Role of users of health care in achieving a quality service.

The modern practice of medicine recognises that patients are not merely passive recipients of advice and procedures from health professionals but that they have an active role in their own care. For there to be a full assessment of the quality of care, contributions are needed from at least three parties: the doctor, other health professionals, and the patient. Sometimes there will be other interested parties for example, parents in the case of young children and carers in the case ofthose who are helping to support people with chronic mental or physical illness. Potential patients are also interested in the quality of their local services. In this paper the term "user" is taken to include not only present and past patients but also potential users of health services that is, the general public. The interests of each of these three groups is not necessarily always the same. The purpose of this paper is to analyse the contribution that users can make to clinical audit, extending the observations made by Donabedian in 1992 in his Lichfield lecture.' In this he assigned three principal roles to users of care, as follows. * As definers of quality, evaluating quality, and providing information that allows others to evaluate quality * As targets of quality assurance, by which he referred to their role as partners or "coproducers" of care * As reformers of care, emphasising their role in improving healthcare systems. Since that lecture there have been other contributions.2 3 We extend the discussion of how users, through involvement in clinical audit, may improve health services. Our review follows Donabedian's earlier framework of structure, process, and outcome.4 We also consider users' involvement in determining access to the process of care.