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Changing practice in health care

The NHS Plan insists that the health service must change. It is “a 1940's system operating in a 21st century world”.1But are the politicians pushing at an open door? Health care practitioners, after all, are adjusting to the National Institute for Clinical Excellence (NICE), the Commission for Health Improvement, and clinical governance. They are working with radically redesigned structures in primary care. In the space of a decade or less, the demand for evidence based practice has spawned new institutes, journals, and information channels and affected practice in each and every health care setting. Indeed, some might be tempted to argue that it is limited government funding for research and innovation that puts a brake on change.

Yet practice is also shifting in ways that engage with and sometimes collide with broader social changes.2 One sign of the times is when patients appear for a consultation with material they have downloaded from the internet or when they act jointly as part of a group of sufferers or service users to demand changes in the form of practice or the way it is delivered. Another is the crescendo of criticism of the General Medical Council (GMC) as one case after another has hit the headlines. Ways of doing things that have never been in question, suddenly seem no longer serviceable. Overused and overly simple as it may be, the call for “modernisation” demands a considered response.

I would single out three areas that need conscious efforts at consensus building if we are to build appropriate 21st century institutions and cope with the conflicts and tensions of social change in a constructive way. They relate to public accountability, interdependence, and diversity.

Public accountability was played down in the design of the postwar welfare state. The culture of the time …