Role of users of health care in achieving a quality service

In their paper Hopkins et al' continue the journal's consistent record of distilling current thought on quality in a concise and luminous way. However, they may have perpetuated an error found in many of their sources. They are preoccupied with users (plural) rather than the individual as a user. Even their section headed "individual users" (plural again) considers mainly the aggregate differences between patients and staff, their communication and information, and general feelings and interests. Because of its statistical appeal I was seduced by the same preoccupation' until considering patient needs analysis as a contributor to quality. This changed my perspective on users "determining the effectiveness of care"' and began a quest for evaluating patient centred, patient measured goal attainment during individual rehabilitation. This began by offering the patient some menu of possible unmet needs which the services might contemplate addressing with him or her,3 ' but most colleagues proved lukewarm about adopting such approaches for routine audit. When Bond and Thomas conducted their survey in 1990 of the Nursing Times5 not one out of 160 accounts of measuring outcomes involved goal attainment by patients. Of the many possible "off the peg" (menu driven) unmet needs oriented measures, we have adopted only one in Cambridge namely, the Canadian occupational performance measure for use by therapists in a pilot service6 where the needs patients would present to us were quite unknown and the treatment options somewhat limited. An evaluation of new nursing skills and resultant outcomes in a service for patients with long term problems suggested that increasing a nurse's flexibility in negotiating with patients who feel "in charge" of their personal (evolving) care plan might generate a good partnership and promote successful outcomes.7 An outstanding example of flexibility in goal attainment measures is the problem/goal/target approach of Marks and Toole,' which seems to enhance the therapeutic alliance between user and nurse, progressively.9 A version of this "made to measure" outcome scaling is now being introduced to patient focused rehabilitation services in the community. We have found that one advantage is the coherence of this type of goal attainment with an individual user's (singular) assets and liabilities.'0