Preventing ischaemic heart disease in one general practice: from one patient, through clinical audit, needs assessment, and commissioning into quality improvement   Commentary: Clinical and economic perspectives have to be integrated when selecting priorities for intervention

Editorial by Fahey and pp 112511301134 Since the introduction of clinical audit 1 2 and the creation of medical audit advisory groups,3 general practice has begun to look beyond reactive care and, more recently, proactive care, towards the new doctrine of clinical effectiveness. 4 5 The white paper Health of the Nation 6 set a range of strategic goals, and fundholding and commissioning gave general practice the means to achieve these goals and more. These changes, together with the need to implement established research findings7and to use resources most effectively,8 put into place a new philosophical framework for the strategic delivery of primary care. If practices are to act within this framework they need some tools, and they need the skills touse them. Conventional clinical audit—looking at the care of cohorts of patients 1 2—is useful, but increasingly it is being linked to significant event auditing in which insights from the care of individual patients are integrated into quality assurance.9–12Health needs assessment13 can then be used to put the results of audits into context and to help a practice prioritise. These priorities (each evaluated against the prevailing evidence and guidelines14–16) form the basis of commissioning decisions which improve patient care. Although this sounds straightforward, few practices have adopted this approach systematically. Often clinical audits are not linked to health needs assessment or commissioning and commissioning is not linked to evidence of need or effectiveness. This article illustrates how one practice linked the elements in the new framework to improve its care for one group of patients—those at risk of ischaemic heart disease. #### Summary points