Editorial

Citation

Gourlay, R. (2003), "Editorial", International Journal of Health Care Quality Assurance, Vol. 16 No. 1. https://doi.org/10.1108/ijhcqa.2003.06216aaa.001

Editorial

When the Journal was launched, 16 or so years ago, "quality" and "quality assurance" were just beginning to be discussed in the UK's National Health Service.

In our editorials we argued for a variety of initiatives to be taken. For example we proposed that "quality management" must have a champion at the top table. We proposed the adoption of a quality management system such as ISO 9000. We encouraged patient surveys and published details of those that were submitted to us. Now the picture is different. The chief executive is now accountable for all aspects of quality – including clinical quality. Albeit the move to top level support was diluted by the responsibility initially being tagged on to a director who probably already had a full portfolio.

On the quality management system, progress was a little slow with only a few hospital departments (pathology, pharmacy, catering, etc.) actually adopting the international standard. Despite this, other accreditation systems flourished with quality standards being made ever more explicit.

Considerable impetus was given to the "a quality movement" by the scandals that were being exposed by a more knowledgeable public and a media that was hungry to expose health care inadequacies. Issues such as competency to practice medicine, long waiting lists and times, insufficient attention to patients and their relatives rights, inadequate control over health professionals, insufficient sharing of information about standards of care have all contributed to raising the issues about the quality of patient care and the organisations that deliver it.

In the UK, like most other countries, health care is high up on the political agenda. Political parties can lose elections on the basis of health care performance.

Given the turbulence surrounding quality in its various manifestations, the UK government has taken a number of initiatives. First, there has been a proliferation of standards, targets and objectives. This for many health professionals has been a mixed blessing. The publication of the targets and their demands can distort health care priorities. Getting waiting lists reduced becomes more important than dealing with "urgent" cases. Not only this, but considerable management effort is devoted to ensuring that targets are met. On the back of the targets, comes a "star system" that highlights "successful" hospitals and provides them with the possibility of less "central control" as well as giving some financial rewards. The system is said to "weed out" management that is underachieving its quality objectives – and there is evidence of those accountable for quality losing their jobs when targets are not met.

Second, a number of organisations have been set up within the framework of clinical governance to support the drive for quality. A brief list of these will show how active this "front" has been:

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  National Institute for Clinical Excellence.

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  Commission for Health Improvement – (to be re-titled "Commission for Health Audit and Inspection").

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  National Patient Safety Agency.

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  National Clinical Assessment Authority.

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  NHS Litigation Authority, which manages the Clinical Negligence Scheme for Trusts.

In addition to these bodies, the NHS has set up the National Service Framework for:

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  Cancer.

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  Paediatric Intensive Care.

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  Mental Health.

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  Coronary Heart Disease.

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  Service for the Elderly.

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  Diabetes.

Without doubt, quality management issues are highly important and very visible. They are given a conceptually cohesive voice by the framework of clinical governance. Is the picture now so changed that we can expect a rosy future for quality management?

In our view, there is still an important component that is missing. This is to do with staff management. Quality management – and thereby clinical governance, demands that staff are strongly committed to managing in a quality fashion; that customer/supplier chains are intact and functioning without conflict pathologies. That the culture is one of support where suggestions and initiatives for improvement are welcomed and acted upon. In two words – staff feel fully "empowered" and "trusted". With so much central "direction", many staff feel pushed about with their voice having little effect. Consultant medical staff are angry about their proposed new employment contract that appears to treat them in the way ancillary staff were treated some years ago. They say that they will not choose medicine as a career for their own children.

This could be the consequence of the significant changes that have already been made and that there is transition "sickness". Whatever the reason, the next push in quality management must be orientated towards the staff, their motivation and their well being. Clinical governance demands that they address questions of continuing professional development. Alongside this must go a "constitution" which elucidates the relationship between management and themselves; provides genuine opportunities for involvement in change; encourages suggestions and initiative taking on which there is feedback to the initiator; and efforts that lead to a culture of innovation where high level performance by individuals and teams is recognised and rewarded.

Robin Gourlay