Involving clinical professionals in managing and planning services.

British Medical Journal, Jan 31, 1998 by S.T. Atherton

A change of government should bring a new and fresh approach to the problems of the NHS, which in turn will invigorate the service and go some way towards correcting the inequities of the past. It is in this spirit that the new white paper on the NHS has been received by most health professionals.

From the doctors' perspective the important chapters are 4, 5, and 6--those on health authorities, primary care groups, and NHS trusts.

Health authorities will be responsible for assessing the health needs of the population and drawing up strategies (health improvement programmes) to meet those needs in concert with all other agencies concerned, including organisations outside health care. This provides an opportunity to rethink bur approach to planning patient care. Assessing needs first and subsequently determining the resources needed to meet those needs is an approach that should be welcomed. Although there is still a cash limited budget for the health service, such an approach would allow us clearly to define the priorities of care and will inform decision making in a way that clearly puts the patients first and should allow all clinical professionals to make their contribution.

Primary care groups, and, ultimately, primary care trusts, are possibly the white paper's most radical feature. The development of these groups has the potential for far reaching change in the provision of health care in Britain. Primary care groups are not optional: all general practitioners will be required to be within a group, and these groups will be answerable to health authorities not only for their financial stewardship but also for their standards of clinical practice. Closer working relationships between general practitioners are an inevitable consequence of this change. Given that general practitioners are not employees but independent contractors to the NHS, it will be interesting to see who will be the accountable officer for a primary care group. Is there potential for an explosion in bureaucracy, with more managers--a chief executive officer, finance director, and, possibly, medical director? All this, of course, runs counter to the white paper's promise to redirect money from bureaucracy to patient care.

For hospital trusts, a major change is the development of clinical governance, which places a new emphasis on the quality of care. This emphasis is welcome, but enormous difficulties exist in measuring the quality of clinical care. Much more work needs to be carried out on outcome measures if we are to determine which health care intervention produces the best outcome. If we are to develop very high quality care we may also discover that there are no efficiency gains and that the cost to the taxpayer may actually increase.

Long term service agreements organised around care groups or disease areas will give hospital clinicians an opportunity to make an important contribution to the future direction of the health service. This approach, together with the development of clinical governance and health improvement programmes, suggests that the government values the contribution of the medical profession in designing the future service and in ensuring its quality. However, there is little in the white paper to give confidence that clinicians will be greatly involved in planning the future health service. Hospital consultants, directors of public health, and general practitioners will have to work together to ensure that the management of the health service takes the role of the clinical professional seriously by involving and encouraging them at all stages of the planning process.

If we are to improve the service that we provide to sick people--and indeed to go further and improve the health of the nation--then we need to develop systems that allow us to take a long term view of the health needs of the population. Only then can we truly plan the resources that are needed to deliver this level of health care. In the past workforce planning has been centralised, done separately for each profession, and of poor quality. We need to look at how to develop integrated workforce plans together with integrated care.

The increased involvement of health care professionals in planning the future NHS is to be welcomed. The professions and the government need to be aware of three major issues: long term health needs, resource implications, and clinical practice that is based on prescribed standards of clinical care.

St Helens and Knowsley Hospitals, Whiston Hospital, Prescot, Merseyside L35 5DR

S T Atherton, director of medical services