BMJ  2006;332 (14 January), doi:10.1136/bmj.332.7533.0-f

Editor's choice

Swept along by the tide

Do health managers read the BMJ? A member of our editorial board tells me that an otherwise evidence-free meeting of senior healthcare managers was illuminated by someone brandishing recent BMJ articles on primary care and deprivation. Whether they changed the outcome of the meeting he does not relate, but I will use this opportunity to tell authors that the BMJ is keenly interested in publishing research that will help improve healthcare systems—variously called effectiveness research, quality improvement, or implementation science.

Faced with imperfect delivery of health care, it's natural to want to change things and to hope that change will be for the better. But Ann McDonnell and colleagues (p 109) warn that enthusiasm for organisational change can undermine attempts at evaluation and can blind people to potential downsides. Acute pain teams and NHS Direct were both top down innovations that were swiftly rolled out across the UK without, say the authors, adequate evaluation, leaving pain teams struggling for funds and NHS Direct under a cloud of uncertain cost benefit. (They could have used payment incentives for GPs as another example (p 71).) By comparison, they say the bottom up introduction of stroke units has been more incremental, and is now supported by good evidence.

Surgery is another area where under-evaluated technologies are adopted, at the risk of wasting resources and harming patients. Charles Wilson says this can be driven by patients' demands, low cost to the surgeon of learning the procedure, and aggressive promotion by manufacturers (p 112). He suggests six key questions that surgeons and institutions should ask before adopting new surgical technologies.

Enthusiasts for change will complain that all this evaluation stifles change—until some other enthusiast imposes an ill thought out change on them. There's no regulatory body that evaluates the safety of computer technologies for hospital administration, but changes here can have harmful consequences (News Extra, bmj.com) or just make you "intemperate" (p 127).

One unwelcome change for some readers has been the closure of access to the BMJ's non-research articles, which up until now were free for the first week of publication. The change was necessary to maintain subscription revenues. The peer reviewed research articles remain open access (free from the day of publication on bmj.com as well as being on PubMed Central), and the whole journal remains free to most countries in the developing world (those on the HINARI list). Non-research articles become free to all after a year of publication. It is always hard to be asked to pay for something that has been free, but we hope that those readers who don't get the BMJ free through their institution will see enough value in it to pay £20/$37/30 for a year's full online access.