What outcome for the NHS?

The mess that is the Health and Social Care Bill continues its weary way through parliament. After the rather too late but increasingly great professional protest of the past few weeks (doi:10.1136/bmj.e1675), can the public be mobilised to persuade the government to abandon the bill? As from next week a campaign of banner advertisements funded by individual donations will attempt to persuade Londoners—and, more specifically, the prime minister—to think again.

But for the moment we have to assume that the bill will be passed. This was the opening premise for a roundtable debate hosted by the BMJ at the Nuffield Trust summit last week. Delegates had heard from the secretary of state for health Andrew Lansley that everything was going fine and all would be well. So we asked 11 leading voices in healthcare to give their views on what the NHS will look like after April (doi:10.1136/bmj.e1661, www.bmj.com/multimedia). Views ranged from impatience to get on with the changes to fears that the new structures will struggle to achieve much needed strategic reconfiguration. Integrated care remains everyone’s holy grail, but opinions are deeply divided as to whether the bill will make this more or less likely.

One thing that all agree is essential is greater transparency on outcomes of care, which the new NHS outcomes framework should deliver (doi:10.1136/bmj.e1080). A focus on outcomes rather than processes of care is an important advance, but you’d expect the BMJ to question the quality of the evidence base underlying those outcomes. Lavinia Ferrante di Ruffano and colleagues do just that. In their Research Methods and Reporting article, they explain how to assess the value of diagnostic tests (doi:10.1136/bmj.e686). Most studies look only at the accuracy of individual tests. Some do better by comparing the sensitivity and specificity of test strategies. Better still are those studies that look at how diagnostic tests change decision making. But the only true way to properly assess the value of different diagnostic pathways, say the authors, is to compare how each one affects patients’ health. This means we must think of diagnosis not as a single event but as a complex intervention. Most of the evidence base for deciding which tests to offer patients won’t attempt this higher level of evaluation. So anyone charged with deciding which tests to buy for their patients should approach the evidence with their critical faculties on high alert.

Someone who has done as much as anyone to demystify the evidence base and promote evidence based medicine is Trish Greenhalgh. Her 10 part series on “How to read a paper” (www.bmj.com/content/315/7101/180), which led to her best selling BMJ book by the same name, are consistently among the most accessed articles on bmj.com. This week, after 21 years as a BMJ columnist, she is signing off (doi:10.1136/bmj.e1620). Her columns have personified for me the unique mix of voices that is the BMJ: good writing based on sound science that puts patients first. Over the years I have agreed with much of what she has written, and one thing in particular: that “the pen is, in some instances, mightier than the randomised controlled trial at effecting change” (BMJ 1994;308:142).