What's gone wrong with health care?

Challenges for the new millennium Edited by Alison P Hill King's Fund 190 pages£14. 99 This fascinating book starts with three brief case histories - based on reallife examples - of situations in which the treatment of patients went seriously wrong.

They include an ininterested GP, failure to respect the wishes of a dying patient, neglectful treatment of an elderly patient and a breakdown in the continuity of care of a seriously disturbed psychiatric patient, culminating in a multiple stabbing and death. There is also a case study of the dilemma facing a health authority in deciding whether or not to fund a millionpound, potentially life-saving therapy for a patient with only a slender chance of successful treatment.

These accounts are followed by a set of commentaries written from the perspective of a patient, a medical ethicist, a public health doctor, a primary care professional, a medical director and a health policymaker.

An underlying theme of all the commentaries is one of a system that is insufficiently sensitive to the needs and wishes of individual patients.

And within this context, failings resulting from breakdowns in the continuity of care stand out. It is when patients are passed from one professional to another or from one organisation to another that breakdowns too often occur. Basic lack of communication is usually the culprit; lack of communication between doctors and patients, between professionals and between different agencies.

But it is far easier to identify health service failings, especially with the benefit of hindsight, than to put in place systems that are less susceptible to breakdown. In its efforts to suggest improvements, this book draws on the collected thoughts of the great and the good of the medical and associated establishment assembled at a Leeds Castle conference in 1999.

Unfortunately, their collected wisdom amounts to only five slim pages on strategy and proposals. So while patientheld records, key workers and care plans all represent worthwhile ways of addressing systems failures, little detailed analysis is provided on their optimal content or methods of implementation.

However, the book, through its graphic account of the way in which the system fails too many patients, adds to the mounting case for a genuinely more patient-centred health service.

Ray Robinson Professor of health policy, London School of Economics.