The latter part of the twentieth century saw a period of extensive and radical change in the structure and operating practices of the UK National Health Service (NHS). The dawn of the twenty-first century heralds a new era, during which the pace of change will be no less dynamic. The publication of the NHS Plan (Department of Health 2000a) presents new challenges for both NHS management and practitioners as the government seeks to modernize the delivery of health care. While the NHS Plan represents a top-down drive towards the development of clinical practice and patient-focused services, opportunities also exist for practitioners themselves to initiate change. The current climate of commissioning and quality provide a unique combination of challenges to nurses working within the community. On one hand, they can begin to visibly contribute opinions as to how services should be provided but on the other hand, they also have to demonstrate effectiveness, and develop their own practice and the way they deliver services. These two challenges may be seen by some as the Straw that breaks the camel's back and sends them off into early retirement or long-term sick-leave. However, the contributors to this book have, collectively and differently, seen these challenges as the greatest opportunity community nurses have had to demonstrate their contribution to health benefits for the population.
The UK NHS is different, if not unique, in terms of its organizational structure. Not only is the health service the largest single employer in Europe, but it is also a highly complex bureaucracy, with many interconnecting constituent parts. Most organizations separate out the functions of manufacture and new product development/innovation. Rarely, if ever, is an employee on the shop floor expected to generate ideas about new ways of working, never mind plan their implementation and