Education And Debate

Quality and professionalism in health care: a review of current initiatives in the NHS

BMJ 1996; 312 doi: (Published 09 March 1996) Cite this as: BMJ 1996;312:626
  1. David Taylor, directora
  1. aGJW Health Affairs, London
  1. Correspondence to: 64 Clapham Road, London SW9 0JJ.
  • Accepted 13 February 1996

Since the start of the 1990s the NHS and the clinical professions have made significant investments in quality management in health care, and a plethora of initiatives has been aimed at service improvement. From a patient's perspective the extent to which these exercises have been cost effective is uncertain, although they have certainly involved great effort and enterprise on the part of many clinicians and managers. An important opportunity now exists to integrate this work into the mainstream of clinical and general service management. If clinicians can accept quality management concepts as central to their professional ethos and regulatory structures this could help them to maintain their professional authority and protect them and their patients from imposed decisions based on inadequate understanding of health care costs and benefits.

Maintaining and improving standards of service and care are central to professionalism in health care. The origins of the bodies that now represent and regulate medicine, nursing, pharmacy, and other professions in the health sector are closely related to the need to protect the public from “quackery” and the excesses of competition. This is appropriate in a service where users—patients—are often profoundly vulnerable.

Strong institutional structures underpin health care professionalism throughout the United Kingdom. Nevertheless, the creation of the NHS internal market has been accompanied by a plethora of initiatives and techniques aimed at improving quality. Many of these challenge traditional assumptions of professional authority. Despite the questionable public popularity of managers, the balance of power in the NHS and other European and North American health care systems seems progressively to be shifting away from clinicians towards health system managers.

This brief review outlines the factors driving such trends. It explores some of the tensions underlying the debates about health care quality issues such as clinical effectiveness and efficiency, clinical audit, institutional …

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