Opinion  

The framing document Leading local change gives some idea. It sets out five principles that PCTs should 'have regard to' when commissioning services and handling service change. So perhaps national principles for local application, allowing local services to be developed to meet local need, is the intended (and welcome) output of the Next Stage review.

There is a consequence to this approach, though - an upside or a downside, depending on your point of view. Principles need to be interpreted, and different interpretations may lead to entirely different actions.

Take the principles in Leading local change. Among other things, they say that change will 'always be led by clinicians and based on best available clinical evidence'. Certainly, clinicians should be involved in change - they understand patients' experience and have the knowledge and clinical vision. But the community nurses who are QNI project leaders know leading change takes enormous effort over long periods, so involving managers in leading change is better that putting it all on the shoulders of clinicians. Leading local change doesn't mention managers.

Another principle states that 'world-class quality of care ... must be led by local clinicians'. Again, it is easy to agree that local clinicians are key to delivering high-quality care. But every nurse on the front line knows the quality of care patients used to receive depended on the preferences, expertise and idiosyncrasies of the doctor treating them. National guidelines and protocols have largely ended this lottery, and are an essential component of modern, high-quality care.

So it's all in the interpretation. Principles are fine, as long as they are not taken too literally, and local commissioners and clinicians are given freedom to take mature and sensible decisions.

- Rosemary Cook, director, Queen's Nursing Institute