aspects that the doctors consider relevant when connecting to the Internet.

Conclusions:Spanish doctors consider the Internet to be a tool that enhances doctor/patient relations. New

technologies are accelerating the substitution of a paternalistic model by ones where the patient has access to more

information and resources. There appears to be a favourable attitude towards seeking a second opinion throught

the Internet, although not towards patients’ ‘chats’.

Voir page 40 le résumé en français. En la página 41 figura un resumen en español.

The role of the citizen in developed Western society has

evolved considerably over the last decade thanks to

the advent of new technologies and we will most likely

experience even more changes in the future as others are

implemented.

Today, patients play a much more active role in health care

than in the past. Their capacity to make choices and

participate in decisions is greater than ever before 1, 2 . This has

ushered in a new model for relations between health care

professionals and patients, and health care systems and the

citizen 3, 4 . The patient has gone from being the ‘object’ of the

health care system to become the ‘subject’, from being

‘directed’ to now playing an role in deciding ‘where to go’.

However, this expanded capacity for patient’s

participation is only as good as the quality of the information

available to him/her. Generally speaking, the information

available to patients, and the patient’s capacity to make

technical judgements even after receiving care is limited,

since the patient usually does not have enough information

to form an educated opinion about the ultimate result of a

medical intervention. This handicap is due to the enormous

gap between the information available about the diagnosis,

treatment and prognosis to the person providing care and to

the service user (the concept of asymmetric information).

The shift in the roles assigned to patients and

professionals can be traced to the progressive substitution of

the paternalistic model that has traditionally characterised

the relationship between patient and health care

professional, by other models that recognise that the patient

has needs and expectations, preferences and criteria, and

that these must be incorporated into the treatment process 5 .

The new information technologies have brought about

notable changes in many aspects of our daily lives. For

health care professionals, these new technologies have

introduced very important changes in the way they conduct

their professional activities, with the adoption of electronic

clinical records and information on-line that can be accessed

from their work stations. These changes have affected both

the content, as well as the framework and channels of

doctor/patients relations: with access to vast amounts of

information, exchanges of opinions and experiences

between professionals (‘chats’), distance learning, new

educational channels, patients’ ‘chats’, consultations by

electronic mail (e-mail) and the use of the Internet to seek a

second opinion. These new options are creating an

environment where ‘e-health’ technologies are configuring

Vol. 40 No. 3 | World Hospitals and Health Services | 31


EHEALTH: SPAIN

different models on where healthcare professionals and

patients interact. These new models are characterised by the

immediacy of communication, improved access and the

large amounts of information now available.

Although the doctor remains the primary source of

information for the patient, the Internet is gaining ground 6 .

Today, at any hour of the day, vast amounts of information

and images are available in great detail, a second opinion can

be sought without the tension of having to request it from

the doctor himself and patients with similar pathologies can

exchange information and compare experiences 7 ; patients

can even consult with their own doctors through e-mail and

can participate in open discussions about issues related to

their treatment with other doctors and patients in chat

rooms, just to cite a few examples of some of the things that

are now becoming commonplace.

The boom in e-health resources should, therefore, come

as no surprise. Proof of the impact of these resources is that

available data indicates that websites providing health

information are the most frequently visited. Data also shows

that 19% of these visitors are in search of a second opinion 8 .

Citizens are eager to play a more active role in taking care of

their own health 9,10 , and the new information technologies

are making this possible.

According to Jadad and Delamothe an e-health 11

application is defined as any use of an electronic information

and communication technology to promote health or

improve healthcare. However, the use of these new

technologies is not uniform in all places, countries or

contexts. Conditioning factors are the patient’s age, level of

education and qualifications, among other features, along

with the health care professionals’ attitudes towards these

new technologies and the extent to which they themselves

use them.

Various studies have been conducted to examine how

patients use the Internet, what they look for and how they

consult health care sites 12 . Some studies focus on the

reliability 13 and quality of the medical information on the

Internet. Fewer studies, however, have examined the

attitudes of health care professionals and their own use of

the Internet for professional purposes. In the case of Spain,

very little is known about the opinions, attitudes and habits

of health care professionals towards e-health.

Spain is undergoing a transition from conventional

communications systems to the adaptation of the new

information and communications technologies (ICTs).

Today, the country occupies the twenty-ninth position in the

worldwide classification of the application of these

technologies and the second to last position in the European

Union. This classification takes into account such variables

as the availability of infrastructures, price of access, level of

education, quality of the ICT services and use of the

Internet 14 . Nonetheless, there is an accelerating rise in the

number of daily consultations by patients who go to the

Internet (connecting from their own homes or workplaces or

the homes of relatives, friends or neighbors) to search for

information about their condition or what their doctors have

told them. Health care professionals must respond to these

changes and adapt to these new requirements, since more

and more Spaniards use the Internet for medical

consultations. (It is people under the age of 40 who are most

apt to use the ICTs in search of further information). These

changes should not be viewed with distrust, but as a shift in

relationship styles.

With this paradigm shift, it is necessary, on the one hand,

to gauge the attitudes of doctors and their current

communications styles and practices in the light of these

new demands while, on the other, assessing their response

to the new possibilities offered by e-health 15, 16, 18 . The aim of

this study was to examine the opinions, attitudes and habits

of health care practitioners when they use the Internet for

professional purposes. We have analysed the information

they look for, whether they believe the Internet is an asset for

patient/doctor relations and what aspects determine

whether or not they use the Internet.

Materials and methods

Design: In August 2003, a 19-question survey was sent to

the doctors in the clinical units of eight public hospitals in

Spain (Santa Cristina (HSTC) and Alcorcón (FHA) in

Madrid, Txagorritxu (HTXA) and Zumárraga (HZUM) in the

Basque Region, San Joan de Reus (HSJR) and Vilanova

(HVN) in Cataluña, Monte Naranco (HMN) in Asturias and

the Hospital of Navarra HNAV), with the intention of

learning about their habits and preferences concerning the

use of e-health resources in their professional activities.

Population: The survey was sent to 901 doctors in

public hospitals in Spain. The hospitals were selected on the

basis of their size (number of beds), location (urban and

rural areas) and as representative of five of the country’s

autonomous regions, each one with its own regional

government that provide universal health care to the region.

Of the eight hospitals where the doctors were surveyed,

four had more than 200 beds (FHA, HNAV, HSTC Y HTXA)

and 4 had less than 200 (HMN, HSJR, HVN, HZUM).

Sample: Within 20 days, a total of 302 doctors had

responded to at least 95% of the items on the questionnaire.

Of the doctors surveyed, 68.8% had children and 31.2% did

not. A breakdown of the average age of the children showed

that 33.4% of the doctors had children under the age of 10,

20.2% from 10 to 20, and 15.2% over 20. This variable was

included under the assumption that a household with a

child over the age of 10 would likely have Internet at home.

Procedures: The questionnaire was developed with

input from health professionals and researchers. A pilot

study was conducted to test the clarity and appropriateness

of the questions. Ten professionals analysed each of the

questions and evaluated their appropriateness, clarity and

possible erroneous interpretations. After this exercise, four

items were changed. The questionnaires were sent to

physicians through internal institutional mail. No reminders

were sent to increase the number of respondents, as

participation was intended to be purely voluntary. All data

gathering was completed on 15 September 2003. Relevant

comparisons of descriptive statistics were made between

and within groups using X 2 and Fisher exact tests (2-sided);

p


EHEALTH: SPAIN

for Social Sciences) for Windows.

The questions were geared to determining the doctors’

Internet habits: where they use the Internet, at home or at

the hospital; the amount of time they devote to using the

Internet; their opinion of the Internet as users: the elements

that make it easy to use, the sites they visit the most, the

perceived advantages of the Internet. The doctors’ responses

helped ascertain their attitudes towards the new ICTs, their

use of the Internet to keep abreast of professional

developments and their use of these technologies as a

channel to communicate with their patients.

Three different aspects concerning the way Spanish

doctors use the Internet were analyzed: The first concerned

what type of information they consult; the second, what

advantages the Internet offers them when managing relations

with their patients; and the third covered the aspects of the

Internet that are relevant to the doctors when they connect

and initiate a search.

Results

The response rate to the survey was 33.52%, ranging from

100% in the cases of San Joan de Reus and Santa Cristina

and 10% in the cases of Navarra and Zumárraga. Of the

respondents, 54% were men and 46% were women; most of

them were between the ages of 30 and 40 (47%), followed

by 27.8% between the ages of 41 and 50; 13.6% were over

50 and 11.3% were under 30. The respondents’ profile is

similar to the profile of all the doctors working in these

hospitals and, therefore, to the profile of the doctors who

did not respond.

Of the doctors who responded, 80% were women and

71% were men who work in hospitals with more than 200

beds, while 20% of the female doctors and 29% of the male

doctors work in hospitals with less than 200 beds.

Where do doctors connect to the Internet?

Of the total, 80.5% are connected to the Internet both at

home and at work; 9.6% are only connected at home, 8.3%

are only connected at work, and 1.7% are not connected to

the Internet either at home or at the hospital. This last group

only corresponded to doctors working in hospitals with

more than 200 beds. The factor of having an Internet

connection at home did not correspond to a more

favourable opinion towards the patients’ using the Internet

to obtain a second opinion (X 2 =4.40, p=0.623), or more

facilities for the patients to correspond with the doctors by

electronic mail (X 2 =3.23, p=0.357).

Our results show that 29.8% of the doctors make similar

use of the Internet at home and at the hospital; 25.5% spend

more time on the Internet at home than at the hospital,

while 24.5% spend more time on the Internet at the hospital

than at home; 9.6% connect only from the hospital, 7.9%

only from home, and 2.3% do not use the Internet at all.

The doctors who use the Internet the most are those with

children under the age of 10, and they use it similarly from

home and from work (36.6%), compared to 25.1% of the

doctors with children over the age of 10 who also use the

Internet similarly from home and work. Whether using the

Internet from home or from work, it is doctors with children

under the age of 10 who use the Internet the most.

Time spent connected to the Internet

The majority of the doctors surveyed (39.7%) use the

Internet less than an hour a day, followed by 23.8% who use

it between one and two hours; 19.2% only connect on a

weekly basis. The average amount of time the doctors in this

study use the Internet is 44.4 minutes per day.

A breakdown by hospitals shows that in hospitals with

less than 200 beds, the doctors spend more time on the

Internet: for the doctors who devote at least one hour a day

to the Internet, 43% work in hospitals with less than 200

beds (the difference was is about 3%), while in the hospitals

with more than 200 beds, 40% of the doctors spend the

same amount of time on the Internet. In the smaller

hospitals, 46.8% of the doctors who are connected to the

Internet less than one hour a day are men, while in the larger

hospitals, 44.4% are women.

What factors facilitate surfing on the Internet?

The following characteristics were found to facilitate working

and searching for information on the Internet:

➜ frequent updates of the sites (78%);

➜ the strong reputation of the source of information (69%);

➜ ease in connecting to the links (48%);

➜ clarity of the language used (45%);

➜ the appearance of the site (12%); and

➜ availability of a web map (12%).

What sites do the doctors visit?

Doctors most frequently consult health care websites:

PubMed (11%), Ovid, Diario Médico and Medline Plus

(5%). Of the sites visited, 33% vary according to the doctors’

medical specialisations. General search engines were also

consulted (Google, 22% and Yahoo, 7%).

Advantages of the Internet

The Spanish doctors consulted in this study perceive a series

of advantages in using the Internet to find different types of

information: 93% believe it is a tool that makes searching for

information easy, and 90% go to the Internet to update their

own knowledge and keep abreast of developments in their

profession. Our findings show that 69% of the information

sought by this group refers to health care issues in general,

while 63% of the doctors claim that they search for specific

information about a specific case, 56% look for published

scientific evidence, and 39% look for information to support

their own scientific research. The doctors surveyed also use

the Internet for non-medical activities: 60% to organize trips,

43.5% for leisure activities and 29% to shop.

Attitudes towards the new technologies

Complementary analyses were conducted to detect any

associations between the use of the Internet to search for

non-medical information and other variables. Results do not

appear to indicated that this variable affects the doctors’

attitudes towards the patients obtaining a second opinion

through the Internet (trips X 2 =4.16, p=0.812; leisure X

2

=4.04, p=0.132; shopping X 2 =1.53, p=0.464), or

Vol. 40 40 No. 33 | | WORLD World Hospitals hospitals and Health health Services services | 13 33


EHEALTH: SPAIN

corresponding with patients through electronic mail (trips X

2

=0.42, p=0.812; leisure X 2 =0.85, p=0.356; shopping

X 2 =0,01, p=0,985).

Doctors who have taken courses over the Internet show a

more positive attitude towards their patients seeking a

second opinion on the Internet (49.6% in favour compared

to 29.7% against, [X 2 =18.54, p=0.0001]). In contrast, we

found no significant differences between doctors who had

taken a course over the Internet and those who had not used

the Internet to stay abreast of their profession, when asked

about their favourable attitude towards receiving and

answering their patients’ queries by electronic mail (X

2

=0.75, p=0.784).

Using the Internet to keep abreast

In response to the survey’s question about what courses the

doctors had taken through the Internet, 63.2% answered

that they had not taken any, while 36.8% indicated that they

had. The doctors who had taken the most courses through

the Internet were at the San Joan de Reus hospital, where

91% of the doctors who responded to the survey had taken

such a course.

Further findings reveal that 47.4% of the doctors read

medical journals in the conventional paper format, while

35.4% use the electronic format.

The Internet as a new channel for communication

When asked about the use of the Internet to enhance their

relationship with their patients, our results indicate that

88% of the doctors surveyed do not participate in ‘chats’ on

health care issues. Of those who do, 8.3% only participate

with other professionals, while only 2.3% ‘chat’ with

patients. However, a striking observation is that 4% of the

doctors in hospitals with less than 200 beds participate in

‘chats’ with patients, compared to 1% of the doctors in

hospitals with more than 200 beds. Nonetheless, 15.9% of

the doctors overall contribute to healthcare websites. We

observed that 12.4% of the doctors receive queries from

patients through electronic mail and that the doctors who

use e-mail to communicate with their patients have a

positive attitude towards their patients seeking a second

opinion on the Internet (20.3% in favour compared to 3.1%

against [X 2 =15,66, p=0,0001]). The same trend was

detected in the doctors who contributed to a website, where

23.9% were in favour and 9.2% were against (X 2 =13.01,

p=0.002). On the other hand, the variable of participating

in ‘chats’ with other doctors did not show any differences (X

2

=7.68, p=0.104).

When asked how often they receive queries from patients

through electronic mail, 81.8% of the doctors said, ‘never’,

while 8.6% receive more than 1% of their consultations in

this format. When asked whether they are in favour or

against patients obtaining a second opinion through the

Internet, 46% said they were in favour of the practice, while

21.5% are against it. The majority of the doctors surveyed

are in favour of seeking a second opinion on the Internet

and the hospitals of Sant Joan de Reus and Santa Cristina

showed the greatest acceptance of this practice where 72%

and 56% of the doctors indicated they were in favour.

Discussion

Internet has become an integral part of our daily lives and all

indicators suggest that over the next few years we will see

new applications and a growth in the number of people who

use the worldwide web. These new technologies provide

many options that go beyond merely trading pencils for

computers and conventional files for electronic medical

records while we continue to practice medicine in the

conventional manner. The new ICTs have ushered in a

change in paradigm that permeates the whole health care

field. Medical professionals must accept the growing

importance of e-health information, and develop their own

websites so they can use this technology as an educational

tool and help their patients differentiate between good and

poor quality information on the Internet 17 .

There is no doubt that access to information provides

many advantages, although the Internet is not free from

certain disadvantages and dangers as well. One disadvantage

is when doctors do not know how to use this tool, or if they

are unable to connect to the Internet at their workplaces. If

they are unfamiliar with the portals or websites that they

visit to find specialized information, they may be exposed to

unreliable and poor quality information 19, 20, 21 .

The results of this study indicate that the doctors

surveyed had a positive attitudes towards the ICTs. As

published in other studies of the subject , the majority of the

doctors participating in this one are in favour of seeking a

second opinion on the Internet, and in fact use some of the

most frequently visited websites (such as Medline plus) for

their own consultations. On the downside, however, only a

small percentages (8.6%) use the Internet for more than 1%

on their correspondence with patients.

The response rate in this study is similar to that registered

for the family physicians in the Jadad study 18 .

In spite of easy access to the Internet and the doctor’s

positive attitude towards using this tool to seek a second

opinion (the results of a survey published in the Spanish

medical daily Diario Médico reveals that 65% of doctors

consider prescribing through e-mail to be a way to improve

clinical work 23 ), it is also evident that many e-health

resources remain untapped. Doctors participation in ‘chats’,

websites and contacts with patients through e-mail

continues to be very low, corroborating the findings of other

studies . This reflects the major differences between the use

of these resources in Spain and in the United States. The

results of the study conducted by the American Medical

Association indicate that 3 out of 10 doctors in the United

States who use the Internet have their own web pages 25 .

Our study detected variables that did not correlate

significantly with the doctors being in favour or against the

patients using the Internet to seek a second opinion. These

included using the Internet to book trips or leisure activities

or to shop. Nor did these variables correlate positively with

using e-mail to correspond with patients or contributing to

a website. A study by the Health on the Net Foundation 26 on

the evolution of the use of the Internet for medical purposes

found that 71% of the doctors surveyed recommended that

their patients seek a second opinion on the Internet and

suggested consulting websites as a valid means of gathering

34 | World Hospitals and Health Services | Vol. 40 No. 3


EHEALTH: SPAIN

information. This is when it is important for the doctor to be

familiar with the sites that offer reliable information and

whose contents offer guarantees when looking for suitable

solutions to a medical problem.

The factors the doctors in our study cited as important

when choosing an e-health website (sites that are frequently

updated, with reputable sources of information, easy links

and are written in clear language) correspond with those

found in other studies. Other technical variables such as the

website design, legibility, exactness and the scope of

coverage have also been found to be determining factors.

Qualitative indicators must also be taken into account.

These include accessibility, frequency of updating,

accreditation, authorship, contact addresses, ease of use,

sponsorship, external reviews, confidentiality, advertising in

general and specific advertisements that are differentiated

from the text 22 .

As has happened in many other countries, in Spain, most

hospitals have made large investments to help their staff

implement the new ICTs. The return on these investments

has been improvements in the services provided, since

consultation procedures have been made more agile and

patients no longer have to go to the hospital for certain

services. However, implementation of these new tools in

Spain’s health care organisations is far from optimum.

Our study presents a series of limitations that make it

difficult to generalise our conclusions. The first of these is

the rapid rate at which the ICTs and their use are developing

in our milieu. More and more people are implementing

them, so that the rates of use reflected in our paper may be

different by the time it reaches the press. Another aspect is

that our study did not classify the participating doctors by

specialisation and presents only overall results. Furthermore,

our sample was not random and did not include hospitals in

all of the autonomous regions. Only doctors in five of the

country’s 17 autonomous regions (Catalonia, Madrid,

Asturias, Navarre and the Basque Region) participated, so we

do not know if their opinions can be extrapolated to the rest

of the country, or whether their use of the Internet reflects

conditions elsewhere. Nonetheless, our study has examined

circumstances in the public health care sector, which

provides universal coverage in Spain and has included

hospitals of different sizes in both the urban and rural

settings that have implemented the ICTs in different ways

and to different extents.

In spite of the limitations outlined above, this study is the

first published on this subject in Spain. Further research is

necessary to examine in greater depth the opinions,

attitudes and habits of health care professionals in view of

their professional use of the Internet. ❑

Acknowledgements

This research was partially funded by a grant from the Foundation for Scientific

Research of Spain (FIS), with reference 01/0480. The study group members

included: Fundación Hospital Alcorcón: Johana Guerrero, Mayerly Olarte. Hospital

Txagorritxu: Mayte Bacigalupe, Andoni Arcelay. Hospital Zumárraga: Esteban Ruiz

Alvarez. Hospital Santa Cristina: M. Antonia Blanco. Hospital San Joan: Joan

Miquel Carbonell. Hospital Vilanova: Encarna Grifel. Hospital Navarra: Javier Gost,

Carmen Silvestre. Hospital Monte Naranco: Vicente Herranz.

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Vol. 40 No. 3 | World Hospitals and Health Services | 35


CLINICAL CARE: DIABETES

The global challenge

of diabetes

PROFESSOR PIERRE LEFÈBVRE (PICTURED)

PRESIDENT, THE INTERNATIONAL DIABETES FEDERATION

ANNE PIERSON

INTERNATIONAL DIABETES FEDERATION

Abstract

Diabetes is one of the main causes of death in most developed countries. Both types of diabetes are spreading

across the globe at an alarming rate, driving the condition to become one of the most challenging health problems

of the 21st Century.

Prevention is essential, and promoting a healthy lifestyle, early screening and investment in national programmes

are key to putting the scourge of diabetes on hold. The International Diabetes Federation (IDF) plays a crucial role

in the global fight against diabetes. Its objectives are to improve diagnosis, care and treatment of diabetes; promote

educational and training programmes; develop insulin availability and affordability and raise awareness of the

condition. The IDF hopes that these actions will not only save but also enhance the lives of people with diabetes.

Voir page 40 le résumé en français. En la página 41 figura un resumen en español.

Diabetes is one of the most common noncommunicable

diseases in the world and is fast

becoming a global pandemic. It is one of the main

causes of death in most developed countries and there is

substantial evidence to suggest that its incidence is

increasing in many developing countries.

The extent of the problem

The International Diabetes Federation (IDF) estimates that

currently some 194 million people worldwide, or 5.1 % in

the adult population, have diabetes and that this figure will

rise to 333 million by 2025 if nothing is done to change this

prediction.

There are two types of diabetes. Type 1 diabetes is caused

by the body’s immune system attacking the beta-cells in the

pancreas that produce insulin. The peak age of onset is

childhood and adolescence, but it can occur at any age.

Insulin is required for survival. Type 2 diabetes is a metabolic

disorder that results from the body’s inability to produce

enough insulin combined to various degrees of resistance to

the action of the hormone. Genetics, obesity, lack of

appropriate diet and insufficient physical activity appear to

play a role in the development of type 2 diabetes. It can be

controlled by diet, exercise and oral hypoglycaemic agents,

but insulin may be required for metabolic control.

Both type 1 and type 2 diabetes are spreading across the

globe. Type 1 diabetes, which accounts for less than 10% of

the total prevalence, is a particular problem in young

northern Europeans. It should be stressed however that the

incidence is increasing in many countries around the world

with an estimated overall annual rise of around 3%.

Type 2 diabetes, which accounts for about 90% of all

cases, is recording the most growth, particularly in rapidly

developing countries. The predicted increase is most striking

in India and China, but no part of the world is spared. In

addition to the alarming rise in numbers, there is also a

growing trend for the disease affecting younger age groups.

In developed countries the sharpest increases affect the over

65s, but in developing countries most new cases are

occurring in those between 44 and 65 years of age. In all

parts of the world type 2 diabetes is also emerging in

children and adolescents. It is presently recognized that type

2 diabetes in children is becoming a global public health

issue. The fact that people develop diabetes at an earlier age

will raise the threat of the onset of all the complications at

an earlier age.

The situation is further exacerbated by impaired glucose

tolerance (IGT), a state in which blood glucose levels are

higher than normal but below the level of someone with

diabetes. IGT often precedes diabetes and currently affects

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CLINICAL CARE: DIABETES

over 300 million people. People with IGT are at high risk of

progressing to type 2 diabetes, and of developing

cardiovascular disease. About 70% of those with IGT usually

go on to develop diabetes.

If action is not taken to stem the tide of type 2 diabetes,

the expection is increasing disability, reduced life expectancy

and life quality and huge health costs for every society in the

world. Diabetes is certainly one of the most challenging

health problems in the 21st Century.

Areas of action

Prevention

The importance of diabetes prevention cannot be

underestimated. Unless significant efforts are made to stop

the rise in diabetes, health care services across the world will

soon be crippled by the costs of treating the disease and its

complications.

The key must lie in prevention: primary prevention, i.e.

prevention of diabetes in the first place, and secondary

prevention, i.e. prevention of complications when diabetes

is present, and the prevention of serious damage from

complications when they occur.

Primary prevention is, of course, the most cost-effective

method of tackling diabetes. Although risk factors for type 1

diabetes are not yet defined, studies show that many factors

can increase the risk of developing type 2 diabetes and that

some of them are modifiable.

Type 2 diabetes has evolved in association with rapid

cultural and social changes, ageing populations, increasing

urbanisation, dietary changes and reduced physical activity,

the same factors that also cause obesity. In fact, being

overweight or obese is one major risk factor for diabetes as

80% of people who develop diabetes are overweight.

Action needs to be taken to prevent type 2 diabetes

through:

➜ Promoting a healthy lifestyle. Maintaining an appropriate

level of physical activity and eating healthily are key to

helping reduce the risk of getting diabetes. A healthy

lifestyle should include:

➜ a healthy, balanced diet (less fat, salt, refined sugar,

alcohol and calories; more fibre, fruit and vegetables);

➜ regular physical activity (e.g. aerobic exercises);

➜ sustained weight loss in the overweight;

➜ stopping smoking;

➜ relaxation methods to combat stress may help, too.

The IDF slogan ‘Eat Less, Walk More’ is more appropriate

than ever.

➜ Early screening for diabetes and its complications in high

risk groups. Although this may lead to a short-term rise

in the use of resources as a result of an increased

identification of new cases, this should be viewed as an

advantage rather than a disadvantage, since early

detection has obvious long-term benefits.

➜ Investment in national programmes aimed at primary

and secondary prevention of diabetes and its

complications.

Treatment

Once diabetes has developed, adequate care and treatment

Improved therapeutic regimes

and new drugs can help prevent

metabolic instability, which in

turn can prevent the onset or

reduce the progression of

chronic complications.



should be made available to all. This means that essential

medical treatment and education should be provided.

Improved therapeutic regimes and new drugs can help

prevent metabolic instability, which in turn can prevent the

onset or reduce the progression of chronic complications.

Findings from the United Kingdom Prospective Diabetes

Study (UKPDS), a landmark 20-year study of treatment for

people with type 2 diabetes, has shown conclusively that

maintaining blood glucose levels as close to normal as

possible can significantly prevent or delay the progression of

diabetic complications such as cardiovascular disease,

kidney, nerve and eye disease and foot ulceration. The study

found that people on drug therapy to control blood glucose

levels experienced a 21% decrease in eye disease and 33%

decrease in kidney problems.

IDF will continue to fight for people with type 1 diabetes

to make insulin available and affordable wherever needed.

There are no limits to the amount of insulin that can be

manufactured with modern technology. However, people are

still dying because of a lack of insulin. Together with

shortages of insulin, many of the other things that are taken

for granted in the middle and high income countries, such

as home blood glucose monitoring, oral agents and antihypertensive

medications, treatments for severe retinopathy

and kidney failure, and well-organised services, are

unavailable in many parts of the world.

Education

Education continues to be a key component in the

prevention and treatment of diabetes. Diabetes differs from

all other medical conditions in one significant respect: the

central role of people with diabetes themselves in achieving

the desired results of treatment. In most other conditions,

the person affected is merely expected to take the

medication as prescribed by the physician. In diabetes, the

person affected has to make multiple complex daily

decisions that have a direct impact on their health. Diabetes

education empowers people with diabetes by encouraging

them to take responsibility for their health and enabling

them to manage their condition themselves.

Today, although many people are aware of the value of

education, findings of a survey with IDF member

associations carried out in 2003 reported many barriers in

the provision of education: financial, limited access, lack of

knowledge and education resources. However, as the world

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CLINICAL CARE: DIAGNOSTIC IMAGING

incidence of diabetes grows efforts to promote selfmanagement

education, training for providers and public

awareness are critical in reducing the humanistic and

economic burden caused by the disease. The goal of

diabetes self-management training is to support the efforts of

people with diabetes to:

➜ understand the nature of their illness and its treatment;

➜ identify emerging health problems in early, reversible

stages;

➜ adhere to self-care practices; and

➜ make needed changes in their health habits.

Diabetes self-management training assists people in

dealing with the emotional and physical demands of their

disease, given their unique socio-economic and cultural

circumstances.

Awareness

It is crucial to alert the public throughout the world that

diabetes is a serious condition, which is currently

underestimated in terms of frequency, impact on quality of

life and in economic terms. Awareness at all levels and strata

of society is the key to success.

➜ Public: There is still enormous prejudice, ill-informed

opinion and lack of awareness about diabetes in most

societies. The more knowledge the general public has

about diabetes, the less prejudice will prevail.

World Diabetes Day: held on 14 November each year, is

organized by IDF in collaboration with the World Health

Organization (WHO). It is the primary global awareness

campaign in the diabetes world. The focus of the

campaign for the last few years has been on diabetes

complications. 2001 dealt with cardiovascular disease,

the number one cause of death in people with diabetes,

2002 focussed on diabetic eye disease, the leading cause

of blindness and visual impairment in adults, 2003 on

diabetic kidney disease, the leading cause of end-stage

renal disease in the developed world. The theme for 2004

is the link between diabetes and obesity whereas 2005

will tackle the diabetic foot.

➜ Policy makers: It is vital that IDF and its member

associations act as lobbyists to put pressure on

governments to pay more attention to diabetes. Together

with our partners in WHO, IDF plans to educate

governments in order to ensure that adequate resources

are available to deal with the many problems associated

with diabetes. Decision makers worldwide must be

encouraged to recognize that the human and economic

costs of diabetes can be significantly reduced by investing

in prevention and education.

IDF and WHO have just embarked on a new ‘Diabetes

Action Now’ programme whose overall goal is to stimulate

and support the adoption of effective measures for the

surveillance, prevention and control of diabetes. A key aim

of the programme is to achieve a substantial increase in

global awareness about diabetes and its complications, and

its main focus is on low- and middle-income communities,

particularly in developing countries.

IDF’s response to the global diabetes epidemic

The International Diabetes Federation is the only

global advocate for people with diabetes. It is a

non-governmental organisation in official

relations with the WHO. Since we first took up the

diabetes cause in 1950, we have evolved into an

umbrella organisation of over 180 member

associations in more than 140 countries

worldwide.

IDF works to promote the free exchange of

diabetes knowledge, improve standards of

treatment and to encourage the creation of

diabetes associations worldwide to enhance

awareness and education.

In summary, in response to the growing

challenge that diabetes represents today and may

represent in the future, IDF has set itself the

following objectives:

➜ to improve diabetes diagnosis, care and

treatment;

➜ to improve insulin availability and affordability;

➜ to raise awareness of diabetes and its

complications;

➜ to lobby governments and healthcare decision

makers;

➜ to promote educational and training

programmes;

➜ to promote a healthy lifestyle for the

prevention of the condition;

➜ to promote a better and more efficient

allocation of resources.

For more information please contact:

International Diabetes Federation, Executive

Office, Avenue Emile De Mot 19, B-1000 Brussels,

Belgium

Tel: +32 2 5385511; Fax: +32 2 5385114;

email: info@idf.org; website: www.idf.org

Conclusion

Success in these areas can only be achieved through

teamwork and collaboration. IDF and its member

associations will continue to work together with other nongovernmental

organisations and WHO to put a halt to the

diabetes epidemic and to enhance the lives of people with

diabetes worldwide. ❑

Bibliography

This article is based on information from the following

IDF publications:

➜ Diabetes Atlas 2003 (2003)

➜ Global Strategic Plan to Raise Awareness of Diabetes

(2003)

➜ IDF position statements

Vol. 40 No. 3 | World Hospitals and Health Services | 39


REFERENCE

World Hospitals and Health Services 2004 Volume 40 Number 3

Résumés en Français

PLANIFICATION ET CONCEPTION D’UNE TRADITION

DE SECURITE DANS LES HOPITAUX DE

THESSALONIQUE

(PLANNING AND DESIGN FOR A CULTURE OF SAFETY

IN THESSALONIKI’S HOSPITALS)

Thessalonique, seconde capitale de la Grèce, est située en

Macédoine dans la partie nord de la Grèce continentale.

Depuis l’ouverture des frontières des pays de l’ancien “bloc de

l’Est” et conformément à sa politique générale à l’égard de

l’Union européenne, Thessalonique est devenue une partie

importante de l’initiative des Balkans, et vise à attirer en Grèce

les patients de l’étranger. C’est pourquoi certains des hôpitaux

les plus modernes de Grèce sont construits dans le voisinage

de Thessalonique. La sécurité des patients constitue un

élément important de cette stratégie de conquête de marché.

Cet article tente d’examiner les caractéristiques d’une volonté

de sécurité qui se concrétise dans la planification et la

conception de deux des hôpitaux de Thessalonique. Ces

caractéristiques se retrouveront dans l’environnement

sanitaire des procédures cliniques actuelles, sur une base tant

qualitative que quantitative, et des suggestions seront faites

pour leur développement futur.

LE DIABETE : UN DEFI A L’ECHELLE MONDIALE

(THE GLOBAL CHALLENGE OF DIABETES)

Le diabète est l’une des principales causes de mortalité dans

la plupart des pays développés. Sous ses deux formes, le

diabète se répand sur tout le globe à une vitesse alarmante,

faisant de cette maladie l’un des problèmes médicaux les plus

épineux du 21è siècle.

La prévention joue un rôle essentiel, et endiguer ce fléau va

nécessiter la promotion d’une vie saine, d’un dépistage

précoce et d’investissements dans les programmes nationaux.

La Fédération internationale du diabète (International

Diabetes Federation, IDF) joue un rôle essentiel dans la lutte

mondiale contre le diabète. Ses objectifs sont l’amélioration

du diagnostic, des soins et des traitements du diabète; la

promotion des programmes d’éducation et de formation ; la

promotion de la disponibilité de l’insuline et à des prix

raisonnables, et la sensibilisation de l’opinion publique à cette

maladie. L’IDF espère que ces actions contribueront à sauver

la vie des diabétiques, ou à améliorer leur qualité de vie.

SANTE DES POPULATIONS EN EUROPE: QUEL EST LE

ROLE DES SOINS DE SANTE?

(POPULATION HEALTH IN EUROPE: HOW MUCH IS

ATTRIBUTABLE TO HEALTH CARE?)

Les soins de santé sauvent-ils des vies? Des commentateurs

comme McKeown et Illich, écrivant dans les années 1960,

jugent qu’ils contribuent très peu à la santé de la population,

et qu’ils peuvent en fait être nocifs. Toutefois, ces auteurs

écrivaient à une période où les soins de santé avaient

relativement peu à offrir par rapport à aujourd’hui. A la suite

d’études plus récentes sur la contribution des soins de santé

à la santé publique, l’opinion générale est maintenant que

McKeown avait raison dans la mesure où “les mesures

médicales curatives ont joué un rôle peu important dans la

baisse de la mortalité avant le milieu du 20è siècle”. Mais la

nature et la portée rapidement changeantes des soins de santé

signifient qu’on ne peut plus présumer que c’est encore le cas.

Plusieurs auteurs ont donc souvent décrit des améliorations

substantielles de la mortalité due à des maladies contre

lesquelles des interventions efficaces ont été introduites. Mais

le débat continue, certains argumentant que les soins de santé

ont des répercussions importantes sur le niveau général de la

santé alors que d’autres assurent que c’est vers les politiques

plus larges comme l’éducation, les transports et le logement

qu’il faut se tourner pour assurer les progrès de la santé.

Inévitablement, il s’agit ici d’une fausse dichotomie. Les deux

aspects sont importants. Mais dans quelle mesure les soins de

santé contribuent-ils à la santé de la population?

ADMINISTRATION DES SERVICES DE SANTE

(HEALTH CARE GOVERNANCE IN THE UK NHS)

Le Plan du NHS a préparé un programme ambitieux de

modernisation du NHS, qui vise à administrer les

performances de l’organisation et à améliorer et élargir les

services fournis. Une bonne administration des services de

santé est une condition préalable essentielle à tout effort de

modernisation. Cet article va explorer les responsabilités et les

implications des comités d’administration des soins de santé,

des directeurs et du personnel clinique pour assurer la bonne

administration des services de santé.

PROGRAMME NATIONAL D’INFORMATISATION DU

NHS

(THE NATIONAL PROGRAMME FOR IT IN THE UK NHS)

C’est une initiative passionnante et innovante du NHS qui

s’achemine vers la mise en place d’un service vraiment ancré

dans le 21 siècle pour ses patients et ses employés.

Tandis que le “National Programme for IT” du NHS entre

dans sa phase de mise en oeuvre, des systèmes et des services

sont en train d’être installés, qui vont révolutionner la façon

dont le NHS opère en Angleterre, pour le plus grand bien des

patients comme des employés.

Le plus grand projet civil d’informatisation, le National

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REFERENCE

Programme vise clairement à soutenir la vision d’un “service

centré sur le patient”, tel que présenté dans le livre blanc du

Gouvernement britannique “Delivering the NHS Plan”. Il est

indispensable à la modernisation du NHS. Il devrait jouer un

rôle essentiel si l’Etat doit répondre à l’augmentation de la

demande de soins de santé.

Le processus d’acquisition lui-même crée de nouvelles

normes, s’imposant comme une initiative modèle au

Royaume-Uni et ailleurs.

DU REVE A LA REALITE: LES ECUEILS DU

DEVELOPPEMENT DES TECHNOLOGIES DE

TELEMEDECINE. PROJET PILOTE EN INDE

(IMPLEMENTING TELEMEDICINE TECHNOLOGY:

LESSONS FROM INDIA)

La technologie des informations et des communications a

partout contribué à combler les déficiences du numérique.

L’application de l’informatique aux services de santé, la

télémédecine, est un moyen efficace de promouvoir l’équité

en matière de prestations médicales. Les pays en

développement ont également commencé à récolter les fruits

de ce miracle des progrès technologiques, mais la

concrétisation de ces rêves n’a pas été aussi rapide qu’elle

aurait dû l’être. La mise en oeuvre d’un projet pilote

d’envergure internationale sur les technologies de la

télémédecine en Inde s’est heurtée à de nombreux écueils dès

la conception de ce prestigieux projet. L’une des premières

leçons apprises durant l’exécution de ce projet pilote dans un

pays en développement, a été de classer les objectifs du projet

et modules plus petits, pour ne pas perdre de vue les

livraisons. Un rapport sur les difficultés rencontrées dans le

développement des technologies de la télémédecine en Inde

servira utilement à la mise au point de programmes de

télémédecine dans les pays du tiers monde.

LES MEDECINS ESPAGNOLS SONT-ILS PRETS A

TIRER PARTI D’ INTERNET?

(ARE SPANISH PHYSICIANS READY TO TAKE

ADVANTAGE OF THE INTERNET?)

Objectif: Analyser les opinions, attitudes et habitudes de

médecins spécialistes au sujet de la santé par Internet, et les

répercussions de ces facteurs sur les relations

malades/médecins.

Méthodologie: On a procédé à un sondage pour analyser les

attitudes, habitudes d’utilisation d’Internet et opinions de

302 médecins répartis dans huit hôpitaux espagnols, sur les

avantages et les inconvénients d’Internet.

Résultats: Sur l’ensemble des médecins interviewés, 80%

ont et utilisent Internet. Près de 40% utilisent Internet moins

d’une heure par jour ; les médecins de petits hôpitaux passent

plus de temps sur Internet et les hommes y passent plus de

temps que les femmes. Les sites les plus fréquemment visités

sont PubMed (11%) et Google (22%); dans le choix d’un

website, les remises à jour régulières et le prestige important

respectivement à 78% et 69% des répondants; 37% ont suivi

un cours par Internet; 35% consultent systématiquement

régulièrement des revues médicales électroniques; 16%

collaborent régulièrement à des websites médicaux, ou leur

envoient des articles; 12% reçoivent du courrier électronique

de leurs patients.

Trois groupes d’information ont été produits par cette étude

dans le but de classer les médecins hospitaliers participants:

les différents types d’information que les médecins

consultaient, la façon dont Internet améliore les relations

médecins/patients et les aspects que les médecins jugent

utiles lorsqu’ils se connectent sur Internet.

Conclusions: Les médecins espagnols considèrent Internet

comme un instrument qui facilite les relations

médecins/patients. Les technologies nouvelles accélèrent la

disparition de l’attitude paternaliste à mesure que les

patients ont accès à davantage d’information et de

ressources. On observe une attitude favorable à la recherche

d’un second avis par Internet, mais défavorable au

“bavardage” des patients.

World Hospitals and Health Services 2004 Volume 40 Number 3

Resumen en Español

PLANIFICACION Y DISEÑO ARQUITECTONICO PARA

UNA CULTURA ORIENTADA HACIA LA SEGURIDAD

EN LOS HOSPITALES DE TESALONICA

(PLANNING AND DESIGN FOR A CULTURE OF SAFETY

IN THESSALONIKI’S HOSPITALS)

Tesalónica es la segunda capital de Grecia, situada en la

región de Macedonia, al norte del continente griego. Tras la

apertura de la frontera de los países de la antigua Europa del

este y siguiendo su procedimiento general de política de la

Unión Europea, Tesalónica se convirtió en una parte

importante de la iniciativa de los Balcanes, cuyo objetivo se

proponía atraer pacientes de otros países a Grecia. Algunos de

los hospitales más modernos de Grecia se encuentran en los

alrededores de Tesalónica. La seguridad del paciente es la clave

principal de esa política destinada a atraer pacientes. En este

artículo, el autor se propone examinar las características de una

cultura de seguridad que forme parte integrante de la

planificación y el diseño arquitectónico de dos de los

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REFERENCE

hospitales de Tesalónica. Esas características deben existir en el

seno de la atención de la salud y dentro de los procesos clínicos

actuales, tanto desde el punto de vista cuantitativo, como el

cualitativo, proponiéndonos finalmente una serie de

sugerencias encaminadas a desarrollar la iniciativa todavía más.

EL PROBLEMA MUNDIAL DE LA DIABETES

(THE GLOBAL DIABETES CHALLENGE)

La diabetes es una de las principales causas de mortalidad en

la mayoría de los países desarrollados. Los dos tipos de

diabetes se están extendiendo en todo el mundo a una

velocidad preocupante, convirtiendo esta enfermedad en uno

de los mayores retos del siglo XXI.

La prevención es fundamental, aunque las claves

principales para detener esta plaga consisten en fomentar un

estilo de vida sano, la detección precoz y la inversión en

programas nacionales. La Federación Internacional de la

Diabetes desempeña un papel primordial en la lucha contra

esta enfermedad. Entre sus objetivos cabe destacar: mejorar

el diagnóstico, el cuidado y tratamiento de la diabetes,

promover programas educativos y de capacitación, mejorar la

accesibilidad y la capacidad de pago de la insulina y aumentar

la toma de conciencia del público acerca de esta dolencia.

Con ello, la Federación no sólo aspira a salvar vidas sinó

también a mejorar el nivel de vida de los afectados.

L ESTADO DE SALUD DE LA POBLACION EUROPEA:

¿HASTA QUÉ PUNTO SE DEBE A LA ATENCION DE LA

SALUD?

(POPULATION HEALTH IN EUROPE: HOW MUCH IS

ATTRIBUTABLE TO HEALTH CARE?)

¿Ayuda la atención de la salud a salvar vidas?. Según

escribían en los años sesenta los comentaristas McKeown e

Illich, ésta no sólo no contribuía en gran manera a mejorar el

estado de salud de la población sinó que además podría

resultar dañina. No obstante, estós se referían a una época en

la que los cuidados de salud no se podían comparar con los

de hoy en día. Estudios más recientes acerca del efecto de la

atención de la salud sobre el nivel de salud de la población

han dado lugar al consenso de que McKeown tenía razón

hasta el punto de que “los servicios asistenciales curativos no

desempeñaron un papel excesivamente importante en la

disminución del índice de mortalidad de antes de mediados

del siglo veinte. Sin embargo, dados los cambios habidos en

la atención de la salud en lo que respecta a su esfera de acción

y su naturaleza, no debemos asumir que este sigue siendo el

caso. Así, diversos autores han descrito a menudo mejoras

muy sustanciales en el índice de mortalidad a causa de

afecciones para las que se han encontrado procedimientos

eficaces. No obstante, el debate continúa mientras algunos

argumentan que la atención de la salud ejerce cada día más

influencia sobre el estado general de la salud del pueblo.

Otros sostienen que la asistencia médica está ampliando cada

vez más su esfera de actividad, con políticas relativas a la

educación, el transporte y la vivienda, mientras que lo que

debería hacer es concentrarse en avanzar todavía más en la

medicina. Esto no es del todo cierto, ya que hasta cierto

punto ambos aspectos son importantes. La pregunta es

¿hasta qué punto influye la atención de la salud sobre el

estado de salud de la población?.

ADMINISTRACION DE LA ATENCION DE LA SALUD

(HEALTH CARE GOVERNANCE IN THE UK NHS)

El Plan del Servicio Nacional de Salud (NHS) del Reino

Unido representa un interesante programa de temas

destinado a modernizar el NHS, dirigir el rendimiento de la

organización y mejorar y ampliar la prestación de servicios. La

buena administración de los servicios de salud es un

requisito indispensable para cualquier intento de

modernización. Este artículo explora las responsabilidades y

consecuencias para las juntas directivas, los jefes y el personal

médico de la asistencia sanitaria para poder garantizar la

buena administración de la atención de la salud.

PROGRAMA NACIONAL DE PUESTA EN SERVICIO DE

UN SISTEMA INFORMATIZADO EN EL SERVICIO DE

SALUD DEL REINO UNIDO

(THE NATIONAL PROGRMME FOR IT IN THE NHS)

Nos encontramos en un momento sumamente interesante y

revolucionario del Servicio Nacional de Salud del Reino

Unido, que da sus primeros pasos destinados a ofrecer un

servicio verdaderamente adecuado al siglo veintiuno para sus

pacientes y personal.

Conforme el Programa Nacional de puesta en servicio de

un sistema informatizado en el Servicio Nacional de Salud se

pone en marcha, el servicio de salud está instalando una serie

de sistemas y servicios que revolucionarán la manera de

funcionar de este sistema en Inglaterra, dando lugar a

numerosas ventajas, tanto para sus pacientes como para el

personal sanitario.

El mayor programa de informatización de la administración

pública, o Programa Nacional, tiene como único objetivo

ayudar a presentar la visión de “un servicio diseñado en torno

al paciente”, conforme resumía el informe del gobierno del

Reino Unido, Cumplimiento del Programa del Servicio

Nacional de Salud. Es un programa crucial para la

modernización del NHS. Es imprescindible para satisfacer la

demanda de cuidados que es cada vez mayor.

El procedimiento para la consecución en sí sentará

precedente, sirviendo de anteproyecto para otros sistemas,

no sólo del Reino Unido, sinó también del más allá.

¿ESTAN LOS MEDICOS ESPAÑOLES DISPUESTOS A

SACAR PARTIDO DEL INTERNET?

(ARE SPANISH PHYSICIANS READY TO TAKE

ADVANTAGE OF THE INTERNET?)

Objetivo: Analizar la opinión, actitud y costumbres de los

especialistas en cuanto al concepto E-Salud (salud

electrónica) y a las repercusiones de estos factores sobre las

relaciones entre el doctor y el paciente.

Metodología: La utilización de una encuesta, encaminada

a estudiar las actitudes, los hábitos en cuanto al uso de

Internet y la opinión sobre las ventajas y desventajas del

Internet, de 302 médicos de ocho hospitales españoles.

Resultados: El 80% de los médicos encuestados no sólo

tienen acceso a Internet sino que además lo utilizan. Casi el

40% está conectado durante algo menos de una hora al día.

Los médicos de hospitales pequeños pasan más tiempo

42 | World Hospitals and Health Services | Vol. 40 No. 3


REFERENCE

conectados y los hombres pasan más tiempo en el Internet

que las mujeres. Los sitios web visitados con más frecuencia

son PubMed (el 11%) y Google (el 22%). Para la selección

de un sitio web, la actualización periódica y el prestigio son

factores de importancia para el 78% y el 69%

respectivamente. El 37% ha seguido un curso de Internet. El

35% consulta revistas electrónicas de un modo sistemático.

El 16% colaboran con, o escriben artículos para sitios web

relacionados con la asistencia sanitaria. El 12% recibe correo

electrónico de sus pacientes.

Este estudio arrojó los tres grupos siguientes de

información con los que clasificar a los médicos hospitalarios

que participaron: los distintos tipos de información que

consultan los médicos, la manera en la que el Internet

mejora las relaciones entre el médico y el paciente y los

aspectos que los médicos consideran más importantes a la

hora de conectarse con el Internet.

Conclusiones: Los médicos españoles estiman que el

Internet es una herramienta muy útil para mejorar las

relaciones entre el doctor y el paciente. Las nuevas

tecnologías están acelerando el proceso de sustitución del

modelo paternalista por otro en el que el paciente tiene

acceso a mayor información y más recursos. Todo parece

indicar que hay una actitud positiva en lo que respecta a

obtener una segunda opinión en el Internet, si bien este no

es el caso en cuanto a los "chats" de los pacientes.

Palabras clave: Internet, e-salud, profesionales sanitarios

DEL SUEÑO A LA REALIDAD: LAS DIFICULTADES DE

UN PROYECTO PILOTO SOBRE LA TECNOLOGIA DE

LA TELEMEDICINA EN LA INDIA

(FROM DREAMS TO REALITY: CHALLENGES FACED IN

DEVELOPING ‘TELEMEDICINE TECHNOLOGY’ A

PILOT IN INDIA)

Las tecnologías de la informática y las comunicaciones (TIC)

han servido para tender un puente entre éstas y el mundo

digital a nivel univeral. La puesta en práctica de las TIC en la

salud -la telemedicina es una herramienta muy útil para

obtener la equidad en la prestación de servicios de salud.

También los países en vías de desarrollo han empezado a

sacar provecho de este prodigioso adelanto tecnológico, si

bien ese sueño no se ha hecho realidad con toda la celeridad

que cabría esperar.

La puesta en marcha de este proyecto piloto sobre la

tecnología de la medicina a distancia se ha visto empañada

por grandes dificultades desde el momento en el que se ideó

esta prestigiosa iniciativa. Una de las principales lecciones

aprendidas para la puesta en práctica de un proyecto piloto

en un país en desarrollo consiste en reducir los objetivos del

programa con el fin de no perder de vista las posibilidades

de éxito. Este relato sobre las dificultades con las que se

tropezó la India al poner en marcha la tecnología de la

medicina a distancia servirá de consejo de suma utilidad

para los futuros programas de medicina a distancia en los

países del tercer mundo.

Vol. 40 No. 3 | World Hospitals and Health Services | 43


REFERENCE

Directory of IHF professional

and industry members

The International Hospital Federation is grafeful to its 'D' members (listed below) who support the world

wide activities of the IHF through their membership. The IHF recommends that you give consideration to

their products and services.

BAHRAIN

AWAL DATA SOLUTIONS

Mr Vinu Thomas, Chairman

Mr Isa A. Al-Borshaid

PO Box 20743,

Manama Diplomatic Area,

State of Bahrain

Tel: (973) 531005

Fax: (973) 533067 / 296494

Email:acicorp@batelco.com.bh

http://www.awalcom.com

BARBADOS

TVA CONSULTANTS LIMITED

The TVA Consultants consortium has an abundance

of experience as architects and quantity surveyors in

the design, construction, and expansion of the major

hospitals and health care related facilities

throughout the West Indies.

Mr Jeremy A.N. Voss

Chief Architect

Grosvenor House, Harts Gap

Hastings, Christ Church

Tel: (246) 426 4696

Fax: (246) 429 3014

Email: tvabgi@sunbeach.net

BELGIUM

AGFA-GEVAERT NV

Ms Caroline Burm

Septestraat 27

B-2650 Mortsel

Tel: (32) 3 444 2111

Fax: (32) 3 444 7908

Email: caroline.burm@agfa.com

BRAZIL

HOSPITALAR FEIRAS CONGRESSOS E

EMPREENDIMENTOS LTDA

Dra W Santos /

Mr J Fco dos Santos

Rua Oscar Freire 379, 19° Andar

São Paulo 01426–001

Tel: (55 11) 3897 6199

Fax: (55 11) 3897 6191

Email:hospitalar@hospitalar.com.br

Internet: www.hospitalar.com.br

DENMARK

BIRCH & KROGBOE

Clausen Steen

Teknikerbjen 34

2830 Virum

Tel: (45) 95 55 55

Fax: (45) 95 55 65

Email: bk@birch-krogboe.dk

NOVO NORDISK, A/S

Novo Allé

2880 Bagsvaerd

Denmark

Tel: (45) 4444 8888

Fax: (45) 4449 0555

Email: webmaster@novonordisk.com

Internet: www.novonordisk.com

FINLAND

INSTRUMENTARIUM 0YJ

Mr Sami Aromaa

Director Global Communications

PO Box 900

31 Datex, FIN-00031 Datex-Ohmeda

Tel: (358) 10 394 11

Fax: (358) 9 146 3310

Email: webmaster@datex-ohmeda.com

Internet: www.datex-engstrom.com

GERMANY

FAUST CONSULT GmBH

Managing Director

Architects and Engineers

Biebricher Allee 36, D-65187 Wiesbaden

Tel: (49 611) 890410

Fax: (49 611) 8904199

Email: faust@faust-consult.de

Internet: www.faust-consult.de

MCC MANAGEMENT CENTER OF

COMPETENCE

Mr Harmut Loewe

Scharnhorststrasse, 67a,

D-52351 Duren

Tel: (49 2421) 121 77 11

Fax: (49 2421) 121 77 27

E-mail: loew@mcc-seminare.de

Internet: http://www.mcc-seminare.de

MESSE DUSSELDORF GmbH

Messe Dusseldorf is the organizer of medical

trade fairs all over the world, the leading one

of which is MEDICA

Mr H Giesen

Project Director

Messeplatz 1, D-40474,

Düsseldorf

Tel: (49 211) 456 001

Fax: (49 211) 456 0668

Email: giesen@messe-dusseldorf.de

Internet: www.messe-dusseldorf.de

SYSMEX EUROPE GmbH

Herr H. Hassenpflug

Director of Communications and Promotion

Bornbach, 22848 Norderstedt

Tel: (49 40) 527 26 0

Fax: (49 40) 527 26 10 0

E-Mail: Hassenpflug@sysmex-europe.com

Internet: http://www.sysmex-europe.com

HONG KONG

TUV ASIA PACIFIC MANAGEMENT

HOLDING

Mr Andrew Lee

Manager

Unit 602C Tech Center

72 TAT Chee Avenue

Kowloon Tong, Kowloon

Tel: (852) 2788 5150

Fax: (852) 2784 1550

Email:alee@tuvpc.com.hk

Internet:www.tuvglobal.com

INDIA

INV. ANF INFORMATION CREDIT

RATING AGA (ICRA)

Dr Shyama S. Nagarajan

4th Floor Kailash Building

26 Kasturba Gandhi Marg

110001,

New Dehli

Tel: (91 11) 233 57940

Fax: (91 11) 233 55239

Email: shyama@icraindia.com

Internet: www.icraindia.com

ISRAEL

SAREL SUPPLIES & SERVICES FOR

MEDIC ISRAEL

SAREL Ltd is the largest Israeli dealer in

pharmaceuticals and medical supplies and

the major supplier to all Ministry of Health

hospitals and clinics.

Dr M. Modai

President and CEO

Sarel House

Hagavish St Industrial Zone

Sth Netanya, 42504 Nethanya

Tel: (972) 9 892 2089

Fax: (972) 9 892 2147

Email: joshua@sarel.co.il

Internet: www.sarel.co.il

LEBANON

FEDERATION DES HOPITAUX ARABES

Dr Faouzi Adaimi

President

PO Box 7,

Journieh Notre Dame

Hospital, Journieh

Tel/Fax: (961) 964 4644

Email: HNDL@terra.net.lb

NORWAY

SYKEHUS UTVIKLING A/S

Mr Nils B. Ebbesen

PO Box 54,

1301, Sandvika

Tel: (47 67) 550712

Fax: (47 67) 559629

Email: nebbesen@online.no

PHILIPPINES

OPTIONS INFORMATION COMPANY

A publishing and event management company.

Ashok K. Nath

Chairman

#10 Garcia Villa Street,

St Lorenzo Village

1223 Makati City

Tel: (632) 813 0711

Fax: (632) 819 3752

Email: ashok@optionsinfo.com

Internet: www.optionsinfo.com

SWEDEN

BOULE MEDICAL AB

Robert Harju-Jeanty

Vice President, Marketing

Boule Medical AB

PO Box 42056

SE-12613 Stockholm, Sweden

Tel: (46) 8-744 77 00

Fax: (46) 8-744 77 20

Email: robert.harju-jeanty@boule.se

Internet: www.boule.se

CAPIO AB

Leading player on the European healthcare

market with units in Sweden, Denmark,

Norway, Finland, UK, France and Switzerland.

Ulrika Bohl

PO Box 1064,

SE-405 22 Gothenburg

Tel: (46 31) 732 4000

Fax: (46 31) 732 4099

Email:info@capio.se

Internet: www.capio.com

44 | World Hospitals and Health Services | Vol. 40 No. 3


REFERENCE

GETINGE INTERNATIONAL AB

John Hansson

PO Box 69

SE-31044 Getinge

Tel: (46) 3515 5500

Email: John.Hansson@Getinge.com

SWECO FFNS ARKITEKTER AB

50 years experience of planning and designing

for healthcare facilities worldwide.

Mr Anders Melin

PO Box 8054,

S-0700 08 Orebro

Tel: (46 19) 168 100

Fax: (46 19) 168 149

Email: anders.melin@sweco.se

Internet: www.sweco.se

WHITE ARKITEKTER AB

H Josefsson

Partner/Architect SAR, SPA

PO Box 2502

S-40317 Goteborg

Tel: (46 31) 608 600

Fax: (46 31) 608 610

Email: hakan.josefsson@white.se

Internet: www.white.se

SWITZERLAND

DIAMED AG

Patrick Jacquier

Head of Parasitology and Infectious Diseases

1785 Cressier sur Morat

Tel: (41 26) 674 5111

Fax: (41 26) 674 5145

Email: p.jacquier@diamed.ch

Internet: www.diamed.ch

JOHNSON & JOHNSON ADVANCED

STERILIZATION PRODUCTS

Mr Hans Strobel

Rotzenbuelstrasse 55

CH 8957 Spreltenbach

Tel: (41) 56 417 3363

Fax: (41) 56 417 3333

Email: hstrobel@cscch.jnj.com

UNITED ARAB EMIRATES

GULF MEDICAL COLLEGE HOSPITAL AND

RESEARCH CENTRE

Mr Thumbay Moideen

President

P O Box 4184, Ajman

Tel: (971 6) 743 1333

Fax: (971 6) 743 1222

Email: gmcajman@emirates.net.ae

Internet: www.gmcajman.com

INDEX CONFERENCES AND

EXHIBITION EST

PO Box 13636,

Dubai

Tel: (971) 4 265 1585

Fax: (971) 4 265 1581

Email: index@emirates.net.ae

Internet: www.indexexhibitions.com

UNITED KINGDOM

ASSOCIATION OF PRIMARY CARE GROUPS

AND TRUSTS (APCGT )

Mr David Selwyn

Secretary

5-8 Brigstock Parade

London Road,

Thornton Heath, Surrey CR7 7HW

Tel: (44) 20 8665 1138

Fax: (44))20 8665 1118

Email: mail@apcgt.org

Internet: www.apcgt.co.uk

EXTENDED SYSTEMS LIMITED

Mr Ben Mansell

Mobile Data Management

7-8 Portland Square

Bristol BS2 8SN

Tel: (44) 117 901 5000 or 0800 085 7090

Fax: (44) 117 901 5001

Email: ben.mansell@extendedsystems.co.uk

Internet: www.extendsys.com

FSG COMMUNICATIONS LIMITED

FSG Communications limited provides

publishing, conferences and exhibitions for

health professionals and the medical industry

involved or interested in Africa.

Mr Bryan Pearson

Managing Director

Vine House,

Fair Green, Reach,

Cambridge CB5 0JD

Tel:(44) 1638 743 633 Fax: (44) 1638 743 998

Email: bryan@fsg.co.uk

Internet: www.fsg.co.uk

GAEL LIMITED

Tulloch Gael

S.E. Technology Park

East Kilbride

Scotland G75 0QR.

Tel: (44) 1355 247766

Fax: (44) 1355 579191

Email: info@mindgenius.com

Internet: www.mindgenius.com

INTERNATIONAL HOSPITALS GROUP

LIMITED

Mr Witney M. King

Managing Director

Hertford Place, Maple Cross,

Herts WD3 2XB

Tel: (44) 1923 726 000

Fax:(44) 1923 896 759

Email: wmk@igroup.co.uk

Internet: www.ihg.co.uk

JONATHAN BAILEY ASSOCIATES (UK)

LIMITED

Mr Nicholas Shapland

Managing Director

3rd Floor, Stephen Building

30 Gresse Street

London W1T 1QR

Tel:(44) 20 7323 4578 Fax: (44) 20 637 9350

Email: nickshapland@jonathanbailey.com

Internet: www.jonathanbailey.com

MARSH EUROPE

Marsh is the leading advisor in integrated

governance, quality, risk management and

insurance matters to healthcare providers around

the globe. Our focus is to reduce the total costs of

risk whilst increasing quality and patient safety

throughintegrated healthcare services and

solutions.

Mr S. Robert Wendin

Tower Place, West Tower

London EC3R 5BU

Tel: (44) 20 7357 1000

Fax: (44) 20 7929 2705

Email: robert.wendin@marsh.com

Internet: www.marsh.com

OLYMPUS UK LIMITED

Mr Peter Wognum

Business Development Manager, EMEA

Dean Way,

Great Western Industrial Park,

Southall,

Middlesex UB2 4SB

Tel: (44) 20 7250 4800

Fax: (44) 20 7250 4801

Email: peterw@olympus.uk.com

Internet: www.olympus.co.uk

PRO-BROOK PUBLISHING LIMITED

Publishers for international government

organizations, NGOs and associations including

the International Hospital Federation, The

Global Forum for Health Research and the

Commonwealth Secretariat.

The Directors

Pro-Brook Publishing Limited,

Alpha House,

100 Borough High Street,

London SE1 1LB, UK

Tel: (44) 20 7863 3350

Fax: (44) 20 7863 3351

Email: info@pro-brook.com

Internet: www.pro-brook.com

QINETIQ

Mr Alun Williams

Managing Director – Health

Cody Technology Park

A1 Building, Ively Road

Farnborough

Hampshire GU14 0LX

Tel: (44) 1252 394 643

Fax: (44) 1252 393 625

Email: ahwilliams@qinetiq.com

Internet: www.qinetiq.com

RISK MANAGEMENT RESOURCE CENTRE

‘Capita Business Services

Mr Neil Griffiths

Managing Director

71 Victoria Street,London SW1H 0XA

Tel: (44) 20 7701 0000

Fax: (44) 20 7222 6122

Email: neil.griffiths@stpaul.com

Internet: www.capita.co.uk

SHEPPARD ROBSON

Sheppard Robson’s healthcare specialists

provide integrated design solutions for projects

ranging from Chelsea and Westminster

Hospital to research facilities in Zambia.

Mr Malcolm Mcgowan

Partner

77 Parkway, Camden Town,

London NW1 7PU

Tel:(44)) 20 7504 1700

Fax: (44) 20 7504 1701

Email:

malcolm.mcgowan@sheppardrobson.com

Internet: www.sheppardrobson.com

THE INTERNATIONAL eHEALTH

ASSOCIATION

Harry McConnell MD FRCPC

Director

3rd Floor, Millbank Tower,

21-22 Millbank,

London SW1P 4QP

Tel: (44) 20 8464 3223

Fax: (44) 7681 1523

Email: hwmcconnell@ieha.info

Internet: www.ieha.info

UNITED STATES OF AMERICA

AEROMEDICAL GROUP INC

Dr M.N. Cowans

1828, El Camino, Suite 703,

Burlingame, CA 94010

CERNER CORPORATION

2800 Rockcreek Parkway

Kansas City, MO 64117

Tel: (816) 221 1024

Fax: (816) 474 1742

Internet: www.cerner.com

CIGNA - International Expatriate Benefits

Mr Markus E. Zettner

590 Naamans Road Claymont, DE 19703

Tel: (302) 797 3494

Fax: (302) 797 3055

Email: Markus.zettner@cigna.com

Internet: www.cigna.com/expatriates

ERNST & YOUNG LLP

Sherry Hayes

Director

1225 Connecticut Avenue, NW

Washington DC 20036

Tel: (202) 327 6000

Fax: (202) 327 6200

Email: sherry.hayes@ey.com

Internet: www.ey.com

ESRI

Mr W Davenhall

Health & Human Services Solution Manager

380, New York Street, Redlands,

CA 92373

Tel: (909) 793 2853

Fax: (909) 307 3039

Email: bdavenhall@esri.com

Internet: www.esri.com

Vol. 40 No. 3 | World Hospitals and Health Services | 45


REFERENCE

GLOBAL MED-NET INC.

A Goeken Group company

Patricia A Schneider

Vice-President

1751 Diehl Road, Suite 400,

Naperville IL60653

Tel: (630) 717 6700 ext 211

Fax: (630) 717 6066

Email: pas81@aol.com

Internet: www.globalmednet.net

HEALTHTEK SOLUTIONS INC

Anthony M. Montville

Dominion Tower,

999 Waterside Drive,

Suite 1910,

Norfolk, VA 23510

Tel: (804) 757 625 0800

Fax: (804) 757 625 2957

Email: solutions@healthtek.com

Internet: www.healthtek.com

HORIZON STAFFING SERVICES

Mr Ahmed Ahsan

President & CEO

Corporate Headquarters

477 Connecticut Boulevard

Suite 215, East Hartford

CT 6018

Tel: (860) 282 6124 x 219

Fax: (860) 610 0078

MEDICAL SERVICES INTERNATIONAL

The President

20770 Hwy, 281 No.

Suite 108, #184,

San Antonio,

TX 78258-7500

Tel: (210) 497 0243

Fax: (210) 497 2047

Email:jramseymsi@aol.com

MEDIFAX EDI INC.

Medifax provides electronic connectivity

services between health plans and health

care providers for processing of health care

transactions.

Jeff Fadler

1283 Murfreesboro Road, Nashville,

Tennessee 37217

Tel: (615) 843 2500 - Ext 2103

Fax: (615) 843 2539

Email: jeff.fadler@medifax.com

Internet: www.medifax.com

MEDIGUIDE

MediGuide provides international healthcare

services to multinational organizations and

operates the world’s only online directory of

hospitals and physicians that is fully

functional in 16 languages.

Heather N. Ficchi

Marketing Assistant

300 Delaware Avenue, Suite 850,

Wilmington, DE 19801

Tel: (302) 425 0190

Fax: (302) 425 0191

Email: hficchi@mediguide.com

Internet: www.mediguide.com


OPINION MATTERS

Musings on the future of

health care systems

BY FERDINAND SIEM TJAM

FMR. PERMANENT SECRETARY MINISTY OF HEALTH SURINAME AND

FMR MEDICAL OFFICER, WORLD HEALTH ORGANIZATION

In the summer of 2000, the World Health Organization

published its World Health Report 2000. This report

considered a national health care system to consist of

three components: health service delivery, fairness of

financing and responsiveness to the need of consumers. It

focussed mainly on activities of patient care, which is also

the main activity of health care systems in Europe and the

USA. A review was made of the prevailing systems and

services of the WHO member states, and the results were

ranked according to their scores. Based on the above criteria,

the health care system of France was ranked as the number

one in the world. This finding raised quite a number of

eyebrows. It caused robust debates within the various

Regional Committees of the World Health Organization

and in national Ministries of Health. Doubt was cast on

the approaches, methodologies and information used for

compiling the ranking in this report. Interestingly, there

was little reaction from Academia, university departments

and health research institutes, and recently, little has been

said of health care systems.

In the summer of 2003, an extreme heat wave hit the

European continent and in the space of a few weeks, over

ten thousand mostly elderly persons reportedly died in

France alone. The prevailing view was that the French

health care system was to be blamed. It had been

deficient in its surveillance, care, early warning and

effective measures in dealing with the heat exhaustion and

dehydration that caused many elderly patients to die. Just

this summer, there was another outburst of anger among

some sectors of senior health care workers in France.

They were of the opinion that the French health care

system’s financing for up-to-date equipment and

remunerations had been lagging behind for too long.

Threatened action could be averted only just in time by

government intervention.

One can ask the question: what went wrong in a health

care system that was found by the World Health

Organization to be the number one only a few years

before? Did the French health care system deteriorate that

quickly? Or had the evaluation of the WHO, so widely

discussed, been incorrect, or was the health care system

concept defined by WHO different from what the people

in France think it should be? Conceivably, the answer is: all

of the above.

The care of the vulnerable and weak elderly is a matter of

domestic, or domiciliary care rather than ‘health care’. Their

need is primarily social, financial and organizational,

including human contact, assistance with cooking, shopping

and moving outdoors. Today, the care for the sick, infirm

and elderly is predominantly dealt with through institutions

and organizations rather than families. Reportedly, this

approach is weak in attention and interest for the dependant

person. And typically, heat exhaustion and accompanying

dehydration is more a matter of attention than medical care.

It remains debatable whether the domiciliary care for elderly,

who effectively suffer from a range of conditions that cannot

be alleviated or improved with a medical intervention,

should be considered a part of the responsibility of the

‘health care system’. The industrial action about insufficient

financing for up-to-date equipment and appropriate

remunerations is an expected and regular eruption in the

social landscape of any society. To what extent should this be

laid at the door of the ‘French health care system’?

In the approach taken by the World Health Report 2000,

financing was given a high profile. However, financing can be

argued to be an essential part of a system in the same way as

gasoline can be argued to be an essential part of an

automobile. Without the gasoline, the car cannot function.

But when considering the automotive concept of the car,

gasoline, not being specific to the car, is generally not

considered a major component of its design and operation.

Evaluating a health care system by the fairness of its

financing is like measuring the knowledge and practice of a

physician by his billing practices. How did the financing

component increase to such importance in the global

perception of a national ‘health care system?’

By the early 1990s, communism was all but gone and

socialism had taken a back seat. Demographic changes in

How did the financing

component increase to such

importance in the global

perception of a national

‘health care system?’



00 | World Hospitals and Health Services | Vol.40 Vol. No.2 40 No. 3 | World Hospitals and Health Services | 47


OPINION MATTERS

many industrialised countries, caused by a decline in births

and an increase in the older age brackets, together with

evolutions in medical technologies shifted interest and

attention. In the USA, a candidate with a democratic

platform that had distinctly Republican elements won the

presidential elections and launched a national debate on

‘health insurance’. In the UK, the labour party succeeded

with a ‘new labour’ programme that was remarkably centrist.

All through the 1990s, the globalization of world trade

and economies, of the market place and of quick financial

success became the dominant theme in Academia, the press

and the airwaves. Development and consequently health

care was hence forth seen primarily in terms of economics

and of fighting corruption. Issues and views in fashion in the

single remaining military and economic superpower came to

dominate academic thinking everywhere. And along the

way, these influences as promoted by the World Bank and

others, marginalized the United Nations and its specialized

agencies such as the World Health Organization. These had

no choice but to fall in line and sing from the same sheet.

In general, but certainly in health care, the world seems to

suffer from the ‘one-approach-will-solve-all’ notion. In the

1950s it was thought that only doctors could improve health

in the world. By the 1960s that belief had shifted to

‘administration’. In the ‘70s there was Primary Health Care

(PHC) and in the ‘90’s we saw the rise of economics as the

solution to all the ills of health. Of all these meanderings,

the PHC approach was the only one that looked toward a

common and communal effort rather than being driven by

an academic discipline or category of professional. That may

explain the relative success of PHC when compared to the

other approaches. What will the future bring?

One can also wonder, what has happened to Primary

Health Care. In its day, there has been much debate about

‘Primary Health Care’ as opposed to ‘Primary Care’ but, by

and large, it carried phenomenal inspiration. For many years,

not withstanding that the concept eluded any simple and

formal definition, PHC galvanized initiatives in all sectors of

all national ‘health care systems’ and may have helped to

expand development aid between countries. Along the way,

it was clear for all involved, that socio-economic development

was the basis of all social systems, and efforts were aimed at

finding alternative organizational patterns for national health

care systems to achieve acceptable results with available

means, effectively by ‘doing more with less’.

It seems that the approach to health predominantly in

terms of financing, has run its course. Old and new threats

are such as HIV/AIDS, Ebola, Malaria, SARS and TB remind

us that the essential dimensions of health are beyond

economics and financing. There is new interest in

developing relevant technologies, human resources,

organisation and methodologies for improvement of the

health of individuals and societies. The prevention of disease

and maintenance of health status is reasserting its place as

the most economic approach in health care.

Further a field, the global community is going through

new experiences. The economic rise of Asia is starting to

impact on the previous global balance of power. The military

dominance of the sole remaining superpower is being

challenged by a distinct entity with a clear but

unconstructive ideology. Action is on a scale that is much

more extensive than the ‘Yankee go home’ movement of the

1960s. The scope of the dissatisfied and disinherited in

today’s world is more powerful than before. Global trade is

showing some surprising elasticity and developments. A new

concern with military force and diplomatic initiatives with a

new significance for the United Nations is shaping up.

The future

Who can predict the future? All through history there have

been many attempts and all have turned out as yet to be

wrong. Therefore, no such attempt will be made here. All

that is offered are some musings, leaving the reader to

formulate his or her idea of things to come, based on their

own views and experiences.

What should a national health care system be in the

context of the nation’s needs and experiences? What

services should and should not be included? By whom

should it be owned and operated? The struggle to come to

terms with health care cost and also the whole range of

social benefits in the 15 or so well-to-do industrialised

countries, will certainly lead to new thinking on the roles,

rights and obligations of the government and the governed.

The high degree and speed of diffusion of ideas, methods

and mechanisms, which has led to almost instantaneous

adoption of approaches in these countries, may however not

lead to simultaneous or identical solutions.

Depending on their historic experience and current stage

of socio-economic and cultural development, the other

countries that constitute the majority in this world, will

adapt and adopt solutions according to their developmental

capacity and position in the geo-politics of the future.

Medical and health technologies will continue to improve

the capacity to deal with injury, physical and mental

degradation and human suffering. At the same time, the old

dangers to collective health by mutant pathogens will remain

present and probably increase, while the ever-present sociopathological

effects of poverty and depravity will probably

only increase. How will that health care system look, work

and be administered in the years to come? Hard to predict,

but everybody would agree that ours is an exciting world,

full of marvels. Fortunately, it also remains a brave world of

many good opinions and intentions, even if they do not

always remain true or useful. Best wishes for your personal

health system. ❑

Curriculum Vitae

Name: Dr Ferdinand Siem Tjam

Ferdinand Siem Tjam is a former Permanent

Secretary of the Ministry of Health in Suriname

and WHO Medical Officer. He is a Medical

Doctor with a degree in Public Health. He

qualified as flight instructor and as an airline

transport pilot, and studies political and

military history, ancient arms and armaments.

48 | World Hospitals and Health Services | Vol. 40 No. 3