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Since 1998 the UK government has developed a comprehensive strategy for quality improvement for the National Health Service (NHS). This includes national guidelines and standards for clinical care, a national system of inspection and monitoring, and a requirement for all NHS organisations to implement quality improvement strategies. A clinician has been appointed with responsibility for quality improvement within every NHS organisation (the clinical governance lead), but these doctors and nurses have been given little specific guidance on what actually to do. The choice of quality improvement strategies is largely for local leaders to decide.
What does the literature suggest is most likely to be effective? On the whole, single interventions have relatively little effect. Simply distributing guidelines or educational material rarely changes clinical behaviour.1 These may be more successful if combined with audit with feedback, computerised prompts, or academic detailing.2–5 Financial incentives can produce change,6 but are a blunt instrument and risk producing perverse incentives. Multiple interventions are generally more effective than single ones.7 Substantial claims are made for continuous quality improvement or total quality management strategies,8 9 but there is little clarity about the circumstances in which they produce major change.1011 Information on quality of care which is released to the public is mistrusted by doctors, but making information available may stimulate provider organisations to change care.12
Given an imperative from the UK government to do something, and a certain amount of guidance from past research on what is likely to work, we now have information from both primary and secondary care on what is actually being done. In this issue of Quality in Health Care Wallace and colleagues report the results of a survey of 86 hospital trusts.13 Virtually all had implemented educational programmes, had developed local protocols or guidelines for care, and had established local quality improvement groups. These were followed closely by formal or informal assessment of care by peers. Feedback of performance data was being used in just over half. Campbell et al14 have reported the results of a comparable survey in primary care. Educational activities were again the most commonly reported and in over half the primary care groups surveyed, the whole primary care group (approximately 50 doctors) was closing for one afternoon a month for joint educational activity—a major cultural change for UK general practitioners. Joint audits across practices were common, with half of the groups surveyed feeding back or planning to feed back identifiable comparative information. Unlike the survey of hospital trusts, more than half were providing financial incentives linked to quality improvement.
Wallace et al asked their respondents whether these strategies are likely to be effective. Despite the effort put into educational programmes and guideline development, fewer than half the respondents perceived these to be effective approaches—a view supported by the literature. Creating clinical groups to focus on specific issues was regarded as the most effective of the techniques being used. Clinical governance leads are faced with a paradox. They are under strong pressure to demonstrate activity. Yet some of the things which the literature shows to be most effective agents for change—such as academic detailing—are also heavily resource intensive. Both surveys indicate that modern approaches to behavioural change are being used, with active involvement of clinicians high on the list; in Campbell's survey over 90% were encouraging the development of personal learning plans by general practitioners. What is clear from both surveys is that a range of simultaneous techniques are being used, which is consistent with the literature on multifaceted interventions being more effective than single ones. This was certainly the experience of one recent quality improvement initiative in UK primary care where major changes in behaviour appeared to have been brought about by a combination of clear leadership and a range of financial and professional incentives.15
So what can be made of progress so far? There is no doubt that much activity has taken place. This is perhaps not surprising since a legal “duty for quality” has been put on NHS organisations, and chief executives of NHS trusts can probably expect to lose their jobs where serious deficiencies of quality are found. A wide range of quality improvement activities are now reported, many of which are at least compatible with the literature on interventions likely to produce change. We do not know how the activities reported by clinical governance leads reflect actual change on the ground, or even whether the respondents have the ability to know if such change is taking place—development of IT systems to monitor quality are a high priority across the NHS, but currently they are woefully inadequate. Likewise, we do not know whether those clinicians who have volunteered for roles as clinical governance leads have the experience of organisational change that is needed for them to be effective. In response to this potential deficit, the NHS has started a development programme for quality improvement leaders.
In terms of top down strategy, the UK NHS probably has the most ambitious quality improvement strategy in the developed world. Local leaders have been appointed throughout the NHS with freedom to develop a range of quality improvement programmes, though with no option to do nothing. In terms of actual results it is too early to tell whether the strategy is being successful. Activities reported so far are limited by the resources available, and clinical governance leads identify lack of time and resource as the major barriers to progress. The success of the policy is likely to depend on whether there is continued investment in an infrastructure for quality improvement and provision of protected time for quality improvement activities. These will be necessary to produce the cultural change among clinicians that will be necessary if quality improvement is to become a mainstream part of clinical practice, and not just an “add on”.16