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As quality of care is so high on the agenda of practitioners and policy makers, it is surprising that there are no systematic reviews of studies of the level of quality provided by healthcare services. In this issue of Quality in Health Care Seddon and colleagues report a systematic review of studies on the quality of clinical care in general practice in the UK, Australia, and New Zealand.1
The authors found that many published reports were methodologically poor and therefore only limited conclusions could be drawn from the findings. Around 90 papers were identified and, not surprisingly, the majority related to management of chronic care and only two related to acute conditions. Practices that took part in the studies were often self-selected, and many of the reports were from single practices. Despite publication of numerous evidence based guidelines in recent years, the authors found that clinical care in general practice consistently failed to meet high standards in all three countries.
Can the findings be assumed to apply to primary care throughout Europe? We can only speculate, but it would be surprising if care in other European countries was found to be substantially better than that revealed in the review. It is more likely that the range of quality would have been wider if a greater number of countries, with diverse healthcare systems and different levels of funding, had been included. The key question in response is: “How can variation be reduced and quality improved?”
The review does not provide information on methods that have been successfully used in general practice in improving quality of care, nor does it indicate whether the drive for monitoring clinical care came from the practices themselves or from other local or national initiatives. Various methods are likely to be used for monitoring the quality of clinical care. However, monitoring must be used in conjunction with a wide variety of methods of implementing change.2 The recent proposals for improving the use of information technology in primary care in the UK will make a wealth of anonymous and aggregated data available for monitoring and reporting aspects of quality of care. Linking variations in care to practices should allow the identification of obstacles to improving quality and therefore inform the choice of strategies to be employed to bring about improvements.
Previous research has identified obstacles to effective health care including clinical, patient related, and resource related categories.3 This study also showed that the main sources of information used in situations of clinical uncertainty were general practitioner colleagues and hospital doctors. In another survey, promotion and improvement of access to summaries of evidence were suggested as more appropriate methods of encouraging evidence based general practice than teaching about the skills of literature searching and critical appraisal.4
The combination of adequate monitoring and targeted implementation strategies implies that healthcare services require well developed systems for managing primary care. In many countries, however, the management of primary care is not a high priority since the vast majority of healthcare spending is accounted for by secondary care. Furthermore, the funding mechanisms in different countries have variable effects on management systems. This is both a problem and an opportunity. The problem is that, until the management of services is adequate, levels of quality are unlikely to improve dramatically. The opportunity is that the diversity in European healthcare systems makes possible evaluations of different systems. If nations were sufficiently motivated, we could determine which systems are associated with higher levels of quality.
Systems of quality assurance have been set up in most countries, but they use different methods which vary from inspection by external appraisers using explicit evidence based criteria at one extreme to informal discussions between colleagues at the other. Recent proposals in the UK have recommended a new framework to support accountability, improve quality, and reduce variations in care. These include the National Institute for Clinical Excellence (NICE) that will provide national guidelines,5 clinical governance (“a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding of care by creating an environment in which excellence in clinical care will flourish”), and new systems for annual appraisal of all doctors supplemented by regular revalidation at longer intervals. In addition, an inspectorate has been set up and given the title of Commission for Health Improvements.5
Almost 20 years ago Sir Donald Irvine (now president of the General Medical Council) pronounced quality of care as the outstanding problem facing general practice.6 Seddon et al1 have made it clear that this situation remains largely unchanged. If the new UK initiative finally resolves this problem, there will be valuable lessons for the health systems of other countries. If the initiative fails there will still be lessons, although they will not be so valuable.