How organisations contribute to improving the quality of healthcareBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1773 (Published 02 May 2019) Cite this as: BMJ 2019;365:l1773
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We thank Dr Crawford for his constructive response. His argument – that changes to the organisation and delivery of care should undergo rigorous evaluation, with a focus on impact on access to care – is well made. We have urged similar in previous commentaries,[2, 3] emphasising the importance of using meaningful measures of impact and remaining open to whether such changes are beneficial or otherwise.
We agree that the evidence base on reorganisation of specialist services has limitations – as noted, our work on stroke service centralisation only analysed changes implemented in urban settings,[4, 5] and evaluation of changes conducted in other contexts would be valuable. We are currently evaluating centralisations of specialist cancer surgery services, and recently published findings indicating that patients, professionals, and the public may be willing to travel for longer to a specialist centre in order to have better care and outcomes.
Given the potential implications of change for patients and professionals, we agree that change need not automatically be of benefit, and that resistance might be a reasonable response to proposals to change. However, as noted in our analysis piece, professional resistance can be driven by vested interests and under such circumstances needs to be challenged in order to achieve the goal of improving patient care. It is therefore important that people planning change – nationally or locally – take a critical view of the research they use (i.e. going beyond headline findings) to weigh potential benefits against the need to ensure that patients are not systemically disadvantaged by a proposed change. Further, this critical interpretation of the evidence should be incorporated into planning, consultation, and implementation, and through to evaluation, with a particular focus on ensuring that patient groups are not disadvantaged by it.
1. Crawford SM. Careful evaluation of change is mandatory. BMJ 2019;;365:l1773rr.
2. Lamont T, Barber N, de Pury J, Fulop NJ, Garfield-Birkbeck S, Lilford R, et al. New approaches to evaluating complex health and care systems. BMJ 2016;352:i154.
3. Ramsay AIG, Fulop NJ. Why evaluate ‘common sense’ quality and safety interventions? BMJ Qual Saf 2016;25:224-5.
4. Fulop NJ, Ramsay AIG, Hunter RM, McKevitt C, Perry C, Turner SJ, et al. Evaluation of reconfigurations of acute stroke services in different regions of England and lessons for implementation: a mixed-methods study. Health Services and Delivery Research 2019;7 https://doi.org/10.3310/hsdr07070.
5. Morris S, Ramsay AIG, Boaden R, Hunter RM, McKevitt C, Paley L, et al. Impact and sustainability of centralising acute stroke services in English metropolitan areas: retrospective analysis of hospital episode statistics and stroke national audit data. . BMJ 2019;364:l1 https://doi.org/10.1136/bmj.l1.
6. Fulop NJ, Ramsay AI, Vindrola-Padros C, Aitchison M, Boaden RJ, Brinton V, et al. Reorganising specialist cancer surgery for the twenty-first century: a mixed methods evaluation (RESPECT-21). Implement Sci 2016;11:155 10.1186/s13012-016-0520-5.
7. Vallejo‐Torres L, Melnychuk M, Vindrola‐Padros C, Aitchison M, Clarke C, Fulop N, et al. Discrete‐choice experiment to analyse preferences for centralizing specialist cancer surgery services. Br J Surg 2018;105:587-96.
Competing interests: No competing interests
Fulop and Ramsay describe how organisations can drive the changes in practice that can result in improved care. There is an underlying assumption in their article that all such change is beneficial.
All humans are capable of self-interest which can lead to errors. In their article the concept of challenge applies to dealing with resistance to change and does not acknowledge the concept that local experts may have valid grounds for opposing a change; the self-interest that is at issue here is that of those who seek recognition for bringing about change whether it is beneficial or not.
Organisational changes should therefore be subject to rigorous evaluation. The changes to the system of managing major trauma are discussed and the paper that offered an evaluation of them is cited but that evaluation raises its own methodological questions.
The reorganisation of stroke services is offered as an example of how a major project can bear fruit and Ramsay and Fulop have been involved in its evaluation. The fact that this process has only been shown to be effective in an urban context is mentioned in that study but is not part of the general discussion of stroke care.
A particular issue is the question of accessibility of services. In the UK a centralised approach to delivery of specialised services in cancer treatment has been assumed for more than half a century. Its weaknesses are apparent but are not often discussed.
All changes in delivery of healthcare should therefore be carefully evaluated. That evaluation should include the question: do these changes restrict access to care?
1] Fulop N and Ramsay A. How organisations contribute to improving the quality of healthcare BMJ 2019;365:l1773
2] Crawford SM Changing the System — Major Trauma Patients and Their Outcomes in the NHS (England) 2008–17. https://doi.org/10.1016/j.eclinm.2018.11.001
3] Morris S, Ramsay A, Boaden RJ Impact and sustainability of centralising acute stroke services in English metropolitan areas: retrospective analysis of hospital episode statistics and stroke national audit data BMJ 2019;364:l1
4] Murage P, Crawford SM, Bachmann M, Jones A. Geographical disparities in access to cancer management and treatment services in England. Health and Place 2016; 42:11-18.
Competing interests: No competing interests