Before I moved into the world of general practice, I used to live in the world of service improvement. It was a strange world, with its own language, traditions and practices. I kind of liked it, and look back on it fondly sometimes as you would when you remember a great place you once visited, like that trip to Sydney in 2003 when England won the rugby world cup, where they put beetroot on their burgers and thought calling me “blue” was hilarious on account of my red hair.

Anyway, in the service improvement world there is an ongoing debate about which type of change is best: should you go for small-scale continuous improvements, or a big bang change? In the world of general practice we are now facing the same question: can we adapt the existing model of general practice through incremental improvements into something different, or is a more radical approach required? Evolution versus revolution.

In the improvement world they use the terms “kaizen” (for evolutionary incremental improvement) and “kaikaku” (for revolutionary radical improvement). In the GPFV, high impact action number 10 is; “Develop quality improvement expertise”. Some believe this is the most important of all the actions because it gives practices a mechanism for making the other changes successfully. It includes techniques such as “plan, do, study act cycles” (or “PDSA cycles”) which encourage rapid cycles of testing of changes to enable successful adoption. This, and the techniques like it, are based firmly in the kaizen school of incremental improvement.

I have recently questioned whether the GPFV is failing to have the desired impact because it is trying to tackle each of the problems individually, rather than creating a clear vision for the future. A number of responses have challenged this, suggesting in particular that if all of the 10 high impact actions were implemented in a single practice that in itself would constitute our required vision.

But would it? If every practice implemented each of the 10 high impact actions, in a structured, incremental way, would the current problems of general practice be over? Certainly life would be better, but would it be enough?

Where they got to in the improvement world is that it is not an either/or. Big bang change is needed to break paradigms and elevate the awareness of people to a higher level of understanding. It is needed in addition to continuous improvement, not instead of it. While some problems can be solved by incremental improvement, others do require radical improvement to start with.

The challenge facing general practice is such that I don’t believe incremental improvement on its own will be sufficient. It needs kaikaku as well as kaizen. While the 10 high impact actions are an important part of the transformation needed in general practice, they are not the totality of it. I understand the GPFV is more than the 10 high impact actions, but if they are the element that provide the vision of the future, my contention remains they are not enough and a more radical transformation is needed.