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M Rawlins, P Littlejohns, Eds. Abingdon, Oxon: Radcliffe Medical Press, 2004, pp 198. ISBN 1 85775 618 5
After years of focusing on throughput and a narrow definition of efficiency, the National Health Service in England turned its attention to dealing with the poor and variable quality of care. A mechanism was established for delivering a coordinated effort to set standards (National Institute for Clinical Excellence; NICE) to monitor them, and an expectation that all staff would have a duty for quality (clinical governance). Although policy makers had not sufficiently thought through the new system before implementing it and several aspects (such as the performance assessment framework and “star ratings”) have been a failure, these core activities have made a difference.
This book brings together a selection of short contributions from the 2003 NICE conference. Although individual sections are rarely of sufficient academic depth or practical detail to add to knowledge or provide guidance for action, it provides a historical record—a snapshot of the sort of activities stimulated by these quality initiatives in gaining evidence, informing clinical practice, implementing and monitoring implementation and the quality of services. It demonstrates the incredible energy and initiative both from the top down and the bottom up to improve quality of care. The true test will be whether the enthusiasm, so obvious from this wide range of contributions, can be sustained and become part of the fabric of the NHS, and to what extent it will be stifled by bureaucracy or taken over and muted by some of the professional bodies (surprisingly absent from the collection).
There is a strong emphasis on the evidence base of clinical services, perhaps most comprehensively applied so far in cancer with the development of national guidance since the mid 1990s (Haward, pp 176–180). In order to produce reliable guidance on a range of health technologies, it is important to summarise evidence in systematic reviews or, where evidence is insufficient, to carry out rigorous primary evaluations of health care. In the NHS the national R&D programme has, over the years, established a process for prioritising and commissioning such evaluations in order to feed directly into the policy needs. The Health Technology Assessment programme (Gabbay, pp 14–17) is perhaps unique internationally in linking the conduct of new evaluations closely to the strategic needs of the NHS. A similar link has been established in research on service organisation and delivery.
If research evidence is one of the key inputs to fuelling the engine of quality improvement in the UK, it is vital that we maintain a system for ensuring its production in a timely way through clinical and health service trials and national clinical databases. Early in the book Sir Iain Chalmers (pp 5–8) highlights some of the threats to high quality evaluative research in the NHS. A mixture of the incompetence of those responsible for developing and implementing arrangements for both ethics and research governance approval and European legislation has resulted in increased bureaucratisation (highlighted also in the 31 July 2004 issue of the BMJ) which makes it more difficult to carry out independent evaluative research in the NHS. Unless this is dealt with decisively, the optimism shared in this book is likely to turn sour.