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GPs don’t have “time or inclination” to make necessary changes to NHS, report says

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f102 (Published 07 January 2013) Cite this as: BMJ 2013;346:f102
  1. Nigel Hawkes
  1. 1London

Clinical commissioning groups will need an unusual combination of skills to meet the challenges that the NHS in England faces, new research concludes.1

And it is far from clear that GPs­­­—the chosen instruments for exercising clinical leadership under the reorganisation of the NHS—have either the time or the inclination to make it work.

John Storey and Richard Holti of the Open University studied the role of clinical leadership in the redesign of sexual health and dementia services in London and Manchester. They said that clinical leadership was often seen as the answer to the problem of managing rising demand without any more money, but they added that such declarations often underestimated the actual challenge and failed to spell out what was needed to make them a reality.

In three of the four service redesigns they examined, GPs had little involvement: clinical leadership came from the hospital sector. “This has implications for the new CCGs [clinical commissioning groups] which will take charge of the largest part of the NHS budget from April,” they wrote.

Service redesign was “inherently difficult,” the report said, because it involved changes that were both clinical and non-clinical, including areas such as organisation of clinics, booking systems, IT systems, and tariffs. To change the way a service was delivered involved challenging established habits in a wide range of occupational areas and in several distinct organisations. In contrast to the government’s mantra that reconfiguration should be locally led, the report found that it was facilitated by national strategy.

Far from inhibiting leadership at a local level, such strategic direction provided the material for local leaders to work with, it said. “Exhortation for more clinical leadership needs to be balanced by continuation of the effort in developing national strategies for particular clinical areas,” it said. Money to facilitate change was also important; modernisation of sexual healthcare in London, for example, required £5m (€8.6m; $11.2m) of funding and seven project support staff.

The experience of those involved in the four case studies showed many pitfalls awaiting the unwary. In some cases, managers objected to clinicians getting involved at all; in others, enthusiastic leaders eager for reform failed to carry colleagues with them and found themselves out on a limb.

Faced with the difficulties, some clinicians had become passive and fatalistic, while others restricted their ambitions on local leadership to a unit level. Relatively few had the necessary combination of persistence and skill to make wide-scale change happen.

Holti told the Times, “Formal project planning is not enough; rather, informal, lateral leadership is important. This is needed in order to bring along clinical colleagues, to reassure them and to win their cooperation and ideas. The most effective service redesigns were achieved when both of these processes worked in tandem.”2

Storey added: “In general, clinical leadership was found to occur at multiple levels, and the role of clinicians in shaping national policy should not be underestimated. Many of the important changes required national endorsement—and often funding—in order to put traction behind good ideas.”

What is striking about the research is the relative invisibility of GPs. Storey said, “In our view, GPs were the least well-equipped, least knowledgeable, and had the least amount of time.” The report itself concluded: “Collaboration between primary care and initiatives in the acute sector appears particularly difficult, apparently because of the pressure on primary care over the last few years and difficulties for GPs in finding the opportunity to take part in wider initiatives.”

Notes

Cite this as: BMJ 2013;346:f102

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