Alluring visions of patient empowerment, social solidarity and healthcare without frontiers were laid out under a cloudless sky in Granada, Spain, at the European Health Management Association last week.
But they were countered by delegates' sobering reports of running health systems for longer living and increasingly demanding patients in the face of growing staff shortages.
The Netherlands anticipates that by 2001, 20 per cent of its nursing posts will be unfilled, a Canadian speaker admitted that services in western Canada were being sustained by South African doctors, and nobody envisaged an early solution to recruitment problems.
In a keynote speech, Dr Michael Decter, chair of the Canadian Institute for Health Information and former deputy health minister in Ontario, reminded the 300 delegates who came from 33 countries, including Albania, Azerbaijan, Bulgaria and Mongolia, that life expectancy had increased more in the past 40 years than in the previous 2,000.
He added that health systems must be prepared for unprecedented demand as the post-war baby boomers become serious consumers of health services in their 50s.
Consumers at ease with fast food and computers would become increasingly intolerant of waiting lists and variable quality, he warned.
'We have become addicted to things that happen fast', he said.
But while many systems provided good-quality care for major accidents, they did less well on chronic conditions and elective surgery.
To keep pace with the expectations of a cash culture, health systems needed to gain much ground in information technology, he said. The human genome project was staggering, 'but most hospitals can't print you out a map of how to get from the parking lot to outpatients', while sluggish progress on developing electronic patient records meant hospitals knew less about their patients than airlines did about their frequent flyers.
'What the public wants is high quality, speed, appropriateness and accessibility, ' he said.
Canada's health service has moved from having 900 semiautonomous hospitals in 1990 to 300 health organisations today, and Dr Decter predicted that all health systems were likely to see a fall in the number and dominant status of hospitals.
'The long-established medical guild is under siege, as doctors are questioned about everything they have long regarded as sacred.
Nurses feel set upon, as their profession is restructured, hospital by hospital, nation by nation.'
Nursing, he considered, is the most 'battered' profession - nobody challenged this view.
No amount of reform would prevent casualties, Dr Decter warned. He cited a case in Winnipeg with striking parallels to events at Bristol Royal Infirmary:
a paediatric cardiac surgery programme, in which 12 of 34 babies operated on died, had only been halted after nurses twice refused to go into the operating theatre.
Deputy medical officer at the UK's Department of Health Dr Sheila Adam considered that the Bristol case demonstrated 'the problems that can arise when technology and patient expectations are out of pace'.
She said it was clear that parents felt they had not been adequately informed of the risks involved in the operations and there was no system for analysing quality.
The NHS had to be prepared for patients wanting more information and having access to more resources. Dr Adam pointed out that the proportion of UK households connected to the Internet had risen from 13 per cent in 1999 to 25 per cent a year later.
Investment in hospital information systems was essential, she argued.
She painted a picture of healthcare in the future that included 'networks of hospitals providing pre-booked protocol-driven care', drop-in specialist clinics, remote diagnosis and monitoring of people with chronic conditions, and 'direct access to self-care via the Internet'.
The picture of the 'wired retired' - older people taking responsibility for their health via the Internet - seemed to capture the imagination of several speakers. But it must be far from the thoughts of Bulgarians, 80 per cent of whom feel they are getting poorer.
It fell to a Polish speaker, Professor Jacek Holowka from Warsaw University, to point out how much political rhetoric and healthcare reality could diverge.
Reforms introduced in 1999 with the declared aims of equity of access, choice of doctor and social solidarity had produced 'major turmoil', with restrictions on entitlement, including the homeless and unemployed, and economising on drugs in order to pay doctors' salaries.
'Contrary to the ministry's intentions, access to service is limited and the quality of services is low. The corrupt practice of forcing patients to pay directly for services flourishes unchecked.'
The original reforms, which were slightly amended last May, amounted to 'a half-hearted attempt to make a smooth transition from a centrally controlled system to regionally organised services controlled by a free market'. Professor Holowka's solution was to 'privatise those hospitals that the local government will agree to sell and introduce private insurance'.
In Western Europe, researchers are grappling with traditional workforce issues. Did the Irish health service offer equality of employment when 70 per cent of its employees are women but most of the senior managers and chief executives are men, asked Eilish McAuliffe, senior lecturer in health services management at Trinity College Dublin.
A study of 300 staff in Eastern regional health authority showed that women were more likely to work part-time and three times more likely than men to have taken career breaks.
They were also more likely to be in the same position as they were when they joined the organisation. Most respondents wanted 'more childcare, more flexible working and more training'.
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