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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 


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


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. 


D Corporate entities engaged in supplying goods and 

services to the health care industry. 


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


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


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 



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


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 


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. ❑ 


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 



(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 


Germany West 

France 

Italy 

UK 

Denmark 

Spain 

Greece 


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). 



250 

200 

MEN 1980 1998 

150 

100 

50 

0 

200 

Portugal 

Austria 


Germany West 

France 

Italy 

UK 

Denmark 

Spain 

Greece 


Sweden 

150 

WOMEN 1980 1998 

100 

50 

0 

Portugal 

Austria 


Germany West 

France 

Italy 

UK 

Denmark 

Spain 

Greece 


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. 


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. 


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


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. 

” 



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 


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 



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 



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. ❑ 


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 


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; 



➜ 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 



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 

Vol. 40 40 No. 33 | | WORLD World Hospitals hospitals and Health health Services services | 25 13


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 



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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Congress Centre, Berlin, Germany, 22-26 July 2002. 


INFRASTRUCTURE 

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and Hospital Epidemiology, Vol. 20, No 4, April 1999, pp.247-278. 

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Epidemion., 1993, 9, 5, pp. 504-10. 



The National Programme 

for IT in the UK National 


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 



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 



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. ❑ 


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’. 


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 



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


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 



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 



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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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. 


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 


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 


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 


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 


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 


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 


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. 


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 


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 


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 


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 


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 


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 


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


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


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.

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