Research, audit, and education.

BMJ 1992;304:698-700 The limited ability of cost containment strategies to resolve problems besetting health services is in? creasingly being recognised. There is a growing aware? ness among politicians, managers, clinicians, and public that, while changes in financial management of health services may help to improve environment in which care is provided, financial measures do not address underlying issues of effectiveness, appropriateness, and humanity of care. Leading for Health: a BMA Agenda for Health emphasises crucial importance in working to improve health by identifying and measuring problems and monitoring new ways of dealing with them.1 The need for a shift in approach was recognised by, among others, Arnold Relman, when he wrote in 1988 of dawn of the era of assessment and account? ability2: We can no longer afford to provide health care without knowing more about its successs and failures. The Era of Assessment and Accountability is dawning at last; it is third and latest?but probably not last?phase of our efforts to achieve an equitable health care system, of satisfactory quality, at a price we can afford. If this approach is to succeed a widespread change in attitude on part of medical profession will be required. There needs to be a far greater acceptance of current uncertainties in medical practice, combined with wholehearted support for evaluative research. Without this it will prove impossible to place health service on a firm, scientific base. This does not mean, as defenders of uncertainty are prone to suggest, that art of medicine is to be sacrificed but rather that wherever possible scientific evidence should be able to be marshalled to suggest that care being provided is effective. The new era can be achieved only through, firstly, an expanded programme of health services research; secondly, medical audit to ensure research findings are adopted in clinical practice; and, thirdly, education to change some well established professional attitudes towards medicine.