Improving primary health care delivery: still waiting for the magic bullet.

E1280 CMAJ, December 13, 2011, 183(18) © 2011 Canadian Medical Association or its licensors It is my experience that few people are short of answers about how to improve health care delivery. The opinions flow even more freely when it comes to suggesting ways to im prove primary care. A recent study by Szecsenyi and colleagues adds to the number of options. The authors show that the use of a European-wide accreditation system of primary care practices in Germany led to a significant improvement in practice management across a range of domains be tween the first assessment and the second assessment three years later. Their study should help to convince policy-makers and professional bodies not already doing so to consider accreditation as a means of improving quality. Indeed, many medical colleges have highly developed accreditation systems. Before we get too excited that the magic bullet — whose existence was questioned in CMAJ 16 years ago — has been found, it is worth considering the context in which the study by Szecsenyi and colleagues was conducted. First, primary care practices in Germany were directed by the government to participate in some form of qualityimprovement program, so why not the one the authors evaluated? This means that, although ostensibly voluntary, this accreditation process was beginning to look like its tougher cousin, regulation. Second, general practice in Germany exists within the context of patient choice, so having a seal of approval in terms of practice quality might well be seen as a competitive advantage. One needs also to consider the limitations of accreditation programs, or any system that uses standards as a means of improving quality. Standards tend to look at structural and processrelated aspects of health care delivery. The standards themselves, depending on the means adopted, have to be precise. In the program evaluated by Szecsenyi and colleagues, a checklist was used. However, this can cause problems in assessment if a health care provider has found an innovative way of getting the same or better outcomes by using a seemingly noncompliant pro cess. Also, definitions of quality change. For example, the standard used for hemoglobin A1C (HbA1C) in the National Health Service’s general practitioner contract in the United Kingdom has likely been too low, causing more harm than good. General practitioners pursuing higher HbA1C levels in patients with type 2 diabetes may miss the standard but provide better care. The greatest risk with standards, whether they are part of an accreditation system, a means of payment within contracts, a part of a regulatory process or a part of another system, is that they could completely miss the point. This is especially true of standards within primary care. What is desired of a good general practice varies by country, chiefly driven by whether there is an obligatory gate-keeping function and a registered patient list or not. The relation between excellent general practice and the efficiency of a health care system is well established. However, those who set standards do not always have a clear view of why it is that strong primary care supports such efficiencies. There are useful pointers in the literature. In the accreditation program evaluated by Szecsenyi and colleagues, the visit was by an assessor who used a checklist. Other accreditation processes use a team of senior peers to make the assessment. This approach has three advantages. First, the visiting team is able to assess whether a noncompliant, but effective, process, such as the one described earlier, constitutes a “pass” — a socalled intelligent assessment (albeit with greater Improving primary health care delivery: still waiting for the magic bullet