The NHS 10-Year Plan to move healthcare from hospitals to communities — a left shift — is not new, but lasting change will not be easy to achieve. Hospitals are gravity wells that are irresistible, dragging in attention and resources. Addressing certain factors are essential to facilitate a left shift and research in the BJGP will continue to cover these: workforce and funding spring to mind as the blindingly obvious. Research can illuminate the hidden work of general practice and offer guidance for models of care. At the time of writing, much remains open to discussion, as the UK Government has provided little tangible detail on neighbourhood healthcare.
It is the unintended, or unanticipated consequences, where vigilance is needed. Take the recent example, where the chronic unaddressed shortage of GPs drove NHS England to create the Additional Roles Reimbursement Scheme (ARRS) in 2019. This then resulted in the ludicrous situation of GPs, especially newly qualified ones, being unable to find work. Some have seen this as a conspiracy, that it was a deliberate cost-saving strategy, but I’ll keep my tinfoil hat in the drawer on this occasion. It struck me that a better explanatory heuristic is my extended version of Hanlon’s razor1 (or it could fall into a sub-category of Murphy’s Law): never attribute to malice or incompetence what can be explained by tampering with complex systems.
We should keep in mind that we can expect unanticipated impacts with this coming left shift in our complex healthcare system. Let’s hope for two things. Firstly, the developments have fairness as a core value — structural changes should be made to ensure we reduce inequalities across our communities; and, second, where good evidence exists, we keep it in mind. That may seem to soft pedal the role of evidence but it should be acknowledged that change in systems does not necessarily stem from original research. A lot of the work is local innovation driven by the people in the community with retrospective evaluation. At this point, I must admit that the BJGP has not always provided an easy home for papers on these types of new initiatives.
There is a letter in this issue expressing exasperation about the number of authors on research papers — inevitable, one might respond, when research is increasingly complex, multidisciplinary, and it is tackling sophisticated questions with collaborations across institutions. It needs a lot of investment and large teams. All these trends have made it even harder to get local innovations and service evaluations published in the BJGP. It is time we responded to that. This month, we are launching a new section of the journal, Innovation in Practice, where we aim to showcase ambitious innovation. The first article details the introduction of a Same Day Urgent Care model in the northeast of England and its impact on acute service usage. It neatly flags some of the challenges ahead for a left shift strategy in a system with non-recurrent funding and hospital-centric reporting standards.
Perhaps you have a systems-level service evaluation that might be suitable for Innovation in Practice? Visit www.bjgp.org/page/authors for advice on how to submit.
Highlights
Research this month looks hard at GP workforce, including numbers of GPs in the NHS, locum doctors, GP turnover, and a realist review explores how we might support GPs to deliver equitable care. A pair of Editorials lean into neighbourhood healthcare and Clinical Practice articles on the approach to lymph nodes in children and recognising thoracic outlet syndrome will guide care. Most importantly, we have our first ever Innovation in Practice article on the introduction of a same day urgent care service.
