Editor’s Briefing

CHANGE HERE

The NHS, with 1.7 million employees, is the world’s fifth largest employer, after the American and Chinese military, Walmart, and McDonald’s. However, unlike armies and chain stores, one of the hallmarks of the NHS is variation and inconsistency — in procedures, practices, and outcomes — and uniform and systemic change is difficult to initiate and sustain. Yet change has also been one of the constant features of the NHS, and further changes are essential if it is to survive. Two recent reports, by Professor Sir Bruce Keogh1 and Professor Don Berwick,2 in the wake of the Francis report and other alarm signals, emphasise the need for large-scale, trans-organisational changes, and also highlight the vulnerability of medium-sized organisations within the NHS, such as hospital trusts, to the failings and foibles of individuals in clinical and management roles. Both reports also reflect uncomfortable truths about the unhealthy management culture that seems to have permeated the NHS from top to bottom.

The Health Secretary’s latest plans include creating a ‘7-day NHS’ which, as well as having implications for the controversy surrounding the provision of out-of-hours primary care, will also expose the serious fault lines that have emerged in staffing levels of doctors and nurses. A blitz on inefficiency and the transforming potential of proper IT systems are also key ingredients. An editorial in a national newspaper that campaigns for improved access to the NHS was entitled Reform or die: the only NHS prescription, to encapsulate the urgency of reform, rather than the traditional prescription of injecting more cash into the system.

The analogy with the commercial sector breaks down again when recognising the absolute centrality of individuals (clinicians, researchers, managers, and others) to innovate, develop, and transform services at local and regional levels. Further questions now need to be asked about the adequacy of the education, training, recruitment, and supervisory arrangements for the creation of the next generation of the NHS workforce.

In this issue of the BJGP we examine a number of aspects of change in the delivery of primary care services, including sustainability, practice organisation, and commissioning. Perhaps unsurprisingly, the NHS is responsible for about 5% of car journeys in the UK, and Andrews and colleagues examine ways that practices can contribute to the reduction of this carbon footprint, pointing out that what is organisationally convenient for the practice may be less than patient-friendly and energy-efficient. Tim Ballard takes a broader look at sustainability and sees how the role of general practice and the quality of the primary care workforce are themselves potential solutions to the problem. The systematic review by Ng and colleagues found limited evidence that practice size was positively correlated with the quality of services provided, although not always with patient satisfaction, while van den Hombergh’s Editorial reminds us how little we really know about the best ways to configure and organise primary care services.

Checkland and colleagues report on the early experiences of clinical commissioning groups (CCGs) and draw out a number of key messages for their effective development, including the need to ensure GP engagement within these complicated organisational structures, and for GPs to ‘understand and buy into the legitimacy of the developing organisation’. There may be a difficulty in moving beyond dealing with the needs of the registered patient population to a more population-based view of service provision. The Debate & Analysis article by Sheehan and Newdick reminds us of the ethical and legal environment within which CCGs, confronted by difficult decisions in resource allocation, will need to work and to show transparency and fairness in their decision making.

The RCGP is currently in consultation with its members and fellows on the highly-charged topic of assisted dying, and in particular the need for the College to declare its position on the matter. We have published a further contribution to this debate from Ilora Finlay in this issue and next month’s BJGP will contain Editorials and Research articles on this subject. We encourage readers to make their views known; the consultation period ends on 9 October.