• coronary heart disease
• National Service Framework
• quality improvement

One of the main challenges currently facing all health systems is the need to improve standards by reducing unjustified variations in care. A variety of approaches have been adopted around the world to meet this challenge. In this issue of QSHC, Underwood and Beck¹ describe the use of National Service Frameworks (NSFs), one part of an ambitious programme of health system reform introduced in the UK in 1997.²

National Service Frameworks are weighty documents produced by “expert reference groups”. These groups consist of representatives from general practice, the Royal Colleges, hospital specialists, and patient advocacy groups. In addition to setting national standards for clinical care, they also define models of service provision and establish performance measures. Progress against these performance measures will form part of the assessment of healthcare providers by a newly established UK inspection agency, as well as forming part of a new appraisal process for individual practitioners. Their successful implementation is thus an important issue for all organisations within the UK NHS.

The coronary heart disease NSF used by Underwood and Beck was the second framework to be published and, as far as the recommended pathways and standards are concerned, probably the most straightforward to implement.^3,4 Underwood and Beck's evaluation is therefore timely. By examining the extent to which the recommendations in the coronary heart disease NSF are implemented once patients have returned to the community following an acute coronary event, the authors are focusing on an issue of wider significance—namely, the sustainability of a system wide quality improvement initiative. The results indicate that initial improvements in clinical care were not maintained and they argue that this is, in part, because the issue of sustainability is not adequately addressed in the framework.

In this context, two issues seem to be important. Firstly, NSFs and other “top down” quality improvement programmes are based on an underlying assumption that patients' interests are best served by following a biomedical model which implements the results of randomised controlled trials. This approach, as others have noted,^5,6 is not without problems. Such “generalisable” results conceal important variations, and the conditions under which randomised controlled trials are performed are very different from “real life”. It is therefore possible that the fall off in prescriptions is actually a function of the transfer of evidence to the real world of clinical practice in which patients have their own ideas about the appropriateness of medical advice. There is some evidence that, when presented with good evidence about risks, patients may make choices that are different from those we might expect.⁷ Without a deeper investigation into the reasons behind the fall off in prescribing, it is hard to draw any conclusions about what is actually happening.

Secondly, Underwood and Beck focus strongly on the role of hospital staff in implementing the standards. This is inappropriate, particularly in the UK. Whilst hospital cardiac rehabilitation programmes are important in the immediate aftermath of the event, the long term adjustments take place in the community, often with the help of primary care staff. If implementation of the service models and clinical guidelines in the NSF are desirable, then it is in primary care that much of the work will take place. The decision whether or not to take powerful drugs with many potential side effects should be taken by patients in partnership with their personal physicians, and should occur in the context of an holistic assessment of the patients' psychological and social, as well as physical, needs. Staff in primary care need support from their secondary care colleagues as well as prompt and comprehensive discharge information to help them in this process. They do not need more secondary care input in the community.

Where we would agree with the authors is in their assessment of the need for greater resources. Helping patients to make truly informed decisions about their lifestyle and medical treatment is labour intensive, and at present primary care in the UK is grossly underprovided with the resources to make this happen. The NSFs cannot be implemented, and early gains will not be sustained, unless extra resources accompany the additional work. The recent announcement of a cash injection for the NHS indicates that this message is at last getting through.