Reflections on quality issues: quality becomes ever more complex.

W hen I became Chairman of the Royal College of General Practitioners in 1998, the medical audit bandwagon, largely based on College values, had run out of steam. A new more sinister one — the identification and weeding out of poor performance was running strongly. This was partly fuelled by the Bristol paediatric cardiothoracic surgery case, and the subsequent Kennedy report, 1 partly by the Shipman case 2 and partly by other cases. The public and political perception of a significant and unacceptable 'quality tail' created pressure for action. The RCGP, by supporting and growing the educational model of quality assurance, had also, largely unwittingly, given the ammunition to a new lobby. From Sir Donald Irvine's quality challenge, 3 the College developed its MRCGP examination and Fellowship by Assessment. 4 While comfortable defining quality, writing standards and assessing those standards at the 'average' and 'highest' levels, the College historically regarded minimum standards and their enforcement as the business of others. However, the emerging political and media consensus in the 1990s was that the numbers of underperforming doctors and their impact on patient care were unacceptable. The new pressure was towards a beguiling vision — most clearly expressed in revalidation — in which all aspects of general practice would be defined and assessed. There would be total assurances of competency at all times and a risk-free environment in which any mishap required blame. Politicians saw any reluctance to agree to this agenda as professional hegemony. Much of my three years as chairman was, therefore, preoccupied with defending the profession from slurs while helping to design safety nets that would be both effective and minimally intrusive for good GPs. We have yet to see the final shape of appraisal, revalidation, and the work of the National Patient Safety Authority. While I recognise that the definition and enforcement of minimal acceptable standards is inevitable and that we, the profession, rather than civil servants, need to be principle players in delivering them, I also want that to be a sub-text to the main message of quality improvement through 'edu-cation', rather than 'regulation'. By this I mean the encouragement and recognition of good general practice, rather than the monitoring and blaming of health professionals. In line with this thinking, the College has, in recent years, introduced Membership by Assessment (also a vital way to establish a broader base for the College), Quality Practice Award, Quality …