Quality in Health Care

The past 10 years have seen the introduction of clinical audit, guidelines on clinical and organisational delivery of care, and more recently an emphasis on evidence based medicine. An intelligent member of the public, particularly if a trained manager, may believe that such an array of managerial tools would be related to an easily measured improved outcome, particularly in a common adult disease such as asthma. The British Thoracic Society (BTS) in conjunction with many allied respiratory healthcare workers produced guidelines for asthma some years ago. A review in 1996 found little evidence to suggest standards of care had improved since the publication of the BTS guidelines, and in the same review the authors concluded that there was little good published research evaluating different ways of organising the delivery of asthma care. Are the guidelines flawed and the asthma clinics run by trained asthma nurses with high levels of educational material and social communication a passing “whim”, or are there more fundamental reasons why we are not able to translate either consensus and/or evidence based improvements into the organisation of clinical care? In this issue of Quality in Health Care, Dawson et al, using case study methodology attempted to unravel the understanding of factors for changes in the organisation of asthma care and treatments. The authors interviewed hospital and primary care physicians of most grades in teaching and non-teaching hospitals and multiple partner and single handed practices using a semistructured interview technique to obtain subjective accounts of the nature and reasons for change as perceived by these physicians. Two striking features of this paper are that within the four hospitals and many of the practices there was a lack of prescribing data, referral rates, emergency admission numbers, and systematic clinical audit, and that the authors accepted that they were unlikely to secure data on patient outcomes. These are surely areas which need urgent consideration.