From the NHS reforms to the neurological examination: further evaluation required
Authors: Kamran Abbasi
Journal: Journal of the Royal Society of Medicine (2014)

The concept of the NHS as a natural experiment isn’t new. Neither is the sense that evaluation of major NHS reforms has barely been attempted and might even be considered undesirable by politicians. Why ask a question that might lose you a general election? The power of the NHS is the public’s emotional attachment to it. Failures of the NHS may not be viewed as unfortunate flaws in the system of care but as political misjudgements.

In politics, misjudgement has a high attrition rate. NHS campaigners have picked off politicians in constituencies where voters have been upset by changes to local services. At the next election, David Cameron, Nick Clegg, and Jeremy Hunt will all be challenged by doctors. Other high-profile politicians may also be targeted by the National Health Action party, who will achieve a publicity triumph if nothing else.

The hurt from the 2012 Health and Social Care Act remains. Questions are unanswered. Has the Health and Social Care Act achieved its objectives? How would we know if it did? Katikireddi et al.1 believe that four methodological challenges must be overcome to evaluate the Health and Social Care Act. First, we need to know what are the reforms to be evaluated. What, then, are the outcomes that are likely to change? When will the reforms have an effect? And, finally, what would have happened if the reforms had not been introduced? All questions are important, although the last one seems the most fascinating.

The authors believe that, even at this late stage and with ingenuity, some valuable information can be gathered. Regrettably, we may never know the true impacts of the NHS reforms. Mexico, Brazil, and China are finding ways to evaluate their major health reforms, yet it remains a task that is beyond us, the nation with a health service that has been a natural experiment since its inception. JRSM encourages further discussion, debate, and research assessing the outcomes of the Health and Social Care Act.

Health policy is important, as are clinical skills. When I mastered the full neurological examination as a medical student it was a major landmark. Now O’Brien2 tells us that there is no such thing, at least in the course of a clinical encounter, as it would take all day and more, waste a considerable amount of time, and achieve very little.

Bartholomew3 believes many open access journals also achieve next to nothing except buffering the cash reserves of publishers. He has a point but it would be wrong to damn all open access publications, plenty of whom, like JRSM Open, offer authors a low-cost route to publication of their work with free dissemination. Others believe, with some good reason, that peer review is a broken system and that publication with minimal or no peer review is preferable. The purpose of peer review at JRSM and JRSM Open is to improve the quality of articles between submission and publication. The decision to publish, whether on health service reforms, the neurological examination, or predatory journals, rests with the editor. All three subjects, I propose in the best tradition of articles in medical journals, require further evaluation.