• primary care groups/trusts
• clinical governance
• quality improvement

Numerous studies over the past 20 years have documented the extent of quality problems with health care in most Western European and North American countries. Efforts to improve the quality of care have therefore taken on increasing urgency, and the Department of Health in the UK has now promoted clinical governance as a mechanism for quality assurance and improvement.

The paper by Campbell and colleagues in this issue of QSHC details the challenges for this policy in achieving its goal, in particular the role and concerns of physicians as to how clinical governance is going to be implemented.¹ The resistance by physicians towards quality assurance and quality improvement efforts are, to my knowledge, common across all countries and health systems. This might seem paradoxical since, if one asked these physicians whether they wanted to deliver the best quality care possible to their patients, they would all say they did. Why, then, this apparent cognitive dissonance between the desire to deliver high quality care and resistance to organised efforts at quality assurance and improvement? I think there are at least four reasons.

The first is that physicians may not agree with the criteria by which quality is being measured. This concern has led to a great deal of expenditure of effort to improve the methods for case mix adjusting outcomes and the specification of processes so that clinicians feel the measures more accurately measure quality. Additionally, there is certainly a feeling on the part of some physicians that some measures of quality represent misplaced priorities, concentrating on those things that can be measured rather than on the things that are truly important for producing good patient outcomes. Fundamentally, however, I do not think that physicians disagree with most of the processes or most of the outcomes used or proposed for quality assurance and improvement. Even if we had perfect measures of quality, I think there would still be substantial physician resistance.

A second objection is that physicians view quality assurance and improvement programmes as an opportunity to blame them for anything bad that may or may not happen to the patient. This comes from the historical role of the physician as “the captain of the ship”, responsible for all aspects of care the patient receives. In some countries, such as the USA, it also raises the fear of financial liability through malpractice litigation. These are very real concerns, and trying to shift the culture from one of blame to one of openness and learning from mistakes will be difficult. However, even if this could be accomplished, I do not believe that this will result in a substantially increased acceptance of quality assurance and improvement programmes on the part of physicians.

“quality measurement and improvement will become as accepted and commonplace in health care as it is in virtually every other process in society”

The third reason for physician resistance is that physicians believe they are being asked to participate in quality assurance and improvement programmes on top of all their other clinical and administrative responsibilities. All too often we see the situation where a quality assurance or improvement effort is mandated without any commitment of resources commensurate to the task at hand. Physicians who are already working long hours, dealing with sometimes complex management issues, simply do not see how they can be expected to put this additional time in on top of everything else. Physician resistance is not likely to lessen without adequate funding for quality improvement efforts.

However, even if we could get perfect agreement on the measures of quality, shift the culture from one of blame to one of learning from mistakes, and provide adequate resources for the tasks at hand, I think there will continue to be physician resistance until they can see in “nuts and bolts” detail how a real programme works operationally and makes a measurable quantum leap in quality. In other words, there are no role models here. And the reason there are no role models is that no one knows precisely how to do this. Here is where the opportunity exists for some fundholders such as the UK National Health Service to show real leadership. Since no one knows exactly how this should work, the NHS should invite primary care groups and trusts to submit proposals for systems of clinical governance designed to make major improvements in quality across multiple conditions, over a fixed period of time (say 3 years), to be measured by any of the plethora of validated technical quality and art of care measures now available. The carrot should be that the NHS will put a substantial amount of new resources into the primary care group/trust to help accomplish these goals. The stick should be that the primary care group/trust is held accountable for the results and that, unless certain measurable yardsticks are achieved, they will have to give back some or all of the money. Then let the best and most creative proposals surface, fund them, and see what happens.

From this process, a model or models will arise that can be shown to work. Once physicians see how it can be done, patients experience how quality has improved, and the NHS sees the vast improvements that can be had for the investment, then quality measurement and improvement will become as accepted and commonplace in health care as it is in virtually every other process in our societies, from manufacturing light bulbs to flying aeroplanes. Let's hope that day is not too far off.