Intended for healthcare professionals


Quality to the fore in health policy—at last

BMJ 1998; 317 doi: (Published 11 July 1998) Cite this as: BMJ 1998;317:95

But the NHS mustn't encourage quality improvement with punitive approaches

  1. Richard Thomson (richard.thomson{at}, Senior lecturer in public health medicine
  1. Department of Epidemiology and Public Health, School of Health Sciences, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH

    News p 97

    In its own words, the consultation document on quality in the English NHS sets out a formidable agenda for change. Nevertheless, it constitutes a major advance, putting quality improvement at the heart of the service.1 The proposals describe a national approach that encompasses the National Institute of Clinical Excellence (NICE); the Commission for Health Improvement (CHIMP); national frameworks in key disease areas; the previously described performance management framework, with indicators relevant to NHS priorities; and a national patient survey. Locally, implementation and monitoring will be delivered through clinical governance, supported by national and local systems for lifelong learning, and reviewed systems of professional self regulation. Do all these elements add up to a coherent approach?

    The national institute will appraise evidence and develop and disseminate guidance and audit methods. It will coordinate or take over current activities such as guideline development and effectiveness bulletins. This is desperately needed because the plethora of guidelines—of variable quality and developed by multiple bodies—has created confusion in the service.2 But how will it deliver this huge agenda, apparently without additional resources? The original role of the Agency for Health Care Policy and Research in the United States was similar, but even with huge resources it could not address the 30-50 annual appraisals proposed here and has had its role considerably curtailed. A further consultation document on appraisal is promised, but the danger exists that the national intitute's influence will be diluted by the requirement to engage closely with sponsoring companies for new drugs and technologies and to consult widely on its conclusions. What will be the status of its conclusions? Will its advice be clear and acted on? Will it be able to meet the differing needs of the Department of Health, of clinicians, and of commissioners? How would it deal with Viagra (sildenafil)?

    The Commission for Health Improvement will undertake a rolling programme of provider and service reviews. The experience with not dissimilar visits to schools by the Office for Standards in Education (Ofsted) is anecdotally one of frenzied and distracting preparatory activity and of a process that may fail to identify issues worthy of improvement. The former Health Advisory Service (not mentioned here) had a similar role and was criticised for inconsistently applying implicit standards and the absence of mechanisms for follow up action. Public reports and follow up action plans may meet some of the concerns about previous NHS review mechanisms, but the Ofsted experience suggests that not all concerns will be met. Furthermore, the role of the commission as a troubleshooter, and threats to send it in to sort out problems, may mean that it creates conflict and defensive reactions. I also worry about the publication of indicators for named hospitals and specialty by specialty. Even if they are over time to be risk adjusted, major concerns about the use and abuse of publicly available indicators exist.36 These concerns may be ignored in the drive to increase public accountability boosted by the recent Bristol case.7 Measurement for improvement is not measurement for judgment.8

    Thus, there may be a problem with reconciling the laudable commitment to continuous quality improvement with elements of the bad apple approach.9 While we need mechanisms to prevent serious problems, the external inspectorial nature of the commission and the publication of performance indicators may be counter to the underlying aims of the strategy, and may distract from the otherwise positive approach.

    The national patient survey is not convincing. What information is it seeking and why? Effort might be better placed in engaging the public in discussions on priority setting rather than eliciting their views on mixed sex wards. Will the survey ask about satisfaction, or health status and social circumstances, both of which are mentioned? Major methodological issues exist in assessing patient satisfaction.10 If the first survey is to take place later this year, what opportunity will there be for rigorous development?

    The phrase “lifelong learning” is new to this document and—alongside multidisciplinary learning and team working—is welcome. Education underpins quality, but much needs to be done to support lifelong learning for health professionals. While reform of the specialist registrar grade has produced educational improvements for doctors in training, present systems of continuous professional development, based around time and points accumulated, are oversimplistic and take little account of individual needs. Nor is there a system of appraisal of career grade doctors to support the proposed personal development plans. And what of other clinical professionals? At present nurses scrape around for small sums of money to attend local courses while their medical colleagues attend lavish international conferences; the balance will have to change.

    If we get it right, clinical governance will be the critical element for change.11 The history of quality improvement activity in the NHS has been one of fragmentation and marginalisation.12 Clinical governance offers a way of bringing together the many disparate components. Making quality of care a board level function is crucial: indeed, it seems absurd that financial issues have dominated boardroom discussion while quality of care has not. Nevertheless, work needs to be done to engage doctors and other clinicians and assuage their fears about the concept.

    Most encouraging overall is the consistency and coherence of the approach of A First Class Service, with a sense of coordination across policy areas. For example, the proposals will mesh with the forthcoming strategies on human resources and information technology. Too often NHS staff have had to change their values when moving from one policy area to another and have been judged against measures (such as the efficiency index) that reflect their achievements as accurately as fairground distorting mirrors. Previously services have been forced by NHS policy to concentrate on finance and activity. This should now change. Despite some concerns, the NHS now has an organisation-wide approach to implementing effective systems of quality improvement within its grasp: we must not allow the opportunity to slip through our fingers.


    I thank Paula Whitty and John Spencer for their advice.

    The author is director of the UK quality indicator project, which feeds back anonymised comparative data to trusts.


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