Effectiveness, efficiency, and leadership

After years of investment to bring the NHS into line with the European Union average for healthcare funding, the money is drying up. That’s hardly surprising, given the global financial crisis and the UK’s national debt. But what will it mean for patients, doctors, and other healthcare workers? Between four and 10 years of austerity, according to Chris Ham (doi:10.1136/bmj.b1760), and Nicholas Timmins (doi:10.1136/bmj.b1754), as they review the Chancellor of the Exchequer’s recent budget statement and its implications for the NHS.

Chris Ham likens the coming funding freeze to bereavement and warns against magical thinking. He means that politicians shouldn’t depend on the private sector for salvation, and that NHS organisations should overcome their fright and quickly engage doctors in making changes that save money and improve outcomes. Doctors, meanwhile, should become better leaders, raise quality, and help to reduce wasteful and unfair variations in practice.

Good timing, then, for the BMJ/King’s Fund debate on 28 April on doctors as leaders. Alan Maynard proposed the motion that “This House believes doctors are neglecting their duty to lead health service change” and exhorted doctors to take the NHS into “the EBM Promised Land advocated by Archie Cochrane and other significant leaders” (BMJ 2009;338:b1578, doi:10.1136/bmj.b1578). Cochrane, of course, was one of the founders of British epidemiology and author of the seminal book Effectiveness and Efficiency: Random Reflections on Health Services (London: Nuffield Provincial Hospitals Trust, 1972). Unlike the healthcare trials he called for, his reflections were far from random. More than 30 years on, Paul Glasziou is still arguing for the same thing—that, as most good ideas don’t work, there should be no new initiatives without piloting and external evaluation (doi:10.1136/bmj.b1765).

Paul was responding to Tony Delamothe, who got in well before the budget to propose 10 relatively painless cuts that the NHS could make while maintaining necessary focus on patient care (BMJ 2009;338:b1457, doi:10.1136/bmj.b1457). Actually, there were nine because the 10th slot was left blank for readers’ proposals. Most responders agreed with Tony’s suggestions, particularly those to cut the drug budget and to call off reorganising—or redisorganising—anything for the next five years. Christopher Burns-Cox added that the maximum salary for all staff should be £150 000, or five times that of the lowest paid in the service: “if people will not work for this amount they are not the sort of people we need in the NHS” (doi:10.1136/bmj.b1765).

You may be feeling depressed after reading all this. We hope you might take heart from (and perhaps refuge in) the BMJ’s online archive, which now goes back to the journal’s birth in 1840 (doi:10.1136/bmj.1744). It’s an extraordinary record of medical ideas, evaluations, achievements, and individuals. We’re justly proud of it and hugely grateful to the US National Library of Medicine and the UK’s Wellcome Trust and Joint Information Systems Committee who made it happen. It’s yours, however, as much as it is ours, and we want you to use it. To spur you on we’re running a competition for articles reporting the best use of the archive, and will publish the winning article in this year’s Christmas BMJ (terms and conditions at www.bmj.com/cgi/doi/10.1136/bmj.b1770).