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 …