What mean by appropriate health care? - BMJ …as guides a review of the literature. They categorise...

Quality in Health Care 1993;2:117-123

What do we mean by appropriate health care?

Report of a working group prepared for the Director of Research and Development ofthe NHS Management Executive

In everyday life we talk about someone having"behaved inappropriately," and we all have anunderstanding of what that means - that insome way the behaviour was not "right" forthe circumstances. Health professionals andthe lay public alike also talk and write aboutthe appropriateness of health care inter-ventions in the same sense. It is importanttherefore to attempt to define what is appro-priate and to distinguish this from effective-ness and efficiency.

DefinitionsEfficacy is the ability of a health care inter-vention to produce the desired outcome in adefined population under ideal conditions. Itshould be distinguished from effectiveness,which is the extent to which that outcome isachieved under the usual conditions of care in"real life," where skills and other resources aredifferent from the experimental conditions.Here, however, we caution that outcomes arecomplex and multidimensional. If the definedoutcome is reassurance, then an interventionthat effectively reassures, even if it fails to alterthe underlying disease, may well be appro-priate. For both efficacy and effectiveness, thetechnical competence of the providers of careis an important variable.

Care that is appropriate has been defined byworkers at the RAND Corporation asfollows.

Appropriate (care) means that the expectedhealth benefit (ie increased life expectancy,relief of pain, reduction in anxiety, improvedfunctional capacity) exceeds the expectednegative consequences (ie mortality, morbidity,anxiety of anticipating the procedure, painproduced by the procedure, misleading or falsediagnoses, time lost from work) by asufficiently wide margin that the procedure isworth doing.' 2

We feel that two important dimensions of thisdefinition are missing: the individuality ofthe patient under consideration and theavailability of health care resources. Wesuggest the following definition.

Appropriate care means the selection, from thebody of available interventions that have beenshown to be efficacious for a disorder, of theintervention that is most likely to produce theoutcomes desired by the individual patient.An intervention can only be appropriate

when certain criteria are satisfied. Thetechnical skills and other resources for theintervention must be available so that it can beperformed to a sufficiently high standard. Theintervention must be performed in a manner

that is acceptable to the patient. Patientsshould be given adequate information aboutthe range of effective interventions. Theirpreferences are central to the choice ofappropriate intervention from those known tobe effective. Their preferences will reflect notonly the primary outcome that they hope toachieve, but also their perceptions of thepotential adverse outcomes that they mightencounter. It follows that patients must be fullyinvolved in discussions about the likelihood ofdifferent outcomes with and without the inter-vention, and about the discomfort and otheradverse events that they might encounter. Theappropriateness of health care interventionsmust also be considered within the currentsocial and cultural context and with regard tojustice of resource allocation.

The use of some of these words may beillustrated by the following example. Coronarybypass surgery is efficacious in reducingmortality over five years in patients with leftmainstem coronary disease. In the bestprospective studies mortality is as low as0 5%.' However, in general use operativemortality is higher, so the procedure is not aseffective as had been hoped on the basis of theevidence from trials.' 3 Larger units canperform operations at lower marginal costthan small units, so they may be more efficient.For an individual patient, however, theoperation may be inappropriate because, forexample, the patient prefers to take his or herchances with medical treatment, or because ofsome serious comorbidity, or for some otherindividual reason.

Different perspectives on appropriatehealth careWe consider appropriateness from theprofessional perspective, the lay perspective,and the perspective of society as a whole.

PROFESSIONAL PERSPECTIVE

Here we are concerned with the prevailingviews within health care professions as to thoseinterventions that most contribute to healthgain. By health gain for an individual we meanthe net increment in health status over his orher lifetime, after subtracting health loss dueto adverse outcomes of the intervention. It isimportant to consider appropriateness inrelation to broad aspects of health care andnot just appropriate investigation andtreatment by doctors. For example, appropri-ateness must be considered in relation tonursing practice and in relation to healthpromotion and preventive medicine.

Members of the workinggroup are listed in theappendixCorrespondence to:Dr A Hopkins, ResearchUnit, Royal College ofPhysicians, 11 St Andrew'sPlace, London NW1 4LE

Accepted for publication14 April 1993

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Working group report

LAY PERSPECTIVEHere we are considering two perspectives: theviews of healthy people who are not ill and theviews of patients. Patients' and professionals'views are congruent insofar as patients expectinterventions to be appropriately targeted anddelivered with technical competence. How-ever, lay and professional views may differ withregard to, for example, judgements aboutquality of life, the value and purpose ofspecialist referral, the need for prescriptions,the purposes of palliative care, and so on.Patients and individuals who are not currentlyill may also have different views about theappropriateness of local services that they wishto see provided.

PERSPECTIVE OF SOCIETY AS A WHOLEBoth lay and professional perceptions ofappropriateness reflect current but alwayschanging social and cultural values of societyas a whole, as well as the effectiveness of thetechnical intervention. However, appropri-ateness is ultimately constrained by finiteresources. Government is responsible fordetermining how much of society's resourcesshould be allocated to health care. Within thissector, purchasers are responsible fordetermining how much to allocate to theprevention of disease and how much to thecare of chronic and acute disorders.There is a distinction between population

appropriateness, similar to effectiveness butconstrained by societal judgements of thevalue of different interventions and byavailable resources, and appropriateness at anindividual level, which is effectivenessmodified by patient characteristics and patientpreference.

Professional perspectivesMany procedures and interventions in currentuse have not been examined by randomisedcontrolled trials and are unlikely to be inthe near future. There is little informationabout the outcomes of care given by nursesand professions allied to medicine. Theconsiderable variations in rates of proceduresthat cannot be explained by local variationsin morbidity or availability of resourcesindicate that there are wide variations in whatthe health professionals take as their workingdefinition of appropriateness. Examplesinclude the striking variations in the ratesof certain surgical procedures in Boston andNew Haven in the United States. Wennberget al showed that, even allowing for thedifferent case mix in the two cities, aBostonian enrolled in the Medicare systemhad in 1982 more than twice the chancesof having had a carotid endarterectomy thana New Haven resident and only half thechances of having had coronary artery bypasssurgery. The length of stay for the firstprocedure was 30%/ more in Boston than in

New Haven.4There is also considerable published

evidence from family practice about variationsin referral to hospital. General practitionerswith a special interest refer to hospital more

patients covered by the topic of their interestthan do other general practitioners. Variationsin general practitioner referral rates persistwhen corrected for case mix and demographicfactors.5Much of the cited work on regional

variations seems to be in the context thatresearch will disclose inappropriate overuse ofinterventions. However, it must be remem-bered that there may well be underuse ofmanyinterventions which might well be effective formany individuals who do not have access tothem, either owing to their own lack ofknowledge of what is available to relievesymptoms or to protect their future, or to lackof knowledge in the health professionals theyconsult.

MEASUREMENT OF APPROPRIATENESS FROMTHE MEDICAL PERSPECTIVEThe best known method of measuringappropriateness is that developed by Brook etal at the RAND Corporation' 2 and exploredin Britain by Scott and Black in relation tocholecystectomy.6 In brief, a list of possible"indications" for a procedure is defined, usingas guides a review of the literature. Theycategorise patients in terms of their symptoms,history, and the result of previous diagnostictests. The indications are then presented to aninformed panel. The panel, not all of whosemembers are specialists, rates whether itwould be appropriate or inappropriate toperform that procedure on a patient with thoseindications. Discussions among panellists aftertheir initial rating, followed by re-rating,reduces the dispersion of the ratings.The RAND panels are undoubtedly a

valuable technique for sharpening doctors'views on appropriateness. However, researchhas shown international variation in what isconsidered to be appropriate. For example, apanel in the United States rated coronaryartery bypass surgery appropriate, with amedian rating of 7 on a 9 point scale ofappropriateness, for a patient with anginaoccurring on mild exertion (class III),receiving submaximal medical therapy, andwith a positive exercise test result, whereas apanel of United Kingdom physicians andcardiologists rated the procedure as clearlyinappropriate (median rating 2/9).7 Thesedifferences may reflect not only the differentcultural values of the societies of the UnitedStates and United Kingdom and the values ofthe panellists but also the fact that the reviewsof the published literature submitted to thepanels have not used scientific methods togenerate the summarised evidence. Originalbut basically statistically unsound papers mayhave been given equal or near equal weight asmore valid work, and unpublished but soundwork resulting in negative observations maynot be available for review.

In addition to international differences inwhat is considered to be appropriate, work bythe RAND researchers has uncovered otherinconsistencies. For one surgical procedurestudied (endarterectomy) the number ofoperations performed by the surgeon each year



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Appropriate health care

was the most important predictor of appropri-ateness. The likelihood of undergoing anappropriate endarterectomy decreased byalmost a third for patients treated by a surgeonwho performed many such procedurescompared with one who performed few.8Brook et al showed that this was not becausethe former group of surgeons operated ondesperately ill patients but because theyoperated on less sick, symptomless patients.Equally challenging is the fact that beingmanaged by a gastroenterologist with a boardcertification compared with another type ofphysician decreased significantly the likelihoodthat an endoscopy would be appropriate asdefined by RAND panels.8

Patients' perspectivesPATIENTS PREFERENCES FOR TREATMENT

Different patients may choose differenttreatments because their values differ. Twopatients with an identical condition whochoose different treatments may both bemaking the correct decision for themselves.For example, some people with prostaticsymptoms such as the need to get up at nightto pass urine may prefer to tolerate theirsymptoms rather than risk incontinence orimpotence, the occasional adverse outcomesof prostatectomy. The way such values areincorporated in decision making varies. Threemethods can be distinguished, ranging frommost to least paternalistic.(1) The health professional may make a global

decision, taking account of the patient'spreferences as he or she understands them,an approach that might be summarised as"doctor knows best." This method hasadvantages. The professional may haveseen the relevant outcomes but the patientknows about them only second hand. Thepatient does not need to worry about rareoutcomes until they actually occur andmay therefore be less anxious. He or shemay even experience a better clinicalcourse from believing in clinical certaintiesrather than knowing the professional'sdoubts. The disadvantages are that thehealth professional may be wrong aboutthe patient's values and, consciously orunconsciously, may substitute his or herown values. When asked, patients almostalways say they want to be more informed.In some circumstances health care pro-fessionals have to act in what they believeto be their patients' best interests - forexample, when patients are unconscious.

(2) The health professional may offer thepatient different options and let the patientmake a global decision. This methodapparently respects more the patient'sautonomy, but again there are difficulties.Patients may make a decision consideredunwise by their doctor because of poorunderstanding of outcomes and faulty ma-nipulations of probabilities. On otheroccasions, however, particularly in chronicillness, decision making will involvepatients who have developed considerableknowledge of their illness.

(3) The health professional may explicitlymeasure the patient's values and combinethese with his or her best estimate of theprobabilities in order to choose a course ofaction which maximises expected utilityfor that patient. This approach adoptsmore formal principles of decisionanalysis.9

The theme underlying discussions aboutwhich course of action to follow should be anexploration of the patient's values. Decisionsshould be reached by negotiation in an open,equal, and transparent relationship betweenhealth professional and patient. Theprofessional understands the disease and thepatient the present experience of illness; each,by listening, moves towards an informedunderstanding of the implications of differentcourses of action and so to an appropriatechoice. Sometimes a carer will need to beinvolved in these discussions; there arepotential conflicts between what may be moreappropriate for the partnership of patient andcarer than for the patient alone.

Patients will also have views on aspects ofappropriateness in relation to the organisationof care and of the hospital inpatient day. Is itappropriate, for example, for inpatients to bewoken at 600 am,'0 and for what type ofsurgical procedures is day surgery moreappropriate?"

MEASUREMENT OF APPROPRIATENESS FROM

THE PATIENT S PERSPECTIVE

Several methods have been developed toassess the perspectives of patients with regardto appropriateness of clinical interventions.Instruments have been developed withacceptable measurement properties thatcontribute systematic evidence on a widerrange of outcomes that supplement moreconventional measures.'2 This new family ofinstruments is important, given the evidencethat health professionals and patients maydiffer in their judgements about matters suchas quality of life. '3 However, there remainvarious problems, including clinicians' doubtsabout the meaning and value of such methods.There are also technical problems concerningthe interpretation of scores provided byinstruments and different ways of describingand eliciting outcomes. Researchers may useas an outcome measure some professionallyderived measure of "functional status" toreflect quality of life, and yet an individualmay regard autonomy, self esteem, andsatisfaction with his or her lot far moremeaningful measures. For all these reasons,the measurement instruments are probably ofmost use at present in clinical trials andevaluative research. 'There are, however, some innovations

which allow patients to select in advance of theintervention the dimensions of "quality of life"which most concern them. For example,Wennberg shows patients who are consideringprostatectomy interactive video recordings ofprevious patients describing relief ofsymptoms and various adverse outcomes ofthe operation. 15



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A patient has to integrate information abouteffectiveness and his or her own values andexpectations when reaching a decision as towhich course of treatment is most appropriate.It should be possible in principle to developmeasures of appropriateness that combinedata on effectiveness and values in wayssimilar to those used by patients and healthcare professionals in reaching decisions.9

Patients also have views on the way in whichhealth care is delivered - for example, the wayin which the history is taken and the problemidentified, the way in which information isgiven, the extent to which the patient isactively involved,"6 and the setting in whichcare is provided. Instruments by which patientsatisfaction is measured are available and arebeing further developed.'7-19

Perspective of societySince publication of the white paper Workingfor Patients20 in 1989 there has been greateremphasis by the government and by providersof health care on giving patients andconsumers greater participation in decisionsabout the choice, standards, and quality ofhealth care. The patient's charter2' and "TheHealth of the Nation"2" have also underlinedthe need for greater public involvement indecisions about health care. Consumerorganisations and single interest groupsrepresenting specific interests of some patientsalso believe that users of health care should beable to influence the allocation of resourcesand standards of care.

MEASUREMENT OF APPROPRIATENESS FROMTHE PERSPECTIVE OF SOCIETYSeveral studies have explored public valuesregarding different health states. Valuesobtained by such methods must be consideredas provisional, partly because of unexploredsocial and cultural diversity of views anduncertainties as to how the future healthbenefits should be discounted, and partlybecause of variations of results obtained bydifferent methods. A major stumbling block isthe difficulty of knowing what weight to placeon people's opinions about the value of healthstates which they themselves have notexperienced. Another approach is theexploration of public preferences for differenthealth care interventions through surveys orother forms of public participation. The mostfamous exercise - the Oregon experiment -involved extensive public consultation, and itsmethods and results are currently the subjectof extensive discussion.23 There is concern thatthe results of such surveys should notdetermine the allocation of resources, which isa political and ethical responsibility of electedgovernment. Little work of this nature hasbeen carried out in the United Kingdom, but"needs assessment" and the provider-purchaser divide may be expected to stimulatethese debates.24 Some general practitionersreport they have run patient participationgroups within their practices as a means ofinvolving the public in decisions about theprovision of health care.

Allocation of resourcesIn the context of limited resources, meansmust be found for the rational and equitabledistribution ("rationing") of resources. Hegin-botham has reviewed some of the issues.25 Theconcept of "health gain," measured on somescale of quality of life or wellbeing, is centralin the current debate, but this may not solveall problems. For example, the provision ofcare that preserves the personal dignity ofpatients with irremediable brain disorders whoare unresponsive to their environment wouldbe seen by most as an appropriate aim of acivilised society; in this example the gain ispresumably to society as a whole rather than tothe individual recipients of care.

Rationing needs to be considered at twolevels: the selection of interventions for a givenhealth problem and the distribution ofresources between different health problems.Whatever system of allocation is adopted at apolicy level, there are likely to be substantialdissenting minorities of the population.Professionals, patients, and pressure groupsmay wish individuals to receive interventionsthat policy holds to be inappropriate, of lowpriority, or not affordable, even though insome such instances the interventions may beof potential benefit to recipients. Pressuresmay be brought on purchasers to provide suchinterventions, and charitable donations maybe sought to purchase facilities that the publicsystem fails to make available. The man-agement of conflict arising from such sourcesis in our view a political rather than aprofessional responsibility. Public pressuremay also arise because of the ability of somepatients to purchase in the private sector inter-ventions which are unavailable or restricted inthe public sector. Clinically inappropriateinterventions should not be available in theprivate sector since clinicians shouldpresumably be unwilling to offer them andinsurers unwilling to fund them.

Decisions about the appropriateness ofservice provision on a population basis canspecify the level of availability of particularinterventions, but it will often be necessary toallow some scope for professional judgementabout what is appropriate for an individualpatient. Moreover, society will wish to ensurethat within the provision of effective services arange of variation is offered to accommodate areasonable degree of individual patientchoice.

Encouraging implementation of effectiveand more appropriate careEffective strategies to change behaviour needto reflect what has been shown empirically towork - namely, that learning is better andbehaviour more likely to change if learning iscentred on the learner, if information is givenin more than one way, and if the informationis perceived as having peer approval.

UNDERGRADUATE EDUCATIONIt is likely that styles of practice are inculcatedin medical school. As medical schools are,entirely properly, orientated towards research



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as well as teaching, some patients in teachinghospitals may have large numbers ofinvestigations, not all of which are necessarilyappropriate outside the context of research.This may influence the subsequent practice ofdoctors on graduation. Medical schoolsshould therefore raise the level of awareness ofappropriateness in practice.

PROVIDING INFORMATION, POSTGRADUATE

EDUCATION, AND CLINICAL AUDIT

Some methods of encouraging changingclinical behaviour by information feedbackhave been subjected to randomised trials, andthe evidence of their effectiveness has recentlybeen reviewed.26 27 Feedback of information toparticipating doctors about their behaviour isnecessary but not sufficient in the process ofmaintaining high quality care. Informationprobably influences clinical practice if it is partof an overall strategy which targets decisionmakers who have already agreed to reviewtheir practice; it is most effective also if"opinion leaders" are involved27 and if theinformation is presented close to the time atwhich decisions are made. It is believed thatthe introduction of clinical audit will improveaccess to data on clinical care and its quality,but as Mugford et al remark: "In the NHS, thelink between those responsible for routine datacollection systems and those concerned withclinical research, audit, and practice review isoften tenuous."26 The NHS ManagementExecutive is funding a project in which isbeing developed clinical terms which can beused consistently throughout the patientrecord and used for analysis of process andoutcomes.

PRACTICE GUIDELINES

One way in which it is hoped to develop moreappropriate clinical practice is the productionof guidelines for the management of somecommon clinical disorders. Guidelines neednot only appear in printed form28; they can beincorporated into general practice and hospitalcomputer systems and may be extended toinclude probabilities of different outcomesaccording to certain patient characteristics -that is, into an algorithmic form. However,practice guidelines have had a variable influ-ence on practice. Their promulgation has beensuccessful in, for example, reducing the rate ofinappropriate x ray examinations29 but ineffec-tive in reducing the rate of caesarean section.30The general view, supported by the research ofKosecoff et al,3' is that whereas consensusdevelopment conferences and the productionof practice guidelines are potentially importanteducational tools, their effects need to beenhanced by focusing on specific aspects ofpractice that need improving, and by suitablefollow up programmes. We also need to makeguidelines more accessible and usable topurchasers of health care.

ROLE OF THE PUBLIC IN CHANGING PRACTICE

Public opinion is certainly an important factorin changing medical behaviour. A recentexample is the rapid swing away from radical

mastectomy in the United Kingdom and theUnited States, a swing which reflects patientpreferences for breast conservation as well asthe scientific evidence about the relativeeffectiveness of the two types of operation.Another example is a change in the rate ofhysterectomy after exploration of this form oftreatment by the media.32

FINANCIAL INDUCEMENTS

As an example of how money can alterprofessional practice, there was in Britain astriking increase in the rate of voluntarysterilisation once supplementary payment wasintroduced. In the United States advertise-ments in specialist journals for high tech-nology investigative equipment that can beowned by doctors regularly refer to the incomethat can be generated from it. In such circum-stances it is not surprising that many investi-gations are inappropriate by scientificstandards. An example from primary care isthe inducement to run health promotionclinics, leading to duplication of care, againstthe available evidence in favour of oppor-tunistic screening within the consultation.

Financial inducements might be developedto reward those who continually provided onlyappropriate care.

LEGISLATION

Legislation alters professional practice.Examples of legislative changes to practiceinclude abortion and the care of the mentallyill.

PATIENTS CONTRIBUTIONS

There is scope for increasing the extent towhich patients make appropriate use of healthcare. Studies have established that patients canbe educated by general practitioners to acceptadvice and reassurance regarding minor selflimiting symptoms rather than receive aprescription, resulting in a reduction ininappropriate prescribing.33 Another study hasshown that patients prefer a directive ratherthan a participative style of consultation.34However, the overwhelming conclusion fromstudies of health professional-patient com-munication is that most patients are relativelypassive in expressing their views and pre-ferences. One study has shown how oralparticipation by patients in consultations wasimproved by showing them a video portrayingmore active patients.35 Increased participationwas also associated with increased medicalknowledge and satisfaction. Such evidencesuggests broader benefits that may beassociated with empowering patients indecision making.

What research is needed?Common sense suggests that priorities forresearch in appropriate care should reflect theimportance of various disorders as indicatedby estimated burdens on our society ofmortality, morbidity, and resource cost andthe degree to which practice, and thereforeresource use, varies. It must, however, beremembered that variations may reflect case



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Topics for future research* The reasons underlying variations in practice* The extent to which practice is based on the

findings of research into effective health carerather than professional and lay beliefs, habit,and expectations

* The best way of measuring the severity ofillness and co-morbidity

* Methods of improving the reliability, sensitivity,and utility of health status measurements

* The value of formal methods of makingdecisions in increasing appropriate care

* The most effective ways of influencinghealth care professionals to change theirpractice behaviour towards more appropriatecare

* The most effective ways of determining theinformation that needs to be communicated topatients and their carers

* The best way of communicating thisinformation to allow people to make informeddecisions

* The best ways of eliciting patients' preferences,including those of old people and of cultural,black, and ethnic minority groups

* The best ways of minimising the adversepsychological effects of sharing informationabout risks

* The ways in which patients reach decisions andthe trades off they make

* The variations in the ways that patientsdiscount the future and the underlying reasonsfor these variations

* The range of outcomes that reflect patientconcerns

* The most cost efficient and sensitive ways ofdetermining outcomes

* The best ways of measuring the satisfaction ofpatients with their care

* The best ways of promoting health so thatpeople do not request care that is ineffectivebut obtain interventions of proveneffectiveness

* The best ways of encouraging appropriate selfcare

* The variety of roles of organised groups indefining or influencing health care and theconsequences of such involvement

* The influence of different methods ofpurchasing health care

* Whether patients in fundholding practices aremore or less likely to have access to particularappropriate interventions (at a given level ofseverity of illness) than those whose care ispurchased by health authorities

* Whether any such differences are attributable todifferences in knowledge or to financialincentives or disincentives

* Whether different methods of purchasinghealth care influence equity of access (forexample, between social classes, different ethnicgroups, and different age groups) to appropriatecare

* The effectiveness and efficiency of interventionsby health professionals with different levels oftraining and in different settings

* The effectiveness of alternative ways oforganizing care

* With regard to organisation of primary care, theappropriate access for different client groups -

for example, the appropriateness of primarycare provision at the workplace

* The best way of delivering care to homelesspeople

* With regard to organisation of inpatient care,the most appropriate way of planning theinpatient day

mix (age, comorbidities, preferences, and soon) and that absence of variation would be acause of concern, indicating a lack of patientchoice.

Understanding what is going onThe working group believes that furthertheoretical development is needed of ourunderstanding of the place of the healthsystem in our society, and of relationshipsbetween consumers and providers of healthservices. In many instances qualitativeresearch will be of value in illuminating ourideas about the delivery of health services.Within such an overall core theory, we en-visage research in several specific areas (box).

Research among both health professionalsand the lay community is necessary to developunderstanding of the reasons for practicevariations. We also need to develop measuresof professional appropriateness based onscientific evidence of effectiveness, and furtherstudy into what constitutes appropriateintervention for defined "indications" - that is,various combinations of severity of disorder,comorbidities, etc. We need to take betteraccount of the perspectives of users of healthservices and to devise better ways of sharinginformation and incorporating theirpreferences. Research is required to define awider range of outcomes which reflect patientconcerns and to improve methods ofmeasuring the value that patients attach todifferent outcomes. We also need to researchthe usefulness to health professionals andmanagement of patients' valuations ofdifferent outcomes. Outcomes valued bypatients should be used more widely inrandomised controlled trials and evaluativeresearch, alongside traditional biologicalmeasures of efficacy. With regard to patientsatisfaction, basic research is still needed toestablish instruments that are reliable andaddress the main concerns of patients. We alsoneed ways of encouraging the responsibilitiesof users of health services.We need to study the valuations that society

places on different sectors of health provision.Research, possibly in the form of actionresearch, is needed in which the role of laygroups is extended - for example, in relationto purchasing and contracts, the developmentof consensus, or clinical audit. Research isalso needed of the organizational aspects ofhealth care, including how best to use thedifferent skills of different health serviceworkers. There is considerable scope forevaluation of general organisation; roles andboundaries within primary care; and roles andboundaries between primary, secondary, andtertiary care.

ConclusionThe working group believes that there shouldbe a wider public and professional debateabout the meaning of appropriate care, and awide debate also about linking public andprofessional perspectives of appropriateness.Allocation of resources will depend in partupon this, as well as on evidence of efficacy



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and effectiveness. The working group hopesthat funding will be available to explore manyof the research issues shown in the box.

The working group thanks its secretary, Dr Timothy Riley, forassistance with its organisation, Mrs Barbara Durr for word-processing, and Professor Andy Haines, who was coopted toone meeting to discuss practice guidelines.

AppendixThis paper is an abbreviated version of a

report produced for the Director of Researchand Development of the Department ofHealth.Members of the working group:

Dr Anthony Hopkins, director, Research Unit,Royal College of Physicians (chairman); Dr RayFitzpatrick, lecturer in medical sociology, NuffieldCollege, University of Oxford; Ms Ann Foster,director, Scottish Consumer Council; Ms AlisonFrater, public health specialist, North West ThamesRegional Health Authority; Professor John GrimleyEvans, professor of geriatric medicine, University ofOxford; Professor John Hampton, professor ofcardiology, University of Nottingham; Dr DeborahHennessy, regional nursing advisor, South WestRegional Thames Health Authority; Professor Ann-Louise Kinmouth, professor of primary medicalcare, University of Southampton; Mr JimThornton, senior lecturer in obstetrics andgynaecology, University of Leeds; and DrChristopher Henshall, Directorate of Research andDevelopment, Mr Henry Neuberger, Economic andOperations Research Division, and Dr TimothyRiley, Directorate of Research and Development,NHS Management Executive.

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