CORRESPONDENCE * All letters must be typed with double spacing and signed by all authors. * No letter should be more than 400 words. * For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BMJ.
* We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when- we receive several on the same subject.
Quality management in the NHS SIR,-D M Berwick and colleagues raised many interesting points in their papers on the doctor's role in quality management. ' 2 Their analysis of the NHS and their proposed solutions, however, left me confused on several points. (1) How does their assertion that "a market can, unconsciously (through the 'invisible hand') achieve efficiency and quality levels beyond those attainable by even the most talented planner," correlate with their subsequent affirmation that the "NHS ... has great potential for rational planned action?" (2) One of the three basic components, they state, of the market model is "consistent and rational buyers." How can you have consistent buyers in a market economy? The main working principle of a market is competition. The survival of the providers depends on their capacity to attract purchasers away from other providers. (3) How would the authors justify the need for the NHS to "operate as a seamless whole" with the resultant fragmentation of the service into thousands of independent provider units that the market principle has produced in the current reforms? (4) Total quality management (TQM) seems like a sensible method to improve a health care service. Its introduction, however, based as it is on cooperation and positive motivation, would seem to be starkly at odds with the present culture of incentives, insecurity, and short termism, engendered by the current reforms. (5) The "new clinical skills" that are advocated for doctors to enable them to practice total quality management, on closer scrutiny turn out not to be so new after all. Improving teamwork and continuing audit are now widely accepted by the medical profession as fundamental to good practice. By all means let us, as a profession, take the "risk" and embrace total quality management in the NHS. I think Berwick and colleagues will find that there is no reluctance on our part to better our own practice, to work with others in the service, and continually to seek to improve the quality of the processes and outcomes of medical care. That is whv we are doctors. What we lack in our present working environment is that culture of trust, cooperation, freedom to suggest developments without robbing Peter to pay Paul, and a feeling that our work is valued by those who control the service. "Reducing fear and apprehension in the TFQM world is a job for leaders" -tell that to our political masters. KATE MACKAY
D)cpartmcnt ot 'lltblic Health MNlediicinc, Lothian Hcalth Board 1 Bcrwick 1)M, Enthovent A, B3unik-er Jl'. Qualitv
774
maagatitgmcnt in
the NHS: the doctor's role-I. BM_ 1992;304:235-9. (25 Januarv.) 2 Berwick DM1, Enthoven A, Bunker JP. Quality management in the NHS: the doctor's role-I1. BMJ 1992;304:304-8. (1
February. )
AUTHORS' REPLY,-We welcome the opportunity to reply to Dr Mackay's points of confusion. (1) Our statement that "a market can ... achieve efficiency and quality. . ." is simply a statement of classical economic theory underlying market economy. The articles explain why it usually fails in health care but how market, forces can provide incentives for improvement if coupled with "rational planned action." (2) A consistent and rational buyer is one who seeks to purchase the product that offers the best combination of quality and price. Consistency refers to buyers' preferences for product characteristics. It does not imply buying from the same supplier. (3) The NHS "operating as a seamless whole" we envisage as a system with built in incentives that foster an equilibrium between the public's health care needs, access to general medicine, provision of public health, acute hospital services, and available resources. TQM (total quality management) we propose as a method by which 'to assist in the integration of the "thousands of independent provider units," the fragmentation ofwhich existed long before the current reforms. (4) If by "short termism" Dr Mackay implies a policy seeking a quick fix, she is right; this would not be an environment in which TQM would flourish. TQM is for the long haul. "A culture of insecurity" might also be an unfavourable one for TQM, but it is important to appreciate' that too much security, as may have existed in the past, may also be counterproductive. (5) We believe that TQM provides a mechanism for the improvement of care, whatever the fiscal constraints. The goals of TQM are to provide better care at lower price (poor care, as we argue in the articles, usually costs more). The successful implementation of TQM should, therefore, lead to more and better care within whatever fiscal limits are set. (6) The skills of teamwork that we encourage transcend those currently practised in the United States or Great Britain. Doctors may be reasonably proficient members of teams of doctors in their own specialty. They are less successful in collaboration with doctors in other specialties or with other health professionals and rarely function effectively on problem solving teams with management (for which management must, of course, assume its share of responsibility). New clinical skills in audit were not among those that we proposed, and Dr Mackay is apparently confused as to the central message of the articles: that total quality management, incorporating continuous
quality improvement of all care, should replace medical aiudit's limited objectives of identifying and improving only that medical care that is substandard. The tone of Dr Mackay's letter and particularly her final sentence suggest that she sees the profession's "political masters" as adversaries. There will always be political masters to whom one must be accountable. One of the goals of TQM might reasonably be to enlist them as collaborators, rather than adversaries, in the quest for an across the board improvement in the quality of care. J P BUNKER CRC Clinical Trials Centre, King's College School of Medicine and Dentistry, London SE5 9NU
A ENTHOVEN
Graduate School of Business, Stanford University, Stanford, California 94305 USA
D M BERWICK Harvard Community Health Plan, Boston, AMassachusetts 02115 USA
SIR, -D M Berwick and others propose that total quality management should be used in the NHS. 2 It is not unknown to the NHS, of course; it and allied techniques such as quality circles have been used by health authorities and endorsed by some regions for some time. New, however, is the suggestion that total quality management should be endorsed nationally. Most care in the NHS, in terms of patients treated, is at primary health care level. Berwick and colleagues make some acknowledgment of the future need of general practitioners: "To fulfil their responsibilities as gate keepers and care givers [they] must understand decision analysis and probability theory. They must be able to take advantage of computerised medical information technology and its access to data relevant to the patient at hand in order to refine the decision whether to refer or to provide care.... For this to happen it will . . be necessary to undergo . .. a level of training and expertise perhaps as demanding as that of the specialist consultant." The role of audit is dismissed: they say that it has been the focus of a vast American industry that has had virtually no impact on the quality of care, and that it had been hoped that the results of medical audit and consensus conferences and clinical guidelines would be adopted by the profession to improve the quality of practice, but this has failed to happen. I both agree and disagree with the authors. Medical audit as introduced into the NHS has not yet had one year of life. To condemn our potential for change on the basis of the American experience is to display ignorance of what medical audit advisory groups are already achieving in every part of Britain. The eight new clinical skills defined
BMJ VOLUME 304
21 MARCH 1992
* We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when- we receive several on the same subject.
Quality management in the NHS SIR,-D M Berwick and colleagues raised many interesting points in their papers on the doctor's role in quality management. ' 2 Their analysis of the NHS and their proposed solutions, however, left me confused on several points. (1) How does their assertion that "a market can, unconsciously (through the 'invisible hand') achieve efficiency and quality levels beyond those attainable by even the most talented planner," correlate with their subsequent affirmation that the "NHS ... has great potential for rational planned action?" (2) One of the three basic components, they state, of the market model is "consistent and rational buyers." How can you have consistent buyers in a market economy? The main working principle of a market is competition. The survival of the providers depends on their capacity to attract purchasers away from other providers. (3) How would the authors justify the need for the NHS to "operate as a seamless whole" with the resultant fragmentation of the service into thousands of independent provider units that the market principle has produced in the current reforms? (4) Total quality management (TQM) seems like a sensible method to improve a health care service. Its introduction, however, based as it is on cooperation and positive motivation, would seem to be starkly at odds with the present culture of incentives, insecurity, and short termism, engendered by the current reforms. (5) The "new clinical skills" that are advocated for doctors to enable them to practice total quality management, on closer scrutiny turn out not to be so new after all. Improving teamwork and continuing audit are now widely accepted by the medical profession as fundamental to good practice. By all means let us, as a profession, take the "risk" and embrace total quality management in the NHS. I think Berwick and colleagues will find that there is no reluctance on our part to better our own practice, to work with others in the service, and continually to seek to improve the quality of the processes and outcomes of medical care. That is whv we are doctors. What we lack in our present working environment is that culture of trust, cooperation, freedom to suggest developments without robbing Peter to pay Paul, and a feeling that our work is valued by those who control the service. "Reducing fear and apprehension in the TFQM world is a job for leaders" -tell that to our political masters. KATE MACKAY
D)cpartmcnt ot 'lltblic Health MNlediicinc, Lothian Hcalth Board 1 Bcrwick 1)M, Enthovent A, B3unik-er Jl'. Qualitv
774
maagatitgmcnt in
the NHS: the doctor's role-I. BM_ 1992;304:235-9. (25 Januarv.) 2 Berwick DM1, Enthoven A, Bunker JP. Quality management in the NHS: the doctor's role-I1. BMJ 1992;304:304-8. (1
February. )
AUTHORS' REPLY,-We welcome the opportunity to reply to Dr Mackay's points of confusion. (1) Our statement that "a market can ... achieve efficiency and quality. . ." is simply a statement of classical economic theory underlying market economy. The articles explain why it usually fails in health care but how market, forces can provide incentives for improvement if coupled with "rational planned action." (2) A consistent and rational buyer is one who seeks to purchase the product that offers the best combination of quality and price. Consistency refers to buyers' preferences for product characteristics. It does not imply buying from the same supplier. (3) The NHS "operating as a seamless whole" we envisage as a system with built in incentives that foster an equilibrium between the public's health care needs, access to general medicine, provision of public health, acute hospital services, and available resources. TQM (total quality management) we propose as a method by which 'to assist in the integration of the "thousands of independent provider units," the fragmentation ofwhich existed long before the current reforms. (4) If by "short termism" Dr Mackay implies a policy seeking a quick fix, she is right; this would not be an environment in which TQM would flourish. TQM is for the long haul. "A culture of insecurity" might also be an unfavourable one for TQM, but it is important to appreciate' that too much security, as may have existed in the past, may also be counterproductive. (5) We believe that TQM provides a mechanism for the improvement of care, whatever the fiscal constraints. The goals of TQM are to provide better care at lower price (poor care, as we argue in the articles, usually costs more). The successful implementation of TQM should, therefore, lead to more and better care within whatever fiscal limits are set. (6) The skills of teamwork that we encourage transcend those currently practised in the United States or Great Britain. Doctors may be reasonably proficient members of teams of doctors in their own specialty. They are less successful in collaboration with doctors in other specialties or with other health professionals and rarely function effectively on problem solving teams with management (for which management must, of course, assume its share of responsibility). New clinical skills in audit were not among those that we proposed, and Dr Mackay is apparently confused as to the central message of the articles: that total quality management, incorporating continuous
quality improvement of all care, should replace medical aiudit's limited objectives of identifying and improving only that medical care that is substandard. The tone of Dr Mackay's letter and particularly her final sentence suggest that she sees the profession's "political masters" as adversaries. There will always be political masters to whom one must be accountable. One of the goals of TQM might reasonably be to enlist them as collaborators, rather than adversaries, in the quest for an across the board improvement in the quality of care. J P BUNKER CRC Clinical Trials Centre, King's College School of Medicine and Dentistry, London SE5 9NU
A ENTHOVEN
Graduate School of Business, Stanford University, Stanford, California 94305 USA
D M BERWICK Harvard Community Health Plan, Boston, AMassachusetts 02115 USA
SIR, -D M Berwick and others propose that total quality management should be used in the NHS. 2 It is not unknown to the NHS, of course; it and allied techniques such as quality circles have been used by health authorities and endorsed by some regions for some time. New, however, is the suggestion that total quality management should be endorsed nationally. Most care in the NHS, in terms of patients treated, is at primary health care level. Berwick and colleagues make some acknowledgment of the future need of general practitioners: "To fulfil their responsibilities as gate keepers and care givers [they] must understand decision analysis and probability theory. They must be able to take advantage of computerised medical information technology and its access to data relevant to the patient at hand in order to refine the decision whether to refer or to provide care.... For this to happen it will . . be necessary to undergo . .. a level of training and expertise perhaps as demanding as that of the specialist consultant." The role of audit is dismissed: they say that it has been the focus of a vast American industry that has had virtually no impact on the quality of care, and that it had been hoped that the results of medical audit and consensus conferences and clinical guidelines would be adopted by the profession to improve the quality of practice, but this has failed to happen. I both agree and disagree with the authors. Medical audit as introduced into the NHS has not yet had one year of life. To condemn our potential for change on the basis of the American experience is to display ignorance of what medical audit advisory groups are already achieving in every part of Britain. The eight new clinical skills defined
BMJ VOLUME 304
21 MARCH 1992
