Whatever the consequences of the Health and Social Care Act turn out to be, the inescapable conundrum facing the UK health system, among many others, is the imperative at the very least to maintain, and preferably to improve, standards of care and patient outcomes in a chilly financial climate. Within this ‘quality agenda’ are a number of still-unanswered questions about, among other things, inequities in the provision of and access to primary care, standards of nursing care and patient safety in hospitals, population health inequalities related to deprivation and exclusion, the morale and commitment of the NHS workforce, and the future of professional education and training. This is, then, no time to freeze in the headlights of reform and to give in to planning blight as the bureaucracy is overhauled yet again. There is, as Captain Jack Aubrey would undoubtedly have said were he in a senior management role, no time to lose: ‘This ship, is England. So it's every hand to his rope or gun, quick's the word and sharp's the action’.1
Which brings us neatly to the parallel challenge of leadership, about which much is presently being written and that, as Veronica Wilkie's editorial explains, has now caught the attention of the General Medical Council, whose recent document sets out a useful framework describing what might be expected of doctors as leaders. Of course, just as most clinicians won't be heavily involved in commissioning services within clinical commissioning groups, so most will not take a lead in setting the course through these troubled waters, if that isn't straining the O'Brian metaphor too much. Indeed, Sir Lewis Ritchie's 2010 James Mackenzie Lecture on the call of leadership2 employed images drawn from the seafaring life of north-east Scotland. And, Andrew Moscrop argues, any old leader won't do – we need leaders with a moral compass, attuned to the values and beliefs of those they lead, in contrast to the ‘unsettling model’ of leadership adopted by the coalition government over the NHS reforms. Quality and leadership are intimately connected. One tells the other where we should be heading and how we'll know when we have arrived.
Quality measurement and quality assurance are major themes of this issue of the BJGP. Mike Pringle's clear exposition of the relationships between performance, accountability, and quality indicators sets the scene for the introduction – much trumpeted, much delayed – of revalidation, the next quality assurance mechanism, about which he is optimistic. Helen Lester and a number of European colleagues report a valuable survey of practice accreditation, another quality indicator, in over 20 countries, and provide some useful pointers to the characteristics of effective and accepted schemes. Jacqueline Hill's paper from the Peninsula Medical School is a welcome exploration of the potential of another innovation – multisource feedback – in formative and summative assessment, and in revalidation. This approach is well-established in many professional and commercial settings and is likely to become an important component of quality assurance in the future. The quality theme runs through other papers on access, prescribing, palliative care, and patients' views of the Quality Outcomes Framework – in which the surprise expressed by a patient on finding that their GP was given an extra payment for taking their blood pressure struck me as particularly salutary.
We have published and written a lot about the challenges of making early and accurate diagnoses in primary care in the last year or two, and have concentrated mostly on serious organic disease and cancer. I think that a number of the studies we have published will have a tangible benefit on diagnostic awareness and precision. It was a pleasure, then, to have the opportunity to publish Sara Ryan and Helen Salisbury's important interview study – ‘You know what boys are like’ – delineating some of the experiences of the parents of children aged between 3–11 years diagnosed with autistic spectrum conditions. Although their conclusions and recommendations for primary care consist partly of generic advice on good consulting practice, their emphasis on a very careful exploration of the concerns and expectations of the parents of these children cannot be overemphasised. Come to think of it, their advice applies with considerable force to the interactional style we ought to expect, but frequently do not receive, from our political leaders.
Finally, we have to say a fond farewell to Professor David Morrell, one of the great leaders and heroes of academic general practice, who died in March, and whose obituary appears in RCGP News, and a big welcome to Trish Greenhalgh, whose first column for the BJGP ‘Outside the Box’ is published this month.
- © British Journal of General Practice 2012