The art of the possible: reforming community health services

In England, there has been a long standing tendency to seek to reform health services via large-scale structural reorganization and via seeking (at least in principle) to boost the power of health care commissioners to redesign services. Based on a review of community nursing services in an urban Primary Care Trust, this paper argues that such an approach has led to a situation where positive service development has stalled as senior managers prepare for the next reorganization (rather than focus on service improvement); where the underlying causes of failure to bring about universal transformation of community health services have not been addressed by ongoing organizational changes; and where providers now seem to look to commissioners to change services (rather than changing them themselves). In contrast, the paper argues that there is significant scope for those working in and managing community health services to focus on what is within their power to change--rather than waiting for others to do it for them.