QUALITY INHEALTH CAREEditor: Fiona MossAssociate editors: Richard Baker, Pam Garside, Richard Grol, Alison Kitson,Michael Maresh, Hugh McKenna, Richard ThomsonTechnical editor. Judith HaynesEditorial Assistant: Michelle Dimler

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Quality in Health Care 1997;6:232-234

LETTER BOOK REVIEWSClinical Effectiveness and Primary CareByM Baker,N Maskrey, S Kirk. (k 18.50; Pp136) 1997. Oxford: Radcliffe Medical Press.ISBN 1 85775 129 9.

Purchasing good quality eye care: theprovider's view

Vafidis rightly points out that a multidiscipli-nary team approach to eye care for diabeticpatients is necessary.' Care for people withdiabetes takes place across the primary-secondary interface and we agree that theintegrated clinics and outreach provision dis-cussed can be effective.We must take issue however with Vafidis'

confident assertion that "most districts haveestablished a scheme locally which aims toscreen all diabetic patients within the area."Would this were the case. We undertook asurvey of provision for diabetic retinopathyscreening in England and Wales during 1996as part of an audit sponsored by the RoyalColleges of Ophthalmologists, General Prac-titioners, and Physicians. We received repliesfrom all 105 health districts, of which 44(42%) had established screening schemesand a further seven (8%) schemes that hadbeen running for a year or less.

In the 44 districts with establishedschemes, a total of 54 schemes existed; manyof these did not cover the whole population ofthe district. Of the 54 schemes we identified,39% were optometrist based, and 32% usedretinal photography, underlining Vafidis'point about the importance of multidiscipli-nary teamwork. Our findings show that fewerthan half the health districts in England andWales were providing population basedscreening in 1996.

GILL GRIMSHAWReserch Fellow

ANDREW WILSONSenior Lecturer

RICHARD BAKERDirector, Eli Lilly National Clinical Audit Centre

JOHN THOMSPONSenior Lecturer in Ophthalmic Epidemiology

Eli Lilly National Clinical Audit Centre, Departmentof General Practice and Primary Health Care,

University of Leicester, Leicester General Hospital,Gwendolen Road, Leicester LE5 4PW UK

1 Vafidis G. Purchasing good quality eye care: theprovider's view. Quality in Health Care1 997;6:92-8.

DIARY

16-18 April 1998Vienna, Austria. The 3rd European Forumon Quality Improvement in Health Care. Theevent will consist ofone day teaching courses,invited presentations, plenary sessions, post-ers, and presentations selected from submis-sions. For further information please contactthe BMA/BMJ Conference Unit, BritishMedical Association, BMA House, TavistockSquare, London WC1H 9JP. Tel 0171 3836605. Fax 0171 383 6869. Email 106005,2356@compuserve.com

Effective Procedures in Maternity CareSuitable for Audit. By Angie Benbow,David Semple, Michael Maresh. (Pp 56; , 8)1997. London: Royal College of Obstetri-cians and Gynaecologists Clinical AuditUnit. ISBN 0902331 80 9.

The work involved in reviewing the literatureto set standards of maternity care on which toaudit is time consuming and may be confus-ing. So-let the Royal College of Obstetri-cians and Gynaecologists (RCOG) ClinicalAudit's prestigous committee do it for youand read their document.The committee has produced a succinct,

clearly laid out 55 page booklet, predomi-nantly referenced through the pregnancy andchildbirth module of the Cochrane Databaseof Systematic Reviews, which recommendsstandards for different aspects of maternitycare. Each topic has suggested auditablestandards, more than 100 ideas to keep youraudit meetings busy and interesting. Todecide which topics to audit, the authorsencourage participation of consumerrepresentation-such as the local MaternityServices Liaison Committee. This will benew territory for many units.

However, although some of the standardswould be straightforward to audit, many arevague and would be difficult audits to try andset up-for example, all women should havefree access to literature regarding alcoholconsumption, or all women should be awareof the results (of their rhesus antibody status)and their importance. Perhaps a subsequentdocument is required which sets out formatsof how to measure such data so that theseaudits have a greater chance of beingperformed and could be compared betweenunits (not league tables).

It is likely that purchasers will take onmany of these advised standards as theyinclude unit based practice standards-forexample, all units offering continuousintrapartum cardiotocography should be ableto offer facilities for fetal blood sampling, or aservice for external cephalic version shouldbe available. I did not find any of thestandards particularly controversial and thinkthat most units will already be working withinthem.The number of patient information leaflets

which are suggested, although laudable, isdaunting and again a central source ofleaflets, which can be adapted to local needs,would be useful. The RCOG and Midwives'Information and Resource Service(MIDIRS) have patient information leafletsbut at a cost.There is a section of procedures not

included because the medical evidence is notyet very strong. Within this section is that ofmeasuring nuchal translucency as a screeningfor fetal abnormality-a test often beingrequested by patients and paid for privately.

I welcome this booklet and it will provevery useful for the obstetric audit coordina-tor.

FELICITY ASHWORTHConsultant Gynaecologist and Obstetrician,

Stoke Mandeville Hospital NHS Trust

Many National Health Service (NHS)strategies have struggled to move from sloganto reality. Clinical Effectiveness and PrimaryCare is about the challenge of not just recog-nising its value and learning for the task, butdoing it in practice the move from compe-tence to performance.

Maslow's hierarchy of human needs de-scribes how we all try and meet our lowerorder physiological needs such as food andshelter-before we move up to giving energyto love and belonging, and then on to curios-ity and the search for knowledge. The authorsuse this as a model to look at the blocks ofevidence based practice. From this poten-tially pessimistic analysis, the book hints atsome solutions. Consultants in the past mayhave won resources for unproved treatmentsby position and forceful personality. Somegeneral practitioner fundholders have usedthe same conflict based approach. Theauthors describe the potential value ofevidence based commissioning, as a coopera-tive activity, meeting not only the higher ech-elons of Maslow's pyramid, but also the lowerprocesses of belonging and self esteem.One of the strengths of the book is the

background of its authors, from general prac-tice, public health, and NHS management,and recognition of the tensions between thesedisciplines. The missing author is perhaps thepatient. We are told that "As the day of thepatient expert beckons, there will be nohiding place for substandard clinical prac-tice." What a wonderful opportunity to usethe traditional general practice skills of work-ing with the patient to enhance theirunderstanding and decision making. I havealready partnered a patient with a rare condi-tion who wished to be the expert, with thedoctor taking the supporting role of mentor,friend, and tutor in critical appraisal!

I greatly enjoyed the book, and found thatit stimulated reflection on how to moveevidence based practice from a slogan to areality. I would have liked a little more on therole of qualitative evidence.

I was interested towards the end of thebook to read that "In the longer term,General Practice will provide the majority ofcare which is now delivered in hospitals." Pri-mary care might well achieve this, and it is allthe more important that general practicemaintains and develops the specialist skills ofthe consultation and understanding thepatient's ideas and beliefs that can allow thepatient with their folder of internet printoutsto share the role of expert.

ANDREW WILSONGeneral Practitioner, Hertfordshire

Measuring Quality in General Practice.Edited by: JGR Howie, DJ Heaney, M Max-well. (,J13.50; Pp 32) 1997. London: RoyalCollege of General Practitioners. (OccasionalPaper 75.) ISBN 0 85084 232 8.

What is quality and does it make it adifference? These questions are answeredonly partially in this fascinating account of amajor research project. The authors werecommissioned by the Scottish Office to carryout an independent evaluation of the ScottishShadow Fundholding Project for somemarker conditions. Secondary analysis of the

232

Quality in Health Care 1997;6:235

Referees

The Journal thanks the following people for their support in acting as referees of submitted papers.

Ahmed P KAshton SAshworth FMAvery A JAvis MBaker DBaker R HBanfield PBark PBarker PBarton ABatstone GBaughan A S JBaxter DBenbow ABlack NBlaney PBooth ABowling ABradley MBrooks GBuchan HBucknall C EBulstrode CBundred P EBuxton MBuxton M JChalliner YChapple JCheater FChurnside RClaydon LClements RColes JMCook GCoulter ACrombie I KCullum NDale JDancy MDawes MDawson SDixon MDonald ADoyal LEben FEccles MEdwards BEssex BFarrell CFawdry R D SFeder GFicker LFirth-Cozens JFitzpatrick RFrater AGaminara E JGarrett AGarrod DGeddes J R

Gill MGiraud AGray CGray JGrimshaw JGrol RGuyMHarrison J F MHarvey GHearnshaw H MHerzberg JHicks NHigginson IJHirsch MHobbs RHowel DHumphrey CHunter DHurwitz BHutchinson AIrvine DJefferson TJefferys PJenkinson CJones KJones S EKee FKeeley DKelly PKendall-Taylor PKirkman RKraemer SLauner JLawrence M SLefebvre CLevyMLloyd B WLong A FLowdon I M RMak VMaresh MMarley JMarriott SMason CMcIver SMcKee MMcKenna HMcKinley RMcManus I CMcNicol MWMiddleton J FMorgan GMorgan M D LMuers M FMurray S ANicolaides A NNorman INormand CO'Malley DOvhed I

Paintin D BPalmer APartridge MPolmear APrendergast MPurves IRenfrew MRice NRigter HRiordan JRobertson NRobinson MRodgers HRogers ERubin GRushton LRussell ERussell IRuta DRyan ARyan KSalisbury CSanders GSanderson CSaunders M ISawicka ESchwartz F WSemple DSensky T EShaw CShaw JSheldon T ASherriffH MSibbald BSpencer JSudlow MSzecsenyi JTaylor PThomson RTurner-Stokes LUnwin NVafidis Gvan der Voort Hvan der Weijden Tvan der Wilt G JVenning PVincent CWalshe KWaterhouse SWedzicha JAWhittington DWilcock PWilson AWolfe CWray JYardumian AZairi MZimmer R

235

Quality in Health Care 1997;6:236-237

VOLUME 6 * AUTHOR INDEX

Aletras V see Sowden A et alAvis M. Incorporating patients' voices in the audit process, 86Ayres P see Renvoize EB et al

Baker R see Grimshaw G et alBaker R. Pragmatic model of patient satisfaction in general practice:

progress towards a theory, 201Baker R et al. Randomised controlled trial of reminders to enhance

the impact of audit in general practice on management ofpatients who use benzodiazepines, 14

Bark P et al. Impact of litigation on senior clinicians: implications forrisk management, 7

Beech R see Wilkinson PR et alBerrow D et al. Understanding the relation between research and

clinical policy: a study of clinicians' views, 181Book reviews Baker M, Maskrey N, Kirk S. Clinical effectiveness

and primary care, 233Benbow A, Semple D, Maresh M. Effective Procedures in MaternityCare Suitable for Audit, 233

Greenhalgh T. How to read a paper: the basics of evidence basedmedicine, 234

Howie JGR, Heaney DJ, Maxwell M. Measuring Quality in GeneralPractice, 233

Hutchinson A, McColl E, Christie M, RiccaltonC, editors. HealthOutcome Measures in Primary and Out-patient Care, 15

Irvine D, Irvine S. Making Sense of Audit: Second Edition, 234Irvine D, Irvine S. The Practice of Quality, 115Marinker M, editor. Review of Sense and Sensibility in Health Care,

176Pickersgill D, Stanton T. Making Sense of the NHS Complaints and

Disciplinary Procedures, 234Sanger J. The Compleat Observer? A Field Research Guide to

Observation, 115Bosanquet N see Hunter R et alBrocklehurst J see Dickinson E and Brocklehurst JBucknall CE see Slack R and Bucknall CE

Challiner Y. Introducing quality assurance into long term care forelderly people: a difficult and worthwhile process?, 153

Crouch R see Patel A et alCullum N et al. Compression therapy for venous leg ulcers, 227

Dale J see Patel A et alDawson S. Inhabiting different worlds: how can research relate to

practice?: editorial, 177de Haan M see Fleuren M et alDelaney F see Sowden AJ et alDickinson E, Brocklehurst J. Improving the quality of long term

care for older people: lessons from the CARE scheme, 160Dickson R see Fullerton D et alDrinkwater C, Greveson GC. Quality in nursing home care: whose

responsibility?: editorial, 118

Eastwood AJ see Fullerton D et alsee Sowden A et al

Farooqi A see Baker R et alFelling A see Wensing M et alFerguson B see Sowden A et alFirth-Cozens J. Healthy promotion: changing behaviour towards

evidence-based health care, 205Fletcher A see Cullum N et alFleuren M et al. Adherence by midwives to the Dutch national

guidelines on threatened miscarriage in general practice: aprospective study, 69

Frater A. Quality of care in developing countries: relevance andreality: editorial, 179

Fullerton D et al. Preventing unintended teenage pregnancies andreducing their adverse effects, 102

Gaffney B see Kee F et alGallagher A see Robins A et alGilbody S see Sowden AJ et alGlenny AM see O'Meara S et alGreveson GC see Drinkwater C and Greveson GCGrilli R see Sowden A et alGrimshaw G et al. Purchasing good quality eye care: the provider's

view: letter, 233Grol R see Fleuren M et al

see Wensing M et al

Hampshaw SM see Renvoize EB et alHarvey G see Morrell C et alHayward J see Berrow D et alHeard S. Quality health care: the hospital chief executive's role, 99Hemminki E et al. Quality of contraceptive services in Finlaad, 62

Higginson IJ et al. Outcome measures for routine use in dementiaservices: some practical considerations, 120

Hodgson CS see Higginson IJ et alHolmes E see Redpath L et alHoward RS see Wilkinson PR et alHulscher MEJL et al. Changing preventive practice: a controlled

trial on the effects of outreach visits to organise prevention ofcardiovascular disease, 19

Humphrey C see Berrow D et alHunter R et al. Alzheimer's disease in the United Kingdom:

developing patient and carer support strategies to encourage carein the community, 146

Jefferys PM see Higginson IJ et alJohnson N see Hunter R et alJones A see Bark P et al

Kazandjian VA see Thomson RG et alKee F et al. Risks and benefits of coronary angioplasty: the patient's

perspective: a preliminary study, 131Kitson A see Morrell C et alKlercker TA et al. Essential dataset for ambulatory ear, nose, and

throat care in general practice: an aid for quality assessment, 35Koponen P see Hemminki E et alKosunen E see Hemminki E et al

Lloyd BW see Robins A et alLundquist P-G see Klercker TA et al

McDonald P see Kee F et alMcElroy H see Thomson RG et alMcGill L see Hunter R et alMikela M see Varonen H and Makela MMaresh M see Wray J and Maresh MMaxwell RJ. Hospital beds and how to survive them, 199Melville A see O'Meara S et al

see Seagroatt V et alMills K see Wilmot J and Mills KMilne R see Seers K and Milne RMokkink HGA see Hulscher MEJL et alMorrell C et al. Practitioner based quality improvement: a review of

the Royal College of Nursing's dynamic standard setting system,29

Moss F Quality in health care: a focus on the care of older people:editorial, 117

Olivieri L see Bark P et alO'Meara S et al. Effective management of obesity, 170Oudshoorn C see Fleuren M et al

Patel A et al. Satisfaction with telephone advice from an accident andemergency department: identifying areas for service improvement,140

PinderJM see Renvoize EB et alPlace M see Sowden A et alPlsek PE. Systematic design of healthcare processes, 40Posnett J see Sowden A et alPugh E see Redpath L et al

Redpath L et al. Use of the critical incident technique in primary carein the audit of deaths by suicide, 25

Renvoize EB et at. What are hospitals doing about clinicalguidelines?, 187

Rice N see Sowden A et alRobins A et al. Evaluation of joint medical and nursing notes with

preprinted prompts, 192Rossiter MA see Robins A et alRoss-Russell RW see Wilkinson PR et alRudd AG see Wilkinson PR et al

Scrivens E. Putting continuous quality improvement intoaccreditation: improving approaches to quality assessment, 212

Seagroatt V et al. Systematic reviews: a cautionary note: letter, 56Seers K, Milne R. Randomised controlled trials in nursing: editorial, 1Semlyen A see Cullum N et alSheldon TA see Cullum N et al

see Fullerton D et alsee O'Meara S et alsee Sowden AJ et al

Sheldon TA see Seagroatt V et alsee Sowden A et al

Sihvo S see Hemminki E et alSlack R, Bucknall CE. Readmission rates are associated with

differences in the process of care in acute asthma, 194Smith C. Measuring quality in contraceptive services: editorial, 59Sowden AJ et al. Volume of clinical activity in hospitals and

healthcare outcomes, costs, and patient access, 109

236

Author index 237

Mental health promotion in high risk groups, 219Stacey A see Redpath L et alSteele JG, Walls AWG. Strategies to improve the quality of oral

health care for frail and dependent older people, 165Sudlow M, Thomson RG. Clinical guidelines: quantity without

quality: editorial, 60

Tait C see Baker R et alThompson J see Grimshaw G et alThomson RG see Sudlow M and Thomson RGThomson RG et al. Maryland Hospital Quality Indicator Project in

the United Kingdom: an approach for promoting continuousquality improvement, 49

Tilford S see Sowden AJ et alTrell E see Klercker TA et al

Vafidis G. Purchasing good quality eye care: the provider's view, 92van der Wouden JC see Hulscher MEJL et alvan de Vleuten C see Wensing M et alvan Drenth BB see Hulscher MEJL et alvan Weel C see Hulscher MEJL et alVaronen H, Makela M. Practice guidelines in Finland: availability

and quality, 75

Vincent C see Bark P et alVogels M see Sowden AJ et al

Walls AWG see Steele JG and Walls AWGWalsh S see Baker R et alWarburton FG see Wilkinson PR et alWensingM et al. The reliability of patients' judgements of care in

general practice: how many questions and patients are needed?,80

Wijkel D see Fleuren M et alWilkinson PR et al. Longer term quality of life and outcome in

stroke patients: is the Barthel index alone an adequate measureof outcome?, 125

Wilmot J, Mills K. Critical incident technique for auditing inprimary care: letter, 176

Wilson A see Grimshaw G et alWilson C see O'Meara S et alWolfe CDA see Wilkinson PR et alWray J, Maresh M. Multiprofessional guidelines: can we move

beyond tribal boundaries?: editorial, 57

Quality in Health Care 1997;6:238-239

VOLUME 6 * SUBJECT INDEX

accident and emergency, Satisfaction with telephone advice from anaccident and emergency department: identifying areas for serviceimprovement, 140

accreditation, Putting continuous quality improvement into accredi-tation: improving approaches to quality assessment, 212

acute asthma, Readmission rates are associated with differences inthe process of care in acute asthma, 194

acute hospitals, Maryland Hospital Quality Indicator Project in theUnited Kingdom: an approach for promoting continuous qualityimprovement, 49

aging, Quality in health care: a focus on the care of older people: edi-torial, 117

Alzheimer's disease, Alzheimer's disease in the United Kingdom:developing patient and carer support strategies to encourage carein the community, 146

angioplasty, Risks and benefits of coronary angioplasty: the patient'sperspective: a preliminary study, 131

assessment, What are hospitals doing about clinical guidelines?, 187audit, Critical incident technique for auditing in primary care: letter,

176Incorporating patients' voices in the audit process, 86Readmission rates are associated with differences in the process of

care in acute asthma, 194

behaviour, Healthy promotion: changing behaviour towardsevidence-based health care, 205

benign prostatic hyperplasia, Systematic reviews: a cautionary note:letter, 56

care, Quality in nursing home care: whose responsibility?: editorial, 118care provision, Essential dataset for ambulatory ear, nose, and throat

care in general practice: an aid for quality assessment, 35clinical audit, Practitioner based quality improvement: a review of the

Royal College of Nursing's dynamic standard setting system, 29clinical guidelines, What are hospitals doing about clinical

guidelines?, 187clinical policy, Understanding the relation between research and

clinical policy: a study of clinicians' views, 181clinicians' views, Understanding the relation between research and

clinical policy: a study of clinicians'views, 181communication, Inhabiting different worlds: how can research relate

to practice?: editorial, 177community care, Alzheimer's disease in the United Kingdom: devel-

oping patient and carer support strategies to encourage care in thecommunity, 146

continuous quality improvement, Putting continuous qualityimprovement into accreditation: improving approaches to qualityassessment, 212

contraception, Quality of contraceptive services in Finland, 62corticosteroids, Readmission rates are associated with differences in

the process of care in acute asthma, 194critical incident technique, Critical incident technique for auditing

in primary care: letter, 176Use of the critical incident technique in primary care in the audit of

deaths by suicide, 25

dementia, Outcome measures for routine use in dementia services:some practical considerations, 120

dental care, Strategies to improve the quality of oral health care forfrail and dependent older people: review, 165

developing countries, Quality of care in developing countries:relevance and reality: editorial, 179

diabetis, Purchasing good quality eye care: the provider's view: letter,233

ear nose and throat, Essential dataset for ambulatory ear, nose, andthroat care in general practice: an aid for quality assessment, 35

elderly, Quality in nursing home care: whose responsibility?: editorial,118

Strategies to improve the quality of oral health care for frail anddependent older people: review, 165

evidence-based, Healthy promotion: changing behaviour towardsevidence-based health care, 205

executive, Quality health care: the hospital chief executive's role, 99eye, Purchasing good quality eye care: the provider's view, 92

general practice, Changing preventive practice: a controlled trial onthe effects of outreach visits to organise prevention ofcardiovascular disease, 19

Essential dataset for ambulatory ear, nose, and throat care in generalpractice: an aid for quality assessment, 35

Pragmatic model of patient satisfaction in general practice: progresstowards a theory, 201

guidelines, Adherence by midwives to the Dutch national guidelineson threatened miscarriage in general practice: a prospective study,69

Changing preventive practice: a controlled trial on the effects of out_reach visits to organise prevention of cardiovascular disease, 19

Clinical guidelines: quantity without quality: editorial, 60Multiprofessional guidelines: can we move beyond tribal

boundaries?: editorial, 57

health care, Quality in health care: a focus on the care of older people:editorial, 117

Healthy promotion: changing behaviour towards evidence-basedhealth care, 205

healthcare processes, Systematic design of healthcare processes, 40hospitals, What are hospitals doing about clinical guidelines?, 187

implementation, Practitioner based quality improvement: a review ofthe Royal College of Nursing's dynamic standard setting system,29

litigation, Impact of litigation on senior clinicians: implications forrisk management, 7

management, Quality health care: the hospital chief executive's role,99

medical and nursing, Evaluation of joint medical and nursing noteswith preprinted prompts, 192

midwives, Adherence by midwives to the Dutch national guidelineson threatened miscarriage in general practice: a prospective study,69

multidiciplinary, Purchasing good quality eye care: the provider'sview: letter, 233

multiprofessional, Multiprofessional guidelines: can we movebeyond tribal boundaries?: editorial, 57

new initiatives, Alzheimer's disease in the United Kingdom: develop-ing patient and carer support strategies to encourage care in thecommunity, 146

notes, Evaluation of joint medical and nursing notes with preprintedprompts, 192

nursing, Identification and analysis of randomised controlled trials innursing: a preliminary study, 2

Quality in nursing home care: whose responsibility?: editorial, 118

obstetric units, Understanding the relation between research andclinical policy: a study of clinicians' views, 181

ophthalmology, Purchasing good quality eye care: the provider'sview, 92

Purchasing good quality eye care: the provider's view: letter, 233organisational performance, Putting continuous quality improve-

ment into accreditation: improving approaches to qualityassessment, 212

outcome, Longer term quality of life and outcome in stroke patients:is the Barthel index alone an adequate measure of outcome?, 125

outcome measures, Outcome measures for routine use in dementiaservices: some practical considerations, 120

patient satisfaction, Pragmatic model of patient satisfaction in gen-eral practice: progress towards a theory, 201

Satisfaction with telephone advice from an accident and emergencydepartment: identifying areas for service improvement, 140

The reliability of patients' judgements of care in general practice:how many questions and patients are needed?, 80

patients' perceptions, Risks and benefits of coronary angioplasty:the patient's perspective: a preliminary study, 131

patients' views, Incorporating patients' voices in the audit process, 86practice, Inhabiting different worlds: how can research relate to

practice?: editorial, 177practice guidelines, Practice guidelines in Finland: availability and

quality, 75pregnancy, Preventing unintended teenage pregnancies and reducing

their adverse effects, 102preprinted prompts, Evaluation of joint medical and nursing notes

with preprinted prompts, 192prevention, Preventing unintended teenage pregnancies and reducing

their adverse effects, 102prevention of cardiovascular disease, Changing preventive

practice: a controlled trial on the effects of outreach visits toorganise prevention of cardiovascular disease, 19

primary care, Critical incident technique for auditing in primarycare: letter, 176

primary care health teams, Use of the critical incident technique inprimary care in the audit of deaths by suicide, 25

priorities, Quality of care in developing countries: relevance andreality: editorial, 179

quality, Quality health care: the hospital chief executive's role , 99Quality in health care: a focus on the care of older people: editorial,

117

238

Instructions for authorsPapers should be sent in triplicate to the editor,Quality in Health Care, BMA House, TavistockSquare, London WC1H 9JR (tel 0171 383 6204).They should be prepared according to the UniformRequirements for Manuscripts Submitted to Bio-medical Journals (Vancouver agreement) (BMJ199 1;302:338-41).

General* All material submitted for publication is assumedto be submitted exclusively to the journal unless thecontrary is stated.* All authors must give signed consent topublication. (Guidelines on authorship are given inBMJ 1991;302:338-41.)* The editor retains the customary right to style andif necessary to shorten material accepted forpublication.* Authors should submit questionnaires not estab-lished and well known.* If requested, authors shall produce the data onwhich the manuscript is based for examination bythe editor.* Type all manuscripts (including letters) in doublespacing with 5 cm margins at the top and left handmargin.* Number the pages.* Give the name and address and telephone and faxnumbers of the author to whom correspondence andproofs should be sent.* Do not use abbreviations.* Express all scientific measurements (except bloodpressure (mm Hg)) in SI units.* Permission to reproduce previously publishedmaterial must be obtained in writing from the copy-right holder (usually the publisher) and the authorand acknowledged in the manuscript.* Keep a copy of the manuscript for reference.* An acknowledgement of receipt of the manuscriptwill be sent.

Specific pointsARTICLES

Articles report research and studies relevant to qual-ity of health care. They may cover any aspect, fromclinical or therapeutic intervention, to promotion, toprevention. They should usually present evidenceindicating that problems of quality of practice mayexist, or suggest indications for changes in practice,or contribute towards defining standards or develop-ing measures of outcome. Alternatively, they shouldcontribute to developing approaches to measuringquality of care in routine practice. The journal isinterprofessional and welcomes articles from anyonewhose work is relevant, including health profession-als, managers, practitioners, researchers, policymakers, or information technologists. Papers areusually up to 2000 words long with up to six tables orillustrations. Shorter practice reports, which may notbe original in concept but must contain informationsufficiently novel to be of importance to other units,are also invited. Articles of a discursive or debatingnature, which do not conform to thecriteria for original papers given above, will beconsidered.* Give the authors' names, initials, and appointmentat the time of the study.* Articles should generally conform to the conven-tional format of structured abstract (maximum 250words; see BMJ 1988;297:156), introduction,patients/materials and methods results, discussion,and references.* Give up to three keywords/phrases.* Whenever possible give numbers of patients/ sub-jects studied (not percentages alone).* Articles may be submitted to outside peer review

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Figures* Should be used only when data cannot beexpressed clearly in any other form.* Should not duplicate information given in the textof the article.* Should be accompanied by the numerical data inthe case of graphs, scattergrams, and histograms(which may be converted into tables).* Should include numbers of patients/subjects (notpercentages alone) whenever possible and relevant.Legends should be given on a separate sheet.

LINE DRAWINGS

* Should be in Indian ink on heavy white paper orcard or presented as photographic prints. One origi-nal and two photocopies of each must be submitted.

HALF TONES

* Should usually be submitted as prints, notnegatives, transparencies, or x ray films.* Should be no larger than 30x21 cm (A4).* Should be trimmed to remove all redundant areas.* The top should be marked on the reverse inpencil.* Labelling should be on copies, not the prints.* The identity of patients in photographs should beconcealed or their written consent to publicationobtained.

References* Should be numbered sequentially in the text.* Should be typed in double spacing.* Should give the names and initials of all theauthors (unless there are more than six, when thefirst six should be given followed by et al); the title ofthe article or chapter, and the title of the journal(abbreviated according to the style of IndexMedicus), year of publication, volume number, andfirst and last page numbers or the names of any edi-tors of the book, title of the book, place ofpublication, publisher, and year of publication, andfirst and last pages of the article.* Information from manuscripts not yet in press,papers reported at meetings, or personal communi-cations should be cited in the text, not as formal ref-erences.* Authors are responsible for the accuracy ofreferences.

Proofs and reprints* Corrections to proofs should be kept to aminimum and should conform to the style shown inWhitacker's Almanack.* Corrections other than printers' errors may becharged for.* Justification for corrections, if necessary, should begiven in a letter and not on the proof* Reprints are available, an order form and scale ofcharges are included when the proof is sent out.