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Before we can take steps to improve the quality of health care, we need to define what quality care means. This article describes how to make best use of available evidence and reach a consensus on quality indicators

Objectives: To identify prescribing indicators based on prescribing analysis and cost (PACT) data that have face validity for measuring quality or cost minimisation. Design: Modified two round Delphi questionnaire requiring quantitative and qualitative answers. Setting: Health authorities in England. Participants: All health authority medical and pharmaceutical advisers in the first round and lead prescribing advisers for each health authority in the second round. Main outcome measures: Face validity (median rating of 7–9 on a nine point scale without disagreement) and reliability (rating 8 or 9) of indicators for assessing quality and cost minimisation. Results: Completed second round questionnaires were received from 79 respondents out of 99. The median rating was 7 for cost minimisation and 6 for quality, and in all except four cases individual respondents rated indicators significantly higher for cost than for quality. Of the 41 indicators tested, only seven were rated valid and reliable for cost minimisation and five for quality. Conclusion: The 12 indicators rated as valid by leading prescribing advisers had a narrow focus and would allow only a limited examination of prescribing at a general practice, primary care group, or health authority level.

Objective To investigate whether the incentive scheme for UK general practitioners led them to neglect activities not included in the scheme. Design Longitudinal analysis of achievement rates for 42 activities (23 included in incentive scheme, 19 not included) selected from 428 identified indicators of quality of care. Setting 148 general practices in England (653 500 patients). Main outcome measures Achievement rates projected from trends in the pre-incentive period (2000-1 to 2002-3) and actual rates in the first three years of the scheme (2004-5 to 2006-7). Results Achievement rates improved for most indicators in the pre-incentive period. There were significant increases in the rate of improvement in the first year of the incentive scheme (2004-5) for 22 of the 23 incentivised indicators. Achievement for these indicators reached a plateau after 2004-5, but quality of care in 2006-7 remained higher than that predicted by pre-incentive trends for 14 incentivised indicators. There was no overall effect on the rate of improvement for non-incentivised indicators in the first year of the scheme, but by 2006-7 achievement rates were significantly below those predicted by pre-incentive trends. Conclusions There were substantial improvements in quality for all indicators between 2001 and 2007. Improvements associated with financial incentives seem to have been achieved at the expense of small detrimental effects on aspects of care that were not incentivised.

This is the third in a series of five articles The UK government has set a challenging agenda for monitoring and improving the quality of health care. It is based on a series of national standards and guidelines, a strategy for quality improvement termed “clinical governance,” and a framework for monitoring the quality of care in and performance of NHS organisations (box). Clinical governance is “a framework through which NHS organisations are accountable for continually improving the quality of their services, safeguarding high standards by creating an environment in which excellence in clinical care will flourish.”1 To be successful this strategy requires effective leadership by clinicians who have responsibility for improving quality; it must engage the doctors and nurses who provide care on a daily basis; and it must have commitment and support from managers within the NHS. #### Summary points Primary care groups and trusts are responsible for implementing clinical governance, including monitoring and improving the quality of care In their first two years they have concentrated on educating and supporting health professionals and encouraging shared learning Information about the quality of care provided in general practice is being shared between practices and with the public, often in a form that permits practices to be identified Many groups and trusts are offering incentives to practices to promote improvements in the quality of care Sanctions and disciplinary action are rarely used when dealing with poor performance Limited resources and the pace of change are potential obstacles to future success in improving the quality of care #### Goals of quality improvement strategies in the NHS National service frameworks, National Institute for Clinical Excellence —set standards, develop guidelines Clinical governance —deliver care, improve quality National performance framework, annual appraisal of doctors, Commission for Health Improvement, national surveys of patients —monitor quality and performance Primary care groups and trusts are responsible for implementing clinical …

OBJECTIVE--To analyse the effect of a fetal surveillance unit, which undertakes a wide range of maternal and fetal tests on an outpatient or inpatient basis, on the number and length of antenatal hospital admissions. DESIGN--A comparison of the number and length of antenatal admissions six months before and five months after the opening of the unit on 1 July 1990. MAIN OUTCOME MEASURES--Admission rate, antenatal bed occupancy, and interval from admission to discharge or delivery. RESULTS--The antenatal bed occupancy rate fell by 22% from 174/100 deliveries during the six months before the unit was opened to 136/100 deliveries in the five months after it was opened. The difference in distribution of lengths of admission after the unit was opened from before was highly significant (Mann-Whitney test = 5.14, n = 752 and 679; p less than 0.0001), and this was due to shorter intervals from admission to discharge and from admission to delivery. In contrast, the antenatal admission rate did not change significantly (50/100 deliveries v 49/100 deliveries). There was no significant change in the stillbirth rate (6/1294 births v 8/1372 births; difference between rates = 0.0012, 95% confidence interval-0.0043 to 0.0067). CONCLUSION--Obstetricians are more prepared to discharge antenatal patients from hospital and, similarly, admit patients for delivery rather than for assessment if the patients are reliably monitored on an outpatient basis. If this change in practice is sustained substantial financial and social benefits will result as well as improvements in organisation, audit, teaching, and research.

Objectives: To assess variation in the quality of care in general practice and identify factors associated with high quality care. Design: Observational study. Setting: Stratified random sample of 60 general practices in six areas of England. Outcome measures: Quality of management of chronic disease (angina, asthma in adults, and type 2 diabetes) and preventive care (rates of uptake for immunisation and cervical smear), access to care, continuity of care, and interpersonal care (general practice assessment survey). Multiple logistic regression with multilevel modelling was used to relate each of the outcome variables to practice size, routine booking interval for consultations, socioeconomic deprivation, and team climate. Results: Quality of clinical care varied substantially, and access to care, continuity of care, and interpersonal care varied moderately. Scores for asthma, diabetes, and angina were 67%, 21%, and 17% higher in practices with 10 minute booking intervals for consultations compared with practices with five minute booking intervals. Diabetes care was better in larger practices and in practices where staff reported better team climate. Access to care was better in small practices. Preventive care was worse in practices located in socioeconomically deprived areas. Scores for satisfaction, continuity of care, and access to care were higher in practices where staff reported better team climate. Conclusions: Longer consultation times are essential for providing high quality clinical care. Good teamworking is a key part of providing high quality care across a range of areas and may need specific support if quality of care is to be improved. Additional support is needed to provide preventive care to deprived populations. No single type of practice has a monopoly on high quality care: different types of practice may have different strengths. What is already known on this topic Quality of care varies in virtually all aspects of medicine that have been studied Most studies look at quality of care from a single perspective or for a single condition What this study adds Quality of care varies for both clinical care and assessments by patients of access and interpersonal care Practices with longer booking intervals provide better management of chronic disease; preventive care is less good in practices in deprived areas No single type of practice has a monopoly on high quality care—small practices provide better access but poorer diabetes care Good team climate reported by staff is associated with a range of aspects of high quality care

OBJECTIVE: To compare the process of out of hours care provided by general practitioners from patients' own practices and by commercial deputising services. DESIGN: Randomised controlled trial. SETTING: Four urban areas in Manchester, Salford, Stockport, and Leicester. SUBJECTS: 2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals) who responded to those requests. MAIN OUTCOME MEASURES: Response to call, time to visit, prescribing, and hospital admissions. RESULTS: 1046 calls were dealt with by practice doctors and 1106 by deputising doctors. Practice doctors were more likely to give telephone advice (20.2% v 0.72% of calls) and to visit more quickly than deputising doctors (median delay 35 minutes v 52 minutes). Practice doctors were less likely than deputising doctors to issue a prescription (56.1% v 63.2% of patients) or to prescribe an antibiotic (43.7% v 61.3% of prescriptions issued) and more likely to prescribe genetic drugs (58.4% v 32.1% of drugs prescribed), cheaper drugs (mean cost per prescription pounds 3.28 v pounds 5.04), and drugs in a predefined out of hours formulary (49.8% v 41.1% of drugs prescribed). There was no significant difference in the number of hospital admissions. CONCLUSIONS: By contrast with practice doctors, deputising doctors providing out of hours care less readily give telephone advice, take longer to visit at home, and have patterns of prescribing that may be less discriminating.