Facilitating quality improvement in primary health care by practice visiting.

Introduction During the past decade, demands for eVective quality assessment in primary health care have increased considerably. “The third revolution of medical care” has seen a move towards more rigorous assessment of clinical interventions and increasing calls for more accountability. Although most agree that quality improvement is important there are many views about the best approach to quality assessment. In the United Kingdom and elsewhere medical audit has been a notable component of quality improvement programmes. Its aims have been defined: “Its purpose is to identify opportunities and implement improvements in the quality of medical care; medical training and continuing medical education; and eVective use of resources”. This statement makes clear that medical audit can contribute to improving health care and professional development. But audit may have other functions. It can be a tool for securing accountability and could be used to control the performance of general practitioners. Broadly, there are two approaches to quality assessment: one a process of internal reflection, the other external inspection. Shaw describes a continuum between clinical audit as a voluntary, educational, internal process for which there are no sanctions and external inspection that is more regulatory and may involve sanctions. Similarly, Sheldon has written of the two poles of audit, one external, done by visitors not personally involved in the work of the unit, and the other internal, carried out by doctors and colleagues, assessing their own work. Marinker states that “the more external the audit becomes, the more others are drawn into making judgements and the more threatening it is to those who are judged”. In Sweden, where primary health care to a listed or a geographically defined population is usually delivered by well functioning multiprofessional teams (box 1), clinical audit that involves the whole team including nurses and paramedics has more relevance than medical audit that is about the work of physicians. Monitoring performance—that is, controlling performance against agreed standards—is important and is widely accepted as necessary because of the share in the overall decrease in resources allocated to health care that is being borne by primary health care. Although there are many stakeholders concerned with improving the quality of care, in our view, it is professional carers who should be driving these initiatives and deciding the best approach. The lack of clear definition allows for interpretation and adoption to find the best approach to suit diVerent localities. Even medical audit may be done in many diVerent ways—one English survey of the literature identified nine major areas of audit activity (table 1).