Public Health (1991), 105, 197 198
© The Society of Public Health, 1991
Editorial
The Quality of Medical Care Consideration o f Medical Audit, like so many of the current innovations, can excite a feeling o f frustration amongst the compulsive-obsessive, and, as most o f the practitioners o f Public Health have this tendency, it is not surprising that discussion o f this subject is punctuated by requests for some precision in definitions, ls it something new? Or is it something which competent clinicians have been doing for the last 2,000 years? Answers to such questions are to be found in a publication of the Department o f Health, ~ 'The Quality of Medical Care'. It is commended as a clear and explicit statement o f current doctrine, and the Working Party which produced it is to be congratulated. One o f this Report's great advantages is that by careful definition o f the terms and concepts it demystifies the subject and converts it to a rational application o f the principles which are taught to every medical student and which are actively pursued and refined by every good clinician. The message is that one cannot do this by oneself but that one is required to support and be supported by one's colleagues in this endeavour. This support, like all scientific activity, must be structured within some sort of institutional framework. The Report describes how this can be done. Where the advice is not so clear or explicit is in the section headed 'Quality in public health medicine'. The difficulty arises from consideration o f the content o f the introduction where, implicitly, medical audit is conceived as applying to the care which a clinician gives his patients. One reads, for example, in paragraph 1.6, the statement: 'The objective o f medical audit is to improve the quality of care doctors provide for their patients'. In this section of the Report referred to above this difficulty is acknowledged. It is accepted that the health of a community is the outcome of a great number of different influences and cannot be considered the responsibility o f an individual. It does however go on to say ' . . . departments o f public health medicine will be expected to join in arrangements which are being made for audit, in the same way as clinical colleagues'. Whatever medical audit means in public health medicine it can't mean the 'same' as for clinical medicine. One gets the impression from reading this section that here we have a political statement. Being cynical, one could say that behind it all is the thought: 'Clinicians have to put up with this so why should public health physicians escape!' There is no doubt that the work o f individual public health doctors should be appraised, but it is only a sophism to call this process 'medical audit'. The true analogy is some sort o f formal review o f the health department o f a community with explicit quantified objectives. Such a process nowadays cannot be used as the measure o f the work of the individual. Even in the heyday o f public health intervention, no medical officer o f health could take sole responsibility for the health o f his community, still less can a director o f public health do so today. He or she can, however, be responsible for the audit o f his or her district. Current practice encompasses this function and recent changes in the Health Service encourage it. It is part o f what is generally considered to be the 'Public Health Process'. The real danger here is not that Public Health is being asked to do something which it should not be doing, but that, by giving it a new name and elevating it to an article o f faith, we become obsessed with a process and measure success by the fulfilment of that process, at
198
Editorial
the expense of what are the real objectives. This is a particular problem o f Public Health because outcomes are usually deferred and difficult to measure. Reference
1. Department of Health (1990). The Quality of Medical Care. Report of the Standing Medical Advisory Committee. London: HMSO.
© The Society of Public Health, 1991
Editorial
The Quality of Medical Care Consideration o f Medical Audit, like so many of the current innovations, can excite a feeling o f frustration amongst the compulsive-obsessive, and, as most o f the practitioners o f Public Health have this tendency, it is not surprising that discussion o f this subject is punctuated by requests for some precision in definitions, ls it something new? Or is it something which competent clinicians have been doing for the last 2,000 years? Answers to such questions are to be found in a publication of the Department o f Health, ~ 'The Quality of Medical Care'. It is commended as a clear and explicit statement o f current doctrine, and the Working Party which produced it is to be congratulated. One o f this Report's great advantages is that by careful definition o f the terms and concepts it demystifies the subject and converts it to a rational application o f the principles which are taught to every medical student and which are actively pursued and refined by every good clinician. The message is that one cannot do this by oneself but that one is required to support and be supported by one's colleagues in this endeavour. This support, like all scientific activity, must be structured within some sort of institutional framework. The Report describes how this can be done. Where the advice is not so clear or explicit is in the section headed 'Quality in public health medicine'. The difficulty arises from consideration o f the content o f the introduction where, implicitly, medical audit is conceived as applying to the care which a clinician gives his patients. One reads, for example, in paragraph 1.6, the statement: 'The objective o f medical audit is to improve the quality of care doctors provide for their patients'. In this section of the Report referred to above this difficulty is acknowledged. It is accepted that the health of a community is the outcome of a great number of different influences and cannot be considered the responsibility o f an individual. It does however go on to say ' . . . departments o f public health medicine will be expected to join in arrangements which are being made for audit, in the same way as clinical colleagues'. Whatever medical audit means in public health medicine it can't mean the 'same' as for clinical medicine. One gets the impression from reading this section that here we have a political statement. Being cynical, one could say that behind it all is the thought: 'Clinicians have to put up with this so why should public health physicians escape!' There is no doubt that the work o f individual public health doctors should be appraised, but it is only a sophism to call this process 'medical audit'. The true analogy is some sort o f formal review o f the health department o f a community with explicit quantified objectives. Such a process nowadays cannot be used as the measure o f the work of the individual. Even in the heyday o f public health intervention, no medical officer o f health could take sole responsibility for the health o f his community, still less can a director o f public health do so today. He or she can, however, be responsible for the audit o f his or her district. Current practice encompasses this function and recent changes in the Health Service encourage it. It is part o f what is generally considered to be the 'Public Health Process'. The real danger here is not that Public Health is being asked to do something which it should not be doing, but that, by giving it a new name and elevating it to an article o f faith, we become obsessed with a process and measure success by the fulfilment of that process, at
198
Editorial
the expense of what are the real objectives. This is a particular problem o f Public Health because outcomes are usually deferred and difficult to measure. Reference
1. Department of Health (1990). The Quality of Medical Care. Report of the Standing Medical Advisory Committee. London: HMSO.
