Quality and professionalism in health care: a review ofcurrentinitiatives in the NHS

David Taylor

Since the start of the 1990s the NHS and the clinicalprofessions have made significant investments inquality management in health care, and a plethora ofinitiatives has been aimed at service improvement.From a patient's perspective the extent to whichthese exercises have been cost effective is uncertain,although they have certainly involved great effortand enterprise on the part of many clinicians andmanagers. An important opportunity now exists tointegrate this work into the mainstream of clinicaland general service management. If clinicians canaccept quality management concepts as central totheir professional ethos and regulatory structuresthis could help them to maintain their professionalauthority and protect them and their patients fromimposed decisions based on inadequate understand-ing ofhealth care costs and benefits.

GJW Health Affairs,LondonDavid Taylor, director

Correspondence to:64 Clapham Road, Londonsw9 oJJ

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Maintaining and improving standards of service andcare are central to professionalism in health care. Theorigins of the bodies that now represent and regulatemedicine, nursing, pharmacy, and other professions inthe health sector are closely related to the need toprotect the public from "quackery" and the excesses ofcompetition. This is appropriate in a service whereusers-patients-are often profoundly vulnerable.

Strong institutional structures underpin health careprofessionalism throughout the United Kingdom.Nevertheless, the creation of the NHS internal markethas been accompanied by a plethora of initiatives andtechniques aimed at improving quality. Many of thesechallenge traditional assumptions of professional auth-ority. Despite the questionable public popularity ofmanagers, the balance of power in the NHS and otherEuropean and North American health care systemsseems progressively to be shifting away from clinicianstowards health system managers.

This brief review outlines the factors driving suchtrends. It explores some of the tensions underlying the

"Healtnproressionsanarneirrepresenrarive boaiesnownave an opporrunityro incorporatequality management concepts fully into their ethical and regulatory systems"

debates about health care quality issues such as clinicaleffectiveness and efficiency, clinical audit, institutionalaccreditation, and individual reaccreditation andexamines the importance of quality management to thefuture development of the health care professions.

Forces driving changeSurvival in good health is valued not only because

people want to avoid pain and other forms of suffering,but because without it they cannot enjoy all the positiveaspects of life. Arguably, the true wealth of a com-munity is best measured by the health status of itspopulation rather than by financial measures such asgross national product.'

In the 1950s and 1960s more spending on health carewas often assumed to lead automatically to betterhealth and so greater general well being. But morerecently enhanced awareness of other determinantsof health-such as housing, employment, and familyand social (class) positioning-has promoted a morecritical political approach to health service funding inall developed countries.Other factors have also led politicians to question

the principles underlying the welfare state and addedto pressures to contain health and social service costs.They include the oil crisis of the 1970s, the emergenceof far eastern and other previously non-industrialisedcountries as economic competitors, and the increasingcost of health care technologies available for treatingthe diseases prevalent in aging populations. Theglobalisation of economic activity and changes inpolitical ideology have profoundly changed the socialclimate in which agencies such as the NHS exist, givingcredence to beliefs that the funding, organisation, anddelivery ofhealth services must radically change.

Quality managementAgainst this background the reforms of Working for

Patients (a white paper title which in itself embodied animplicit challenge to the health care professions) wereintroduced in the NHS at the start of the 1990s. Theemerging NHS internal market has seen much effortput into many types of quality management initiative(see box).2 Given such an apparently disparate range ofactivities, together with the competing claims of healthprofessionals, managers in NHS trusts, and managersin health authorities all to be the true guardians ofhealth care quality, it is not surprising that a degree ofconfusion and cynicism has resulted.There have also been many attempts by academics

to model and define health care quality. In theUnited Kingdom the best known of these includeDonabedian's distinctions between quality related tostructure, process, and outcome and Maxwell's sixdimensions-effectiveness, acceptability, efficiency,access, equity, and relevance.3 The use of suchapproaches can help promote valuable insights into thestrengths and weaknesses of services. But complexintellectual analyses of "quality" risk leaving manyhealth care workers uncertain and worried that theirworking lives are being diverted towards the pursuit ofa chimera called quality that has little to do withpatients' real needs.

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IMOV

Quality (management) initiatives in the NHS

Initiative/techniqueAccreditation systemsAnticipated recovery pathwaysAuditBenchmarking/benchmarking clubsBusiness process re-engineering

BS 5750/ISO 9000

Clinical auditCochrane Centre

Communications programmes

Complaints systems

Consumer surveys

Disease management

Effectiveness Bulletins

External probity and VFM(value for money) auditInspectorates

King's Fund organisational audit

Medical/professional auditPatient's Charter

Patient focus

Performance indicators and targetsProtocols/guidelines

Quality of life measurement

Quality management assessmentsystemsRisk (and claims) managementsystems

Total quality management

DescriptionTechniques for assessing institutional fitness to practiseMultidisciplinary methods for planning and monitoring treatmentsProcess for the systematic, cyclical review of the objectives and standards of practiceSet of techniques for comparing processes between competitor organisationsRadical review of organisational activities, implemented using the methods of totalquality management (TQM, see below)A form of accreditation based on review of documentation of standard operatingprocessesMultidisciplinary, professionally led systematic review ofpatient carePart of the NHS research and development programme; it organises systematicreviews of randomised controlled trials and other evidence of the effectiveness ofclinical careGood communications between providers of services and all their internal (sameorganisation) and external customers are an integral part of quality managementThe facilitation and analysis of customer complaints is also important in totalquality management (see below)Large numbers of surveys and monitoring exercises, of varying quality, have beenconducted by NHS agencies since 1990Term commonly applied to health care quality management initiatives funded orrun by the pharmaceutical industry. Also linked to the US term "managed care"Produced by academic teams in York and Leeds as a part of the research anddevelopment programme's push towards evidence based careIncludes NHS studies such as those commissioned by the Audit Commission.External audits may have either or both policing and developmental functionsPublic service health and welfare inspectorates include the Health AdvisoryService and the Mental Health CommissionA form of accreditation and linked developmental support run by the King's Fund,an independent policy and educational institutionUnidisciplinary auditA set of monitored patient rights and standards first established in 1992 as partof central government's Citizen's Charter initiativeAn approach originally developed by US management consultants, designed toensure that patients' "journeys" through care processes are timely and convenientAs contained, for example, in the Health of the Nation programmeSets of treatment options and agreed decision making criteria, which may serveas a basis for systematic evaluation of clinical and allied care standardsThere are now over 400 English language instruments available for assessing qualityof life, either in relation to specific conditions or overall wellbeingA form of organisational audit. Examples include the Malcolm Baldrige award inthe US and the European Quality AwardAn approach to quality improvement based on techniques designed to minimisethe risk of unwanted events for which the organisation might be liable or otherwiseincur costsSee text: TQM techniques seek to enhance organisational sensitivity to customerrequirements and optimally involve everyone in an organisation in meeting them

In fact, quality definition and quality managementinvolve two conceptually simple tasks:* agreeing the desired attributes of any given type ofgood or service; and* establishing ways of working to produce goods andservices with such attributes as efficiently as possible.

In essence all the various systems available to helpimprove health care quality, from professional auditand quality assurance programmes to commerciallymarketed disease management and "total qualitymanagement" tools, include only three key elements:* techniques for understanding the requirements andexpectations of service customers/users/patients-inthe customers' order of importance;* techniques for overcoming barriers to cooperationbetween groups within organisations, for sharinginformation and skills, for facilitating individual andorganisational learning, and for releasing individualenergy and enthusiasm into efforts aimed at meeting orexceeding customers' expectations; and* empirical techniques for measuring performance

and attaining agreed standards and for analysing andimproving the processes of producing and deliveringgoods and services.

Value for money?In ideal settings, where people needing goods and

services have a good understanding of the attributes ofthese goods and services and can pay for them directly,approaches of the type indicated above represent apotent protocol for commercial success. Furthermore,the pursuit of sectional profit will be consistent withoverall public interests. The only losers will be thoseproducers or service suppliers who fail to invest inquality. Quality is also free to those that achieve it inthe sense that it is often cheaper to do something oncewell than to have to repeat poorly done work, althoughin areas such as health the costs of good care normallyexceed those of neglect.But ideal worlds are hard to find. The health care

market is by no means perfect. Critics of health care

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quality management have questioned the evidence ofthe effectiveness of the techniques used. They havequestioned the extent to which patients have benefitedfrom the up to £1 billion spent in the NHS on variousforms of audit, service standard setting, data monitor-ing, and other types of quality initiative since the startof the 1990s.

It has been suggested, for example, that in complexareas such as the care of seriously ill patients thesimplistic application of market based concepts ofconsumer sovereignty may undermine professional-patient relationships. And if misapplied the use ofeasily measurable indicators to assess performancein the health sector could draw attention away fromaspects of care which, although difficult to measure,are more important to the wellbeing of both indi-viduals and populations. At worst, critics claim,the aggressive managerial pursuit of better quality canmerely serve as a smoke screen to conceal reductions instaffing, and ultimately in the provision of care itself.

Balance and integrationSuch concerns have some substance. But they

should not be permitted to detract from the funda-mental point that-despite the conflicts over controland funding within the NHS-professionals, politi-cians, and managers share important commoninterests in trying to ensure that health care processesare genuinely effective and efficient in meeting patients'requirements. Conducted with integrity quality man-agement programmes address precisely this issue. Andthere is currently little reason for complacency aboutissues such as, say, standards of communication withpatients within the NHS.

Actually realising opportunities for improvinghealth care often demands greater mutual respect andcooperation than currently exists between clinicians,trust managers, and health authority staff. Members ofthese groups often unnecessarily mistrust each other'sunderlying motivations. One key to achieving bettermutual understanding lies in realising that each groupis typically concerned with different-but equallyvalid-levels of quality (fig 1).4The experience of many organisations in many

parts of the world confirms that scientifically basedapproaches to analysing and changing ways of workingcan bring significant benefits, not least in terms ofpromoting greater intemal consensus. Many cliniciansand service managers firmly believe that quality man-agement techniques have similar benefits to offer inhealth care and that participation in quality improve-ment exercises such as the Sigma projects in Trent and

Population based care: health outcomes andservice quality considered across all dimensions

System and agencies. Complex trade offs often required.quality Traditional focus of managers in health

authorities and political level health policydecision making

Information

Service standards and user/purchaser satisfactionnstitution

considered in relation to the requirements of theyInstitutional clients served/selected. Regulation of processes<quality y and costs often central activities. Natural focus

of market oriented provider managers

andprioritisation

Individual care: access and effectiveness dominantEpisodic considerations, together with relief of immediate

quality distress. Frequently the main focus of professionalconcerns about quality

Levels ofhealth care qualities

the West Midlands can add significantly to staffmotivation and willingness to innovate.4Hence, although it can be convincingly argued that

there is no longer room for esoteric cults of quality,Japanese or otherwise, practised in isolated specialistdepartments, this does not mean that the investmentsin quality management made in the past few yearsshould be abandoned. Rather, there is a good case forarguing that they should be built on as constructivelyand economically as possible. This will demand de-mystification of what such techniques involve and theirintegration into the mainstreams of clinical and otherforms of health care-including purchasing-man-agement.5 6

Clear policies and professional valuesBoth nationally and at district level the achievement

of this goal of integration is likely to require cleardecision making on issues such as organisational andassociated clinical audit and the use of systems ofaccreditation and reaccreditation to confirm the fitnessof institutions-from district hospitals to nursinghomes and specialist centres to primary care practices-to provide services. Many people working in andusing the NHS are currently looking for firmerguidance on what standards of care provision areacceptable. This is understandable in a time of rapidtechnical and social change and downward pressure onboth central and local government service costs.

Similarly, there is a need for clear thinking bothnationally and locally about public health and pur-chasing issues like needs assessments and the level ofprovision of specialist services. A National HealthService-even a primary care led one-has a respon-sibility for establishing credible systems for ensuringthat sufficient volumes of the right things are beingdone in each locality, as well as that they are being"done right." (Secretary of State for health, StephenDorrell, in address to Manchester Business School,January 1996.) Improving clinical services alsodemands better use of health economics alongsidebetter (quality) management, to enable more sensitiveprioritisation of competing quality improvement goalsand deeper understanding of the circumstances inwhich treatments are appropriate-that is, effectiveand efficient in meeting the needs of particularindividuals.

Critically for the future of health service develop-ment, the health professions and their representativebodies now also have an opportunity to incorporatequality management concepts fully into their ethicaland regulatory systems. The participation, forinstance, of the British Medical Association7 and theBMY (joint organiser with the Institute for Health CareInformation of the first European forum on quality inhealth care held this week in London) in initiativesdesigned to disseminate awareness of health carequality management techniques is of value not simplybecause of its immediate practical potential for pro-moting better care. It is important also in relation to theresolution of long term problems relating to the controlof health care resources and the legitimacy of man-agerial interventions which influence clinical decisionmaking.

Out ofthe health care crisisSince the 1970s the power ofhealth service managers

has tended to increase, challenging if not supersedingprofessional authority in many health care systems.8Patients and the public are uncertain about suchdevelopments, fearing on the one hand that decisionsabout their care may no longer be taken by individualsthey trust but aware also that traditional professional

BMJ VOLUME 312 9 MARCH 1996628

approaches-based mainly on fostering individualtechnical expertise-have not always guaranteed goodquality care. In this sense there can be said to be ahealth care crisis, even at a time when people are livinglonger than ever before.The integration of quality management concepts

into the core activities of the clinical professions wouldenable their members to participate more fully ineconomic and financially based management decisionsabout health service development. Contrary to thefears of some of those concerned to eliminate neglectand inadequate care, this would not mean thatclinicians would have to accept suboptimal standardsof individual patient care as desirable on overall"quality" grounds. Rather, it should equip membersof the clinical professions to work more effectively witheach other and their non-clinical colleagues in theinterests of their patients, and as members of theirorganisations. This in turn would help professionals to

recover some key aspects of their eroded authority, andto ensure publicly acceptable balance in the processesof institutional and system wide health care decisionmaking.

1 Sen A. The economics of life and death. ScientificAmerican 1993;268(5) :18-25.2 NHS Management Executive. The A-Z of quality. Leeds: NHS Management

Executive, 1993.3 Maxwell R. Quality assessment in health. BMJ 1984:288:1470-2.4 Foster A, Ratchford D, Taylor D. Auditing for patients. Quality in Health Care

1994:3(suppl):16-9.5 Ribgy B. A role fit for purpose? Journal of the Association for Quality in

Healthcare 1995:3:3-15.6 Binney G. Making quality work. London: The Economist Intelligence Unit,

1992.7 British Medical Association, Association of Quality in Health, National

Association of Health Authorities and Trusts. Partnership agenda: managingquality in health care. London: BMA/AQH/NAHAT, 1995 (draft report ofconsensus meeting September 1995).

8 Freidson E. The profession of medicine. London: University of London Press,1988.

(Accepted 13 February 1996)

Over the Counter Drugs

Patients, society, and the increase in selfmedication

Alison Blenkinsopp, Colin Bradley

This is thefirst offourarticles examining theimplications oftheavailability and use ofnon-prescription medicinesfor health services inBritain and elsewhere

Department ofPharmacyPolicy and Practice, KeeleUniversity, Keele,Staffordshire ST5 SBGAlison Blenkinsopp, directorofeducation and research

Department ofGeneralPractice, University ofBirmingham MedicalSchool, BirminghamB152TIColin Bradley, senior lecturer

Correspondence to:Dr Blenkinsopp.

BMg 1996;312:629-32

Selfmedication with over the counter medicines haslong been a feature ofthe lay health system. With thereclassification of certain drugs, the public can buypreparations that were previously available only onprescription. Sales ofover the counter medicines arenow equivalent to a third of the NHS drugs bill;governments throughout the world see self medi-cation as a way of shifting some of the cost of healthcare onto consumers. The trend towards increasedself care and with it the increasing empowerment ofpatients has many potential benefits; collaborationbetween doctors and pharmacists will be critical.

Over any two week period, nine out of 10 adults willreport having experienced at least one ailment.'2 Non-prescription medicines, commonly known as over thecounter orOTC medicines, are used to treat one in fourof these episodes.2 Sales of over the counter medicinesin pharmacy and grocery outlets reached £1268 5million in 1994 (box 1)-about a third of the NHSdrugs bill of C3 6 billion.

Box 1-Market breakdown for majorcategories ofnon-prescription medicines3Pain £1964m (16-7%)Skin, 143 5m (113-3%)Cold £93-9m (74%/o)Cough £68 lm (5.4%)Sore throat £72-7m (5.7%)Indigestion £73-9m (5-80/%)Total market (1994) £1268 5m

In the late 1980s the government fuelled the over thecounter market by making it easier to reclassify certainmedicines from prescription only status to allow overthe counter sale in pharmacies. Progress was slow atfirst, with 11 medicines being reclassified between1983 and 1992 (table 1), but since 1992 a further 40medicines have been reclassified. This widened rangeof non-prescription medicines has highlighted the roleof pharmacists, to whom the public is increasinglylooking for advice.

Box 2-Factors promoting and inhibitingthe reclassification ofdrugs to pharmacystatusPromoters:* Patient empowerment (increase in the autonomyethic)* Rise of consumerism* Decreasing power of the professions.* Changing balance ofpower within the professions* Pharmacists' drive to extend their role* Government policy to contain the NHS drugs bill* Possible influence of health care systems outsideBritain* Pharmaceutical companies' wish to protect profits

Inhibitors:* Professionals' protection of their domain* Doubts about patients' competence in self care* Pharmacists' anxieties about increased responsi-bility

What is driving thePOM to P changes?Factors promoting and inhibiting the reclassification

of drugs are shown in box 2. The deregulation isoccurring against a background of pressure on theprimary care drugs bill. Self care and self medicationwith non-prescription medicines are seen by govern-ments throughout the world as a means of shiftingsome of the responsibility and cost of health care fromgovernment and third party payers onto consumers.Increasing scrutiny of NHS prescribing costs haspressured pharmaceutical companies to protect theirmarkets. Reclassification of a drug not only createspotential new business in the non-prescription market-place but can also promote an existing brandedmedicine that is also available on prescription. Thepharmaceutical industry has therefore-unsurpris-ingly-embraced the opportunities offered by selfmedication. So too has the Royal PharmaceuticalSociety, which has actively and consistently lobbied formoves from prescription only medicine to pharmacystatus.

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