Dening quality of care

S.M. Campbell*, M.O. Roland, S.A. Buetow

National Primary Care Research and Development Centre, The University of Manchester, Williamson Building, Oxford Road,
Manchester M13 9PL, UK
Abstract
This paper denes quality of health care. We suggest that there are two principal dimensions of quality of care
for individual patients; access and eectiveness. In essence, do users get the care they need, and is the care eective
when they get it? Within eectiveness, we dene two key components eectiveness of clinical care and
eectiveness of inter-personal care. These elements are discussed in terms of the structure of the health care system,
processes of care, and outcomes resulting from care. The framework relates quality of care to individual patients
and we suggest that quality of care is a concept that is at its most meaningful when applied to the individual user of
health care. However, care for individuals must placed in the context of providing health care for populations which
introduces additional notions of equity and eciency. We show how this framework can be of practical value by
applying the concepts to a set of quality indicators contained within the UK National Performance Assessment
Framework and to a set of widely used indicators in the US (HEDIS). In so doing we emphasise the dierences
between US and UK measures of quality. Using a conceptual framework to describe the totality of quality of care
shows which aspects of care any set of quality indicators actually includes and measures and, and which are not
included. 7 2000 Elsevier Science Ltd. All rights reserved.
Keywords: Quality; Care; HEDIS; NHS
Introduction
Growing demand for health care, rising costs, con-
strained resources, and evidence of variations in clini-
cal practice have increased interest in measuring and
improving the quality of health care in many countries
of the world. Quality improvement is high on the
national agenda both in the UK (Roland, Holden &
Campbell, 1999) and in the USA (Schuster, McGlynn
& Brooks, 1998). There has been a move away from
assessing costs and activity to assessing quality with an
emphasis on both ecient use of resources and on the
eectiveness of health care. In the UK this trend has
led to an emphasis on both performance measurement
and quality improvement for the NHS, and the devel-
opment of a national performance framework (Depart-
ment of Health, 1997; NHS Executive, 1999). Within
this, clinical governance will form a framework
through which `NHS organisations are accountable for
monitoring and improving the quality of their services',
with the aim of promoting `an environment where
excellence of clinical care will ourish' (NHS Execu-
tive, 1998a,b).
The increasing focus by governments on improving
Social Science & Medicine 51 (2000) 16111625
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PII: S0277- 9536( 00) 00057- 5
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* Corresponding author. Tel.: +44-0161-275-7601; fax:
+44-0161-275-7600.
E-mail address: stephen.campbell@man.ac.uk (S.M.
Campbell).
quality of care requires that the concept is clearly
understood. In this paper we dene quality of care.
We focus specically upon care received by individuals
from formal institutional health care systems which in-
dividuals or carers have chosen to access. Care in this
context refers to care provided by any health care pro-
fessional. We suggest that there are two dimensions of
quality in this context; access and eectiveness. In
essence, do users get the care they need, and is the care
eective when they get it? There are two key elements
of eectiveness clinical eectiveness and the eec-
tiveness of inter-personal care and both of these
should be related to need. These elements are discussed
with reference to the structure of the health care sys-
tem, processes of care and outcomes resulting from
care. The aim of accessing eective health care for in-
dividuals is to maximise health benet according to
need. We suggest that quality of care is a concept that
is at its most meaningful when applied to the individ-
ual user of health care.
However, care for individuals must be placed within
the context of providing health care for populations.
We also dene quality of care for populations by refer-
ence to a separate but overlapping set of criteria
reecting the opportunity cost of providing care for
any individual patient or group of patients. We show
how our framework can be of practical value by apply-
ing the concepts outlined to the set of performance in-
dicators proposed for use in the UK (NHS Executive,
1999) and a widely used set of US quality indicators,
HEDIS 3.0 (National Committee for Quality Assur-
ance, 1998). A framework is important as it both
increases understanding of what such sets of indicators
mean and also those aspects of care that should be
covered and which are, and are not, actually being
covered.
Many symptoms experienced by individuals are not
presented to formal health care systems (Rogers, Has-
sell & Nicholaas, 1999). We recognise that pathways
to formal care are complex and multidimensional
(Campbell & Roland, 1996; Rogers et al., 1999).
They are dependent on factors which include the
sociodemographic characteristics of the population
(Ben-Shlomo, White & McKeigue, 1992; MacIntyre,
McIver & Sooman, 1993), health need (Evandrou,
Falkingham, Le Grand & Winter, 1992; Feinstein,
1993) and factors such as lay support (Robinson &
Graneld, 1986; Oakley, 1994), frequent attendance
(Neal, Heywood, Morley, Clayden & Dowell, 1998)
and health beliefs (Egan & Beaton, 1987; Murray &
Corney, 1990; Van der Kar, Knottnerus, Meertens,
Dubois & Kog, 1992).
However, this paper does not focus on the attributes
of health care systems which might inuence consulting
behaviour. Rather, we focus specically upon care
received by individuals from formal institutional health
care systems starting from where an individual or carer
has decided to access care. We rst dene the com-
ponents of care, then the attributes of quality. We
bring these together to provide a framework to
describe quality of care.
Dening health care
Denitions of care are varied and contested (Hey-
man, 1995; Webb, 1996; McCance, McKenna &
Boore, 1997). For the purposes of this paper, we dene
health care as being composed of health care systems
and actions taken within them designed to improve
health or well-being. Donabedian (1966, 1988) rst
proposed a systems-based framework of structure, pro-
cess and outcome. These have also been described as
categories of care (Ellis & Whittington, 1993). Donabe-
dian's model has been used previously as a basis for
dening quality (Steen, 1988; Tarlov, Ware, Green-
eld, Nelson, Perrin & Zubko, 1989; Baker, 1995;
Irvine & Donaldson, 1993).
It is necessary to distinguish between the structure
of health care, actual care given (process) and the con-
sequences of the interaction between individuals and a
health care system (outcome). We suggest that out-
come is not a component of care but a consequence of
care. Similarly, structure is not a component of care
but the conduit through which care is delivered and
received. Fig. 1 shows the key domains underlying
structure, process and outcome for care received by in-
dividuals from a health care system and the dimensions
of each of these domains.
Structure
Structure refers to the organisational factors that
dene the health system under which care is provided
(Donabedian, 1980). We identify two domains of
structure: physical characteristics and sta character-
istics, and Fig. 1 shows the dimensions of each of
these domains. Components of the dimension of
resources include, for example, personnel, equipment
and buildings. The ways in which those services are
organised would include, for example, opening hours
and the existence or otherwise of a booking system
for appointments. These are both structural elements
of the health care system. Structural features of
health care provide the opportunity for individuals to
receive care but do not guarantee it. On the whole
structures, whilst being able to increase or decrease
the likelihood of receiving high quality care, are indir-
ect and contingent inuences on care. However, struc-
tural features within a systems based model of care
can have a direct impact on processes and outcomes,
e.g. if necessary equipment or skills are not available
S.M. Campbell et al. / Social Science & Medicine 51 (2000) 16111625 1612
to undertake an eective examination or if all
appointments are booked-up prohibiting a patient
accessing care.
Process
Processes of care involve interactions between users
and the health care structure; in essence, what is done
to or with users. Process is the actual delivery and
receipt of care. Two key processes of care have often
been identied: technical interventions and inter-per-
sonal interactions between users and members of a
healthcare system (Blumenthal, 1996; Donabedian,
1988, 1992; Irvine, 1990; Tarlov et al., 1989; Steen,
1988).
Technical care refers to the application of clinical
medicine to a personal health problem (Donabedian,
1980) and is based upon a theory of function which
can be evaluated for ecacy and generally standar-
dised. Care should be appropriate and necessary
(Kahan et al., 1994; Brook, 1994). In practice, care is
often overused, i.e. provided when inappropriate, and
underused, i.e. not provided when necessary (Brook,
McGlynn & Cleary, 1996; Schuster et al., 1998). Both
necessary and appropriate care must be seen from
both ends of the scale; for example, appropriateness is
used as much to dene what is inappropriate as appro-
priate.
Both `clinical care' and `technical care' have been
used to describe the more bio-medically oriented
aspects of health professional's behaviour. We suggest
that clinical care is the more appropriate term to use
as there are also technical aspects to inter-personal
care, e.g. specic skills in relation to giving infor-
mation to patients. We therefore dene the process of
care in terms of clinical and interpersonal aspects of
care.
Interpersonal care describes the interaction of health
care professionals and users or their carers. This
includes ``the management of the social and psycho-
logical interaction between client and practitioner''
(Donabedian, 1980). A number of skills underlie good
inter-personal skills including: communication, the
ability to build a relationship of trust, understanding
and empathy with the patient (Blumenthal, 1996) and
to show humanism, sensitivity and responsiveness
(Carmel & Glick, 1996). Patients want explanation and
discussion about their symptoms (Woloshynowych,
Valori & Salmon, 1998), and to be involved in de-
cisions about their management.
Both clinical and inter-personal care processes
involve the denition and communication of problems
or needs, diagnoses, their management and co-ordina-
tion by the patient and professional concerned. In ad-
dition to actions taken by an health professional,
identied as elements of process in Fig. 1, the process
of care may be further classied into preventive care,
care for chronic disorders, and care for acute illness.
This classication is particularly relevant to quality
measurement, since quality indicators abound for the
rst, are patchy for the second, and almost absent for
the third. The lack of quality indicators for acute
minor illness has important implications for assessing
the quality of general/family practice where they form
the bulk of all presenting problems. Clinical and inter-
personal aspects of care are relevant for each consul-
tation and apply equally to chronic, acute or preven-
tive care.
Outcome
Outcomes are consequences of care. Structure as
well as processes may inuence outcome, indirectly or
directly. For example, a patient may die from cervical
cancer either because a screening service is not avail-
able (structure) or because her cytology report is mis-
read (process). However, the relative importance of
each of these components will vary in dierent situ-
ations and the relationships between them are not
necessarily linear.
Fig. 1. A systems based model for assessing care.
S.M. Campbell et al. / Social Science & Medicine 51 (2000) 16111625 1613
The eectiveness of structure and processes (both
clinical and inter-personal) can be dened in terms
of their capacity to result in two principal domains
of outcome: health status and user evaluation
incorporating non-health as well as health related
outcomes. There may be feedback loops with, for
example, an individual's user evaluation (outcome)
inuencing their subsequent consulting behaviour, or
care negotiated in one consultation aecting sub-
sequent decisions (Rogers et al., 1999).
Our framework focuses upon care for individual
users so outcome in Fig. 1 refers to health status
and user evaluation, e.g. satisfaction, enablement
(Howie, Heaney & Maxwell, 1996) and health re-
lated quality of life. These must also be related to
patient expectations and to the needs of that indi-
vidual patient (Stott et al., 1997). User evaluation
may include assessment of outcome (symptom resol-
ution) and/or processes of care (e.g. communication
skills of the health professional). Although outcomes
may be explicitly related to process for both health
status (e.g. Antiplatelet Trialists' Collaboration,
1994) and user evaluation (e.g. Schmittdiel, Selby,
Grumbach & Quesenberry, 1997), this is not always
the case (Long & Faireld, 1996). This is because
outcomes are often causal rather than logical conse-
quences of processes and their activation is contin-
gent upon a wide variety of factors. Outcome C
will not always follow logically from process B
using structure A. Care processes may have little or
no consequence on disease outcomes if, for example,
an illness has an immutable natural history.
There has been considerable debate about whether
process or outcome should be assessed as measures
of quality of care (Davies & Crombie, 1995; Brook,
McGlynn & Cleary, 1996). In general, process
measures are better indicators of quality of care if
the purpose of measurement is to inuence the
behaviour of the health care system: processes are
common, under the control of health professionals,
and may more rapidly be altered. Outcomes are
often rare, may follow a change in process by up
to 10 years (e.g. management of hypertension), and
may be dependent on factors outside the control of
the individual health professional (Giurida, Grav-
elle & Roland, 1999). However, process measures
suitable for measuring quality should be clearly
linked to evidence of improved outcomes.
We have dened care as a systems based model
composed of health structures and two processes of
care (clinical and inter-personal) which result in con-
sequent outcomes. However, whilst systems and pro-
cesses increase or decrease the likelihood of
individuals receiving the care they need, they do not
guarantee quality care. We now consider the concept
of quality.
Dening quality
Quality has been dened in a number of dierent
ways (Crosby, 1979; Donabedian, 1980; Maxwell,
1984; Peters, 1987; Juran, 1988). Denitions of quality
are either generic or disaggregated approaches
which are not inherently incompatible but can be seen
as opposite ends of a continuum. Generic denitions
of quality include excellence (RCGP, 1994), expec-
tations or goals which have been met (Ellis & Whit-
tingham, 1993; Steen, 1988), `zero defects' (Crosby,
1979) or tness for use (Juran, 1988). Other generic
denitions are more complex. For example, the Insti-
tute of Medicine (Lohr, 1992) has dened quality as
the `degree to which health services for individuals and
populations increase the likelihood of desired health
outcomes and are consistent with current professional
knowledge'. Generic denitions are not easily operatio-
nalisable and trade both sensitivity and specicity for
generalisability.
Disaggregated approaches, on the other hand, recog-
nise that quality is complex and multidimensional
(Donabedian, 1980; Maxwell, 1984; HSRG, 1992;
Wineeld, Murrell & Cliord, 1995). They dene qual-
ity according to individual dimensions or components.
Some examples of previous denitions of quality of
care using disaggregated approaches are included in
Fig. 2.
Each individual component of quality provides a
partial picture of quality when viewed on its own, but
oer more specicity in dening quality when viewed
in combination. However, we propose that there are
only two domains of quality access and eective-
ness. For individual patients, all dimensions of quality
suggested previously, including those listed in Fig. 2,
can be subsumed by and appropriately regarded, as el-
ements of access and eectiveness. Quality of care
may, in this way be reduced to two questions. First,
can an individual get the care they need when they
need it? Second, when they get the care, is it eective
both in terms of clinical eectiveness and inter-per-
sonal relationships? We now develop this proposition
by applying access and eectiveness to the systems
based model of care (structure, process and outcome)
described above.
Dening quality of care for individual patients
We propose a combined generic and disaggregated
approach to dening quality of care. Our denition of
quality of care for individuals is:
whether individuals can access the health structures
and processes of care which they need and whether
the care received is eective.
S.M. Campbell et al. / Social Science & Medicine 51 (2000) 16111625 1614
Fig. 3 shows how access and eectiveness can be re-
lated to health care structures, to processes of care,
and outcomes, to produce a taxonomy of quality of
care for individual patients. We now develop this argu-
ment by considering separately access and eective-
ness.
Access
The rst part of our denition of quality of care
emphasises ``whether individuals can access health
structures and processes of care which they need''. The
most basic dimension of access to a health structure is
geographic/physical access (Haynes, 1991). This may
relate to geographic barriers to getting to health care
facilities such as rurality (Watt, Franks & Sheldon,
1993; Cox, 1994), or use of premises themselves such
as access by disabled or elderly people (Bentham &
Haynes, 1985). Availability is the extent to which the
health care system provides facilities (structures) and
services (process) which meet the needs of individuals.
Examples include access to a female general prac-
titioner, a specialist clinic, or a member of a health
care team other than a doctor (e.g. nurse practitioner,
physiotherapist or counsellor). The latter is increas-
ingly important given the emergence of a far more
diverse range of skills among health care providers as
part of attempts to increase the costeectiveness of
care (Pritchard & Pritchard, 1994).
Organisational access is a sub-component of avail-
ability. If people are physically able to access a health
facility, they may still face barriers to accessing care in
terms, for example, of the length and availability of
appointments, or whether the health professional can
speak their language. In a system where the primary
care practitioner acts as a gatekeeper, access to second-
ary care or other members of the PHCT is determined
by access to the primary care practitioner and by his
or her referral behaviour.
We suggest that three of the four attributes of qual-
ity identied as being of particular relevance to pri-
mary care (Stareld, 1994) are sub-components of
access. First contact, comprehensiveness a range of
services and care broad enough to meet all common
needs as they occur and provider continuity or
longitudinality are all sub-components of the structural
Fig. 2. Examples of previously described dimensions of quality of care.
Fig. 3. Dimensions of quality of care for individual patients (dimensions of quality of care for populations are considered separ-
ately in the text).
S.M. Campbell et al. / Social Science & Medicine 51 (2000) 16111625 1615
aspects of availability, rather than quality attributes in
their own right. Our view is that continuity of care is
not a unique dimension of quality but a structural
characteristic that may produce benets, though is not
guaranteed to do so (Freeman & Hjortdahl, 1997). For
example, continuity of care from an ineective pro-
fessional with poor communication skills does not con-
stitute high quality care, even though such a
professional could nevertheless score well on access
and patient evaluation dimensions.
In this paper, we do not include equity as a com-
ponent of quality of care for individuals as equity
requires a element of comparison of individuals within
a population; however, we do regard equity as a key
element of quality of care at the population level,
which we discuss later.
Monetary costs of access at the individual level are
only relevant to the payer. This may be the patient
where services are not free at the point of delivery. So
aordability is a key component of access in countries
where health care is not provided by the state. Finan-
cial barriers may also be important in other systems,
either in terms of the material cost of attending an
appointment (transport costs, childcare, prescription
charges) or the opportunity cost incurred, for example,
in loss of earnings. Other barriers include having to ac-
commodate competing social role commitments into
the daily routine which may prevent, for example,
mothers with young children accessing health care on
their own behalf (Young, 1996).
Health status and user evaluation are the principal
outcomes of quality of care for individuals relating to
access (Fig. 3). User attitudes cannot be separated
from nor properly understood without reference to the
experiences with which they are connected (Cornwell,
1984). These evaluations may inuence future decisions
about accessing care; e.g. an individual may feel disin-
clined to consult if the last time they consulted they
were treated unsympathetically (Murray & Corney,
1990). User evaluation thus forms part of a feed back
loop with acceptability a dimension of outcome within
user evaluation which may inuence whether an indi-
vidual seeks to access formal care in the future.
Eectiveness
The second part of our denition of quality of care
relates to whether, when accessed, the care received by
an individual is eective. Eectiveness is the extent to
which care delivers its intended outcome or results in a
desired process, in response to need. Fig. 3 shows the
two key elements of eectiveness clinical care and
inter-personal care.
The eectiveness of clinical care depends on the
eective application of knowledge based care. Knowl-
edge-based care refers to both evidence-based medicine
(Sackett, Rosenberg, Gray, Haynes & Richardson,
1996) and care which is regarded as legitimate (Dona-
bedian, 1990). The latter relates to aspects of care that
may be widely accepted without necessarily having
scientic evidence of eectiveness. Knowledge-based
care incorporates the extent to which a treatment or
service is consistent with patients' reasonable expec-
tations and contemporary professional standards of
care, reecting both societal and professional norms.
For example, primary care counselling has been found
to be popular with patients (Priest, Vize, Roberts &
Tylee, 1996; Scott & Freeman, 1992) and is widely im-
plemented within primary care in the UK (Sibbald,
Addlington-Hall, Brenneman & Freeling, 1993) but as
yet there is limited evidence for its eectiveness (Roth
& Fonagy, 1996). Care is only described as evidence-
based when there is good scientic evidence of a link
between process and outcome; for example, the role of
aspirin in secondary prevention of coronary heart dis-
ease (Antiplatelet Trialists Collaboration, 1994).
Once again, processes and outcomes are context
specic for each individual person because quality of
care for individual users requires that individual cir-
cumstances and the complexity of individual patients
must be considered. Eective care, therefore, requires
appreciation of the patient's personal experience of ill-
ness (Stewart, Brown, Weston, McWhinney, McWil-
liam & Freeman, 1995) and must align the agendas of
the professional and the patient (Tuckett, Boulton,
Olson & Williams, 1985). Care should be planned for
and with individual patients (HSRG, 1992, p. 2154;
Stewart et al., 1995) through negotiation between
doctor and patient (Buetow, 1999) and shared respon-
sibility for care (McGlynn, 1997). Focusing on the
eectiveness of patient centred processes reduces the
risk of over-emphasising scientic/technical aspects of
care at the expense of the experiences of the individual
patient. Originating in the psychodynamic study of
professional patient interactions (Balint, 1964), patient
centredness is increasingly regarded as a set of skills
which can be taught (Stewart et al., 1995) and which
are related to improved outcome (Howie, Hopton,
Heaney & Porter, 1992). Patient-centredness is con-
cerned with the meaning of care for individuals (Stew-
art et al., 1995; HSRG, 1992) rather than care which is
generalisable to all.
Co-ordination or integration of care for individual
patients is also an important attribute of quality (i.e.
eectiveness) of care, and is a further attribute of par-
ticular relevance to primary care (Stareld, 1994). We
suggest that co-ordination is a sub-component of both
clinical eectiveness and the eectiveness of inter-per-
sonal skills. Co-ordination refers to the eectiveness
with which health professionals deal with those other
organisations, or other professionals within the same
organisation, which impact directly or indirectly upon
S.M. Campbell et al. / Social Science & Medicine 51 (2000) 16111625 1616
the health or health related quality of life of the
patient (e.g. social care, education or housing).
We suggest that eectiveness, when related to indi-
vidual patients, should refer to maximising care and
desired processes and outcomes based upon need. We
consider ecacy (Donabedian, 1990; O'Leary &
O'Leary, 1992) to be a redundant component of qual-
ity of care because we are unable to conceptualise high
quality care which involves delivering treatments which
are ecacious (in ideal settings), but ineective in rou-
tine healthcare settings. We also reject acceptability as
a basic component of quality or as an attribute of
care: it is more appropriately regarded as an outcome
or consequence of care: it is a component of users'
evaluation.
Stakeholder perspectives of quality of care
Much has been written about the fact that dierent
stakeholders (e.g. users, professionals and payers) de-
ne and perceive quality of care dierently (McGlynn,
1997; Annandale & Hunt, 1998; Ovretveit, 1992; Joss
& Kogan, 1995; Blumenthal, 1996; RCGP, 1994). The
contingent nature of quality means that there will be
dierent perspectives upon the dimensions of access
and eectiveness and on what constitutes a desired
process or outcome. For example, eciency and cost
eectiveness are principally concerns of managers
(reecting a more societal perspective) whereas users
emphasise patient-centredness in response to their (in-
dividual) needs, e.g. humaneness, kindness, communi-
cation and access (Wensing, Grol & Smits, 1994).
Dierences between users and health professionals
(Van der Waal, Casparie & Lako, 1996), for example
when an evidence-based intervention designed to pro-
duce a outcome is not wanted by the patient (Mulley,
1995), will provide examples of the eectiveness of the
patient-centredness of care.
For some stakeholders, e.g. a national healthcare
system, it is the outcome for a population which is of
greatest importance, rather than the outcome for indi-
viduals. We now discuss how quality of healthcare
may be dened for populations, since this diers in
some important respects from quality of healthcare for
individuals.
Dening quality of care for populations
We have suggested that quality of care has most
meaning when applied to the level of the individual
user of health care. After all, it is individuals who are
the recipients of care. Questions about quality of care
for individuals cannot be answered by reference to
populations, only put in to the context of a social con-
struction of quality of care. Borrowing from economics
we recognise that care is not given as part of a closed
model ceteris paribus. For example, most economic
evaluations of health care adopt a societal perspective
and focus on the optimisation of health benet for
populations (Craig & Sutton, 2000). Whilst quality of
care for individual patients may therefore be under-
stood with reference to the framework outlined in
Fig. 3, it also needs to be understood in terms of, and
may be contingent upon, care for populations.
Care for whole populations may potentially conict
with care for individual patients, for example, because
of prioritisation of resources towards particular health
needs. We have argued that consideration of quality of
care for an individual requires information which is
context specic to that user. However, a societal per-
spective requires information about all potential users
of health care (Birch & Gafni, 1992) and this requires
consideration of opportunity costs. What is done to an
individual user of health care (in terms of resources,
including time as well as costs) may, therefore, be con-
tingent upon what is done to all other users of the
health care; particularly within systems with resource
constraints. This divergence reects Donabedian's dis-
tinction between individual and social quality (Dona-
bedian, Wheeler & Wyszewianski, 1982), with the
former based upon the individual and the latter
emphasising aggregate net benet (or net utility) for
the entire population (Donabedian, 1980). At the
population level we propose that there are three ad-
ditional key factors: equity, eciency and cost which
contribute to our model of quality of care for popu-
lations. We therefore dene quality of care for popu-
lations as:
the ability to access eective care on an ecient
and equitable basis for the optimisation of health
benet/well-being for the whole population.
Access
Quality of care can only be understood within the
overall context in which health care is provided. Local
or national factors help dene the context in which
health care is provided in organisations and these
are often outside the control of health professionals
(Heath, 1995; Goldstein & Speigelhalter, 1996).
Examples of such factors include the availability of pri-
mary and secondary health care services, such as com-
munity psychiatric services and the availability of
social services or local authority services. Theses are
dimensions of structural availability at a societal level.
Supply factors have been found to be important deter-
minants of utilisation (Evandrou et al., 1992).
In our framework, we dene equity as a sub-com-
ponent of access relevant to structure and process; it is
S.M. Campbell et al. / Social Science & Medicine 51 (2000) 16111625 1617
dened as the extent to which all individuals in a
population access the care they need. Denitions of
access must emphasise a notion of access according to
need and the timely use of services (Evandrou et al.,
1992; Maxwell, 1992; Field & Lohr, 1992; IOM, 1993);
both in terms of horizontal equity (equally accessible
to eective care for all users), and vertical equity
(greater access to eective care for those with more
need). The test of equity are systematic dierences in
use and outcomes (IOM, 1993). We support Maxwell's
(1992) concept of relevance as whether `the overall pat-
tern and balance of services (is) the best that could be
achieved, taking into account the needs and wants of
the population as a whole' but suggest it is a sub-com-
ponent of availability. In essence, services should be
available on an equitable basis according to need. As
with care for individual patients, health status and user
evaluation are key outcomes of access for populations,
in addition to equity. However, equitable access does
not automatically translate into equitable eectiveness.
Eectiveness
Within the domain of eectiveness, we again dene
equity as an important component of quality of care
for populations. In addition, we dene eciency as an
attribute of quality of care for populations. Eciency
is to the ratio between benet and costs. In essence,
the most ecient use of care to maximise outcome,
which can involve allocative eciency (focusing on
procedures which produce maximum benet) and tech-
nical eciency (employing procedures in the most tech-
nically competent manner). Denitions of eciency
which are output-specic concentrate upon maximising
desired outcomes for individual users (Ryan & Shak-
ley, 1995). However, achieving maximum desired out-
comes for all individual users may not be sustainable
or aordable at the population level. We recognise the
importance of costeectiveness when referring to
health care for populations where choices have to be
made between diering priorities for the allocation of
scarce resources. At the population level, inputs are as
important as outputs and resources should be distribu-
ted eciently to where there is the most potential for
health gain (Blaxter, 1996). It is up to society to
choose whether resources should be allocated to par-
ticular sub groups within a population (Donabedian et
al., 1982) based, for example, on decisions about need
and equity (Bevan, 1998).
There is a need to balance eectiveness and e-
ciency to gain the highest net benet to individuals
and society (Donabedian, 1980). Eciency and quality
are not mutually exclusive the challenge is to fuse
economic and clinical incentives (Brook, 1997). How-
ever, whether related to either individuals or popu-
lations, the ratio of cost to benet (process or outcome
benet) will increase when care is ineective. Ineective
care is inecient (Ovretveit, 1992; Crosby, 1979).
Aordability at societal level is a sub-component of
availability and relates for example to the rationing or
prioritising of treatment. At population level the e-
cient use of care for the maximum desired outcomes
(health status and user evaluation) within costs is para-
mount. This is, in essence, a `welfarist' approach to
health care with an emphasis upon the sum of (health)
benet received by each individual in society (Ryan &
Shackley, 1995). However, ecient care must be pro-
vided on an equitable basis.
We suggest, therefore, that at the societal level there
are four outcomes of eectiveness; user evaluation and
health status and, in addition, cost and equity.
Practical application of the framework
In this section, we demonstrate the utility of the
framework by applying it to two sets quality indi-
cators, the NHS National Performance Framework in
the UK, and the HEDIS set developed for the assess-
ment of health plans in the United States by the
National Committee for Quality Assurance (NCQA,
1998). We show how the framework can be used to
demonstrate what aspects of care are being measured
and what are not, and we also show how it can be
used as a framework to permit critical analysis of qual-
ity indicators.
The UK government has recently published a
National Performance Assessment for the National
Health Service (National Health Service Executive,
1999). This framework is intended to be applied at
health authority level (populations 200,000500,000).
The HEDIS set of measures provides a common data-
set to enable purchasers and consumers of health care
to choose between health plans (NCQA, 1998). Annual
reporting of HEDIS measures us required of health
plans for accreditation by the NCQA. At present there
are over 100 indicators, with many more being devel-
oped, particularly in the area of clinical eectiveness.
The indicators in the two sets are summarised in
Table 1. In some cases, the distinction between access
and eectiveness is articial. For example, in the UK
indicators, teenage pregnancy rate is specically
advanced both as an indicator of availability of ser-
vices and of the eectiveness of those services. The fol-
lowing critique is not intended to be comprehensive,
but rather to demonstrate how a conceptual frame-
work can be used critically to examine measures of
quality of care.
Access and availability
Inspection of Table 1 shows that neither set of indi-
S.M. Campbell et al. / Social Science & Medicine 51 (2000) 16111625 1618
Table 1
HEDIS and the National Performance Framework compared
Quality of care
dimensions for individual
patients (from Fig. 3)
National Performance Framework indicators proposed
for use by the National Health Service Executive (1999)
Performance indicators in HEDIS 3.0, 1999
dataset (NCQA, 1999)
Structure
Geographic access None None (though could be included in patient
survey)
Physical access None None (though could be included in patient
survey)
Aordability None Cost/member/month
Availability Rate of use of ambulatory health services
% Adults registered with dentist No. of providers (primary care, mental health,
obstetric and dentists) accepting new patients
% Children registered with dentist
Size of in-patient waiting list Co-ordination with education and social
services
Outpatient (within 13 weeks of referral) and inpatient
(within 3 months of decision to admit) waiting times
Eectiveness Qualications of physicians
No. of doctors who left in previous year
Physicians' incentives to overtreat or
undertreat
Financial stability of health plan
Process
Aordability None None
Availability % Follow up after admission for mental
health problem
% Dental checks in children in the last year
Availability of interpreters
No. of well child/well adolescent visits
Length of stay (fractured neck of femur, stroke) Length of stay (elective admissions, maternity
care)
Day surgery rate Elective surgery rate
Admission rates (hospital, nursing home)
Outpatient utilisation rate (primary care,
emergency room, outpatient surgery, mental
health, chemical dependency)
Eectiveness of clinical
care
% Children immunised % Children and adolescents immunised
% Smokers receiving advice
%>65 receiving inuenza vaccine
% Mammography in target population % Mammography in target population
% Cervical screening in target population % Cervical screening in target population
% Pregnant women starting prenatal care by
13 weeks
% Recommended prenatal and post-partum
visits
% Post MI patients receiving beta blocker
% Diabetic patients with eye exam in
previous year
Elective surgery rate (e.g. appropriate=CABG, hip and
knee replacement, cataract replacement,
inappropriate=D&C, grommet insertion)
Hospital readmission rates within 28 days (emergency,
and mental health)
Hospital readmission rates (mental health and
chemical dependency)
Avoidable admission rate (ENT and urinary infection,
heart failure, epilepsy, diabetes, asthma)
(continued on next page)
S.M. Campbell et al. / Social Science & Medicine 51 (2000) 16111625 1619
cators contains information on structural barriers to
seeking care (e.g. physical or geographical access). This
is potentially a serious omission, especially for some
population groups such as the elderly or disabled. To
some extent this is rectied (especially in HEDIS) by
regarding utilisation as a measure of access: the UK
set contains no information on primary care utilis-
ation. However, as HEDIS is designed for the evalu-
ation of care provided to those enrolled with health
plans, it does not address a key equity issue in the US
a large uninsured population.
Eectiveness
The greatest dierences between the two sets of indi-
cators are seen in the areas of clinical eectiveness and
outcome measurement. These are large and reect
major dierences between the two health care systems,
and in particular dierences in the information systems
in the two countries.
UK data on eectiveness relies almost entirely on
population aggregated rates of procedures, e.g. admis-
sion rate for diabetes, volume of benzodiazepine pre-
scribing. This makes the assumption that there are
correct normative levels for these and (in these
examples) `high is bad'. In the UK data, screening of
children, women of cervical screening age and women
of breast screening age are the only ones where an el-
ement of `need' is built into the denominator. While
data on utilisation rates are collected in the HEDIS
set, it is much more specic about procedures having
been carried out in specic population groups e.g.
smokers advised to stop, and percentage of patients
receiving beta blockers post myocardial infarction.
Table 1 (continued )
Quality of care
dimensions for individual
patients (from Fig. 3)
National Performance Framework indicators proposed
for use by the National Health Service Executive (1999)
Performance indicators in HEDIS 3.0, 1999
dataset (NCQA, 1999)
Rate of discharge to usual residence following stroke
(within 56 days) and fractured neck of femur (within 28
days)
Delayed discharge over age 75
Case-mix adjusted length of stay
Emergency admission rate for >75 s
Operation rate for recurrent hernia
% Orchidopexies carried out below age 5
Psychotropic prescribing (volume of benzodiazepine
prescribing)
Eectiveness of
interpersonal care
None Included in patient satisfaction survey see
patient evaluation below
Outcome
Health status Under 16 conception rate % Elderly receiving functional status
questionnaire
Mortality (all cause age 1564, 6574, deaths from
cancer, circulatory disease, suicide and accidents)
30 Day mortality post myocardial infarction and post
surgery
Cancer registration
5 Year survival rate (breast and cervical cancer)
Infant mortality and stillbirth rate
Decayed/missing/lled teeth in 5 year olds
Notication rate for
measles, pertussis and
TB
Episode rate for fractured femur
User evaluation/
experience
Rate of operations cancelled for non-medical reasons Patient satisfaction survey
Patients waiting >2 hours in A&E No. of patients who disenrolled in previous
year
DNA rst outpatient attendance
Costs of care Generic prescribing rate Drug prescription costs
Unit cost (mental health) High cost DRGs
Costs per member per month
S.M. Campbell et al. / Social Science & Medicine 51 (2000) 16111625 1620
This type of indicator is also prominent among indi-
cators being developed by NCQA, with the 1999 set
(NCQA, 1999) containing cholesterol management
after cardiovascular events, and details of comprehen-
sive diabetes care. Dierences in types of data avail-
able for quality indicators in the two countries relates
largely to the system of billing in the US which has led
to the development of detailed clinical databases and
which are now being used to assess quality. The
absence of such databases in the UK and the conse-
quent reliance on information that is currently routi-
nely available and which can only be collected at
population level is a severe limitation of the UK indi-
cators (Shekelle & Roland, 1998).
Eight out of the ten current clinical eectiveness in-
dicators in HEDIS 3.0 relate to preventive care, reect-
ing the prominence traditionally given to screening in
US healthcare. However, this balance will be redressed
with the inclusion of the types of new indicators out-
lined above: the HEDIS indicators are gradually being
expanded into areas where health gain is most likely to
result from a reduction in variability of performance.
This emphasis is not seen in the UK indicators, in
large part because of the limited nature of the data
available for constructing indicators in the UK.
Health outcomes
However, while the HEDIS set appears replete with
information on process measures of eectiveness, it is
severely decient in terms of clinical outcomes: these
are limited to the percentage of elderly receiving an
annual functional status questionnaire. In contrast, the
proposed UK set contains detailed mortality data, and
some morbidity data. This reects two major dier-
ences between the health care systems. The NHS pro-
vides universal coverage and has a very strong public
health focus. So, mortality data gures prominently in
the UK set.
The focus of the HEDIS indicators is on health plan
members, and not on the population. Since health
plans can choose who they enrol, inclusion of health
status and mortality might increase cream skimming
by health plans, and could perversely lead to worse
care for the population overall if health plans selec-
tively discouraged enrolment by those who were likely
to have poor health outcomes. To a limited extent, the
HEDIS set tries to address the issue of cream-skim-
ming, but only by recording the characteristics, includ-
ing ethnic group, of enrolled Medicaid (welfare
assisted) patients.
However, although health outcomes are required to
assess the magnitude of a health problem in a popu-
lation, they are not necessarily good performance indi-
cators for the behaviour of individual health care
professionals unless sophisticated case mix adjustment
can be made. Health outcomes are often determined
by population characteristics and behaviours outside
the control of individual health professionals, e.g.
socio-demographic population characteristics (Giuf-
frida et al., 1999). They follow indirectly from individ-
ual health encounters, or may be separated from these
by many years (e.g. as in the care of diabetic or hyper-
tensive patients). They are therefore more suitable for
use in the UK, where the government in concerned
with the performance of the whole system, but less
suitable in the US context, where year on year
improvement is sought against published benchmarks.
Inter-personal care
One of the key important elements of quality of care
which we have identied is the quality of inter-personal
care and communication. The authors of both UK and
US sets of indicators are gradually incorporating users'
experiences as a measure of the performance of the
health care system. Direct assessment of interpersonal
care is omitted entirely from the published NHS indi-
cators, although the NHS started at the end of 1998 to
conduct annual patient surveys, and it is planned that
these will be reported at health authority level. Reports
of patient experiences have recently become an signi-
cant part of HEDIS with the inclusion of a mandatory
standard patient survey (CAHPS) in the most recent
version of HEDIS (NCQA, 1999). The HEDIS set also
includes information on patients who disenrolled in the
previous year, which may in part relate to deciencies
in inter-personal aspects of care. Inclusion of this indi-
cator reects the greater ability of US patients to move
between dierent types of health care: this choice is
available in the UK for primary care (though rarely
exercised), but scarcely exists for secondary care within
the NHS.
Discussion
There is no universally accepted denition of care,
quality or quality of care. In this paper we suggest that
quality of care for individual patients is dened by
their ability to access eective care with the aim of
maximising health benet in relation to need. This is
not to say that other dimensions of quality identied
previously in Fig. 2 are not important, but that their
role in delivering quality of care for individuals is
dependent upon users actually getting the care they
need and it being eective. Both access and eective-
ness, and the structure and processes of health care,
are measured by their capacity to result in desired out-
comes and/or processes as negotiated by user and
health professional.
We have suggested that quality of care is a dierent
S.M. Campbell et al. / Social Science & Medicine 51 (2000) 16111625 1621
concept when considered for individual users or whole
populations. At the societal level quality of care is the
ability to access eective care on an ecient and equi-
table basis for the optimisation of health benet/well-
being for the whole population. However, we regard
quality of care to be a concept that has most meaning
when related to individual users. The complexities and
needs of individual patients or consultations are only
discernible at the level of the individual and by focus-
ing upon what is required for an individual in their in-
teraction with a health care provider. People
presenting to a health professional expect good indi-
vidual care (Stott et al., 1997) which they will evaluate
in relation to how it meets their individual needs
(McGlynn, 1997). Population based measures of qual-
ity of care should, in part, be judged in terms of their
ability to reect the aggregation of individual encoun-
ters. However, this is not to say that people should
necessarily get what they want the health needs of
individuals must be balanced against optimising health
outcomes for society.
There is a discrepancy between dening the various
aspects of quality of care and the methods currently
available for collecting the data and/or the political
will, by organisations and governments, to collect data
using dierent methods. We have emphasised how
dierent stakeholders value dierent components of
quality of care. Moreover, our conceptual framework
places inter-personal care equally with clinical care as
a key process of quality of care. Importantly, the
methods of measuring dierent elements of dened
care are not standardised and dierent methods
requires dierent methodologies for measuring quality
of care (Blumenthal, 1996). For example, methods for
measuring patient-centredness and communication
skills are more time consuming and expensive than
computer searches of hospital clinical databases to
determine admission rates. Strict reliance on explicitly
measuring data quantitatively contained in administra-
tive datasets can only measure those elements of qual-
ity of care which are consistently and reliably recorded
therein. It is unlikely that data collected for adminis-
trative of nancial purposes will meet the requirements
of data to be used for quality assessment or quality
assurance. Whether policy-makers give equal weight to
other perspectives and methods is a political rather
than conceptual issue. The potential expenditure on
comprehensive quality assessment is very considerable,
and choices will need to be made between spending
money on quality assessment or on direct patient care.
The assessment of quality on its own is not sucient:
it needs to be linked to eective (and cost eective)
methods of improving quality.
Moreover, if quality indicators are developed as
quantitative statistical measures (as with NPF and
HEDIS) it is important to consider statistical and prac-
tical issues. These include the reliability and validity of
the data collected, the feasibility (ease and cost) of col-
lecting the data and dierences in availability and com-
parability of data between and within countries.
We have not considered how the various com-
ponents of quality of care might be weighted or com-
pared with one another. We have dened quality of
care as accessing eective care according to need.
However, is a user, who receives good access but inef-
fective care, receiving worse or better care compared to
a user who has had diculties accessing eective care?
Moreover, is a procedure which is rated as eective by
a health professional, but rated poorly as an outcome
by a user, good or bad care? Such questions are im-
portant for measuring, as opposed to dening, quality
of care and whilst these highlight often potentially irre-
concilable dierences between dierent stakeholder
perspectives, they will form the test of our ability to
measure patient-centred care. Ultimately a national
framework must assess quality of care from perspec-
tives important to professionals, payers and patients
(McGlynn, 1997).
We have applied the framework to a widely used set
of indicators in the US and a set of indicators pro-
posed for use in the UK. Both the UK National Per-
formance Framework and HEDIS attempt to move
beyond simple activity measures to include indicators
based on evidence and user evaluations. However,
most of the indicators rely solely upon readily collect-
able data and on standardised population measures.
Whilst this is perhaps inevitable, there is a risk that
they will perversely reduce quality for other elements
of care, e.g. those which have wide professional and
public legitimacy (though limited evidence of eective-
ness), and inter-personal aspects of care. There are
dangers that by dening explicitly what is to be
measured, this encourages health care organisations/
professionals to ``jump through the hoop'', safe in the
knowledge that it is only performance in these aspects
of care that will be measured. Moreover, inevitably,
discussion of quality of care and cost often go hand-
in-hand on both sides of the Atlantic. In the UK
others have emphasised how quality of care forms part
of a wider UK government strategy to manage public
services (Hoggett, 1996; Traynor, 1996) driven by a
desire to get ``more for less'' (Hood, 1991). In the
USA there is a growing movement to ensure that the
new organisational structures for measuring quality do
not sacrice quality at the expense of costs (Schuster et
al., 1998). Importantly, quality of care is both an end
in itself, but can also be used as a means of addressing
other agenda (e.g. control of health care expenditure).
Any discussion of quality of health care must be set
within the context that health care does not operate in
a political vacuum.
We believe that both sets of indicators are to be wel-
S.M. Campbell et al. / Social Science & Medicine 51 (2000) 16111625 1622
comed as important advances in measuring quality of
care; in what is essentially a new and very rapidly
expanding discipline. The HEDIS set is getting more
comprehensive with every edition and the NHS set is
the rst of its kind in the UK. The challenge for the
future is to focus on all the important aspects of qual-
ity of care (using the most valid methodology possible
and whether data are readily available using existing
systems at present or not) whilst trying to minimise
perverse incentives. Both sets incorporate a range of el-
ements of quality of care and, in so doing, also empha-
sise that quality of care can not, and should not, be
measured by one global indicator.
Our models explicitly acknowledge the potential con-
icts between focusing upon individuals or popu-
lations. Providing a framework which denes quality
in relation to care allows some of the strengths and
weaknesses of any set of quality indicators to be
assessed. It exposes those areas of quality of care infre-
quently addressed, e.g. acute care, co-ordination
between professional groups looking after an individ-
ual patient and inter-personal aspects of care, and also
access for `hard to reach groups'. Enthusiasm for any
individual set of indicators needs to be tempered with
understanding about what care is not being measured
(and subsequently potentially improved). The frame-
work outlined in this paper oers a basis for such
analysis.
Acknowledgements
The authors would like to thank Peter Bower, Toby
Gosden and Ruth Young for helpful comments on ear-
lier drafts of this paper.
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