In our era of “assessment and accountability” in health services it is important to be able to assess quality. Much has been written about measuring quality and quality assessment,^1,2 and there are some valuable and well known frameworks available for doing this.^3,4 Quality frameworks tend to include a number of different dimensions. It is clear that the concept of quality must be multidimensional but it is surprisingly difficult to map the frameworks onto each other.

Maxwell³ offers us an apparently comprehensive six dimensional framework (effectiveness, efficiency, equity, acceptability, appropriateness, and accessibility) which can be used to assess the quality of health services but, in Maxwell’s framework, certain key and essential elements such as (Donabedian’s) structure and process⁴ or attention to a more holistic approach to anticipatory health care offered to the individual are omitted.

Toon’s framework⁵ for conceptualising quality in the primary care setting in the UK is less well known. It includes four dimensions of quality: biomedical, business, teleological, and anticipatory. The biomedical dimension relates to the technical quality of care—how well care is offered from the point of view of known effective and appropriate interventions; the teleological dimension is related to the acceptability and humanity of care; the business dimension is about process and efficiency; and the anticipatory dimension is about offering holistic care—not just dealing with expressed demand but also with unmet need.

It is possible that frameworks differ because of fundamental differences in conceptualising the measurement of quality. For example, among health service researchers and practitioners there is a strongly held view that it is more appropriate to measure the processes than the outcomes or the effectiveness of individual services, since evidence based care is all about assessment of the appropriate circumstances in which to apply known effective interventions.

This is the approach taken by Steel et al⁶ in their paper in this issue of QSHC on developing quality indicators for older adults, where a number of evidence based criteria developed in the US have been adapted for use in the UK. The paper lists 119 potential quality indicators derived by Wenger et al⁷ using the evidence and consensus development methods, 102 of which were rated as applicable to the UK situation by a panel of experts.

But is this a reasonable approach? Known effective interventions may be misapplied or used in inappropriate or unsympathetic settings. Some would argue that outcomes or effectiveness are what matters and that processes may be immaterial so long as good outcomes can be achieved. However, there are drawbacks to this approach too. Good outcomes can result from inappropriate care. A very low mortality may result from unnecessary surgical intervention. As Brook et al point out,² not all poor processes result in poor outcomes.

It is possible that both of these “mainly process” or “mainly outcome” approaches pay inadequate attention to the views of patients who may be concerned with the humanity, acceptability, equity, or potentially more holistic nature of health care and the need to reflect these dimensions in quality assessment. Of course these are to a certain extent secondary dimensions, since there is no point in offering ineffective care more equitably or more humanely. But one of the reasons for the apparent mismatch between quality frameworks may be that “quality” of services depends on one’s viewpoint.⁸

It appears then that there may be differing viewpoints from which quality frameworks are constructed and used—the population perspective; the external auditor or evaluator’s perspective; the individual practitioner, patient or carer perspective; the payer perspective. Frameworks may differ because of these differences of perspective. And although it might be thought that an ideal framework for assessment of quality would incorporate all the essential elements from the different frameworks, it is likely that this might make for an unwieldy and potentially unusable quality measuring tool.

Wenger et al developed the original quality indicators for use in assessing the quality of clinical care for vulnerable elderly people in the US,⁷ and they occasionally used telephone interviews with patients to assess whether the care provider had complied with the quality indicators. Steel et al suggest that this might be a good idea in the UK because case note review is often difficult and time consuming. It is important, however, that, if these quality indicators are to be used in the UK in interviews with individuals, then they should be independently validated for that purpose with elderly people and with their carers. There is currently little evidence to support the contention that the technical quality of care is best assessed by patients themselves. To what extent are the proposed quality indicators comprehensible and assessable by means of an interview? To what extent do they relate to the concerns of the elderly people themselves? It may be that issues relating to humanity, acceptability, equity, or the holistic nature of health care are not covered—but they are key concerns of elderly people.

The objectives, the viewpoint, and the potential costs and drawbacks as well as the potential benefits of any quality assessment need to be very clearly understood before it is undertaken. The quality indicators developed by Steel et al are a good start, but they will need more work before they can be widely or routinely used in quality assessment across the UK, and the context in which they are used will be crucial.