Intended for healthcare professionals

Editor's Choice

Calling all social entrepreneurs

BMJ 2018; 362 doi: (Published 30 August 2018) Cite this as: BMJ 2018;362:k3671
  1. Fiona Godlee, editor in chief
  1. The BMJ
  1. fgodlee{at}
    Follow Fiona on Twitter @fgodlee

Do you see yourself as a social entrepreneur? If not, could you imagine becoming one? To fit the bill you would need to be motivated by altruism, not profit, able to think creatively, and willing to stimulate disruptive change despite not necessarily being in a formal leadership role.

These are the attributes that healthcare most needs if it is to flourish in an uncertain future, says Nick Black in his essay (doi:10.1136/bmj.k2605). Sadly, they are attributes that have been inadvertently stifled in the UK by three decades of national strategy, central guidance, rigorous assessment, and public accountability. This era of assessment and accountability, predicted by the editor of the New England Journal of Medicine in 1988, has delivered much of what it promised by way of better outcomes, more productivity, and less geographical variation, says Black. But these have come at great cost, imposing a bureaucratic, intellectual, and emotional burden on staff and creating “a low trust system” that discourages risk taking.

Meanwhile, the challenges are mounting. One of the greatest of these for health and care systems around the world is the growing number of frail elderly people. David Reeves and colleagues report that about 3% of people aged 65 or older are severely frail and 10% are moderately frail (doi:10.1136/bmj.k3349). They argue that identifying and properly planning integrated care for such patients has the potential to improve outcomes and reduce the burden on primary care.

Doctors may take some convincing that this will actually improve their or their patients’ lives. The evidence of benefit from assessment and care planning is slim, say the authors. And the overall growth in workload is taking its toll. Fewer GPs want to work full time (doi:10.1136/bmj.k3652), and more and more practices are at risk of closure, including, symbolically, in Tredegar, home town of Aneurin Bevan, the Labour health minister who launched the NHS (doi:10.1136/bmj.k3600).

Nick Black concedes that more money would provide some relief to hard pressed services, but only in the short term, and he worries that this might actually delay the tackling of underlying causes. He gives some heartening examples of real innovation in how health and social care are being designed and delivered.

What seems clear is that, as well as all you budding social entrepreneurs, we need courageous and enlightened leaders who will allow your creativity to emerge.

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