Final Report > Chapter 27: Care of an Appropriate Standard > The past: an absence of standards and of monitoring > The gradual shift towards an interest in standards and in monitoring

The gradual shift towards an interest in standards and in monitoring

5 The Royal Colleges and various specialist associations of healthcare professionals, sometimes allied to Royal Colleges and sometimes not, issued, and indeed continue to issue, suggested standards of care (as distinct from standards of professional practice), guidelines and guidance to their members. Other organisations also contributed and contribute from time to time, such as the British Medical Association (BMA). The DoH, through the Clinical Standards Advisory Group, [4] also played a role. But all of this guidance was advisory. It was seen as an exhortation to best practice. There was no assumption that it should normally be followed. Indeed, none of the various bodies had any authority to cause their guidance to be followed. What such guidance constituted was an extension of the notion that standards were for the individual professional, to the idea that they could be for the profession as a group. There was rarely, if ever, any involvement of non-professionals in the development of the guidelines, nor any coherence necessarily between the various guidelines.

6 As regards information on performance which could help clinicians to reflect on and to improve the quality of care, there were exceptions to the general lack of data, most notably in the case of four national Confidential Enquiries. [5] The reports of these Confidential Enquiries covered only certain specified areas of healthcare. They depended on the co-operation of clinicians to submit data. Not all did so. The data were then aggregated and anonymised. This process encouraged the participation of professionals who were otherwise anxious at comparisons being made which might not be informed. It inevitably meant that comparisons could not be easily made. In particular, the prospect of patients gaining any information on the performance of Dr X in Unit Y in Hospital Z was lost. A similar process was evident in Bristol. The Society of Cardiothoracic Surgeons collected and distributed in aggregated form data about mortality rates in paediatric cardiac surgery (from the UK Cardiac Surgical Register). While ahead of other specialties in this regard, participation was voluntary. The data were made available only to those surgeons who were members of the Society, though they in turn could decide to make the data more widely available. The Society itself did not make the data known to the various hospitals nor to the public.

7 As regards the role of learned journals (and other literature) as a source of reliable information on practice whereby professionals could compare their performance with that of others, it was accepted wisdom that bad results were less likely to be written up in the literature. The data on performance were assumed to be skewed. The picture presented in the literature and the reality of everyday treatment were, consequently, regarded as some distance apart. It followed that all healthcare professionals whose performance did not meet the standards achieved in the literature were able to persuade themselves that it was the literature not they who were out of line. Thus, until recently, the patient and the doctor were steering their way towards quality of care with only the crudest of maps.

Footnotes

[4] The Clinical Standards Advisory Group existed between 1991 and 1999. Its function was to advise the Secretary of State, as requested, on standards of clinical care in the NHS and on access to and availability of services to NHS patients

[5] They are the Confidential Enquiries into (1) Maternal Deaths (since 1952) (2) Stillbirths and Deaths in Infancy (since 1992) (3) Peri-operative Deaths (since 1987) and (4) Suicide and Homicide by people with Mental Illness (since 1992)