When is a standard, not a standard? When it is a recommendation

A standard may be defined as `an accepted or approved example of something against which others are judged or measured'. I suspect that we all use the concept of a standard when trying to judge the quality of any service provided; but how do we know what the standard is for a specific aspect of clinical practice and how it is produced? If one takes the first part of the definition as a standard being an `accepted example', who has accepted it as such? Is this acceptance based on scientific evidence obtained from properly conducted studies or is it just that it is `accepted' normal practice (as opposed to unacceptable practice). If the standard is an `approved example', one must once again ask by whom it is approved. An `approved example' might be the Recommended Minimum Standards for Obstetric Anaesthetic Services [1]. This sets out clear unambiguous levels of staffing and care that should be attainable for all units as a minimum to provide an acceptable level of care. Returning to the original definition, a standard is something `against which others are judged or measured'. Clearly, the former option introduces an element of subjectiveness and thus may be open to bias or confusion in interpretation. The idea of the comparison being `measured' is scientifically much more attractive, but it depends upon there being a suitable unit of measurement and a robust measuring tool to provide the necessary objective assessment. Whatever, as standards will form an important part of clinical governance, where do we find them for the various aspects of our work? As part of the changing pattern of administration within the UK, there has been a move towards devolution of certain powers away from central government; the National Assembly for Wales is one such devolved body. Whilst restricted in some aspects of taxation and financial matters, the Assembly has responsibility for the provision of services, including health, education and general infrastructure. The Assembly, through the Welsh Medical Committee, has recently requested information on the provision of pain services in Wales. There was a perceived inequality in the services provided across the principality in respect of all aspects of pain management. A working group was commissioned to evaluate the extent of services provided and to compare this to an accepted standard. Herein started the search for a standard for pain services! My area of involvement was acute pain management. A questionnaire, linked with information gathered annually by the Welsh Acute Pain Interest Group, gave us a clear indication of the staff, equipment and facilities available in all acute hospitals in Wales. The next task was to find a suitable standard against which to judge our services. Try as I may, I could not find a standard, only recommendations. One well-known set of recommendations in relation to acute pain management is contained within the joint report of the Royal College of Surgeons and the, then, College of Anaesthetists into Pain after Surgery [2]. Among the recommendations made back in 1990 were: there should be an acute pain service in all acute hospitals, all major hospitals should have a high dependency unit, there should be education for all staff involved in pain management, and research should be encouraged. These are clearly laudable aims but only the first two can be measured in an objective way and then only as to their existence as no figures for the structure or level of the provision are given. As to the other two recommendations, the assessment of implementation is largely subjective. In 1992, the National Assembly for Wales in its former guise of the Welsh Office, produced a document entitled Pain, Discomfort and Palliative Care as part of a series of Protocols for Investment in Health Gain [3]. Many of the recommendations emanating from that report were similar to those of the Pain after Surgery report [2] but figures were attached to provide targets for achievement. In the realm of acute pain, a target was given to `reduce the proportion of people in severe pain after an operation to under 20% by 1997, and to under 5% by 2002 (based on figures for 1993)'. On the surface, this would seem to be a reasonable attempt to provide a standard for improvement but to be useful, there needed to be a tighter definition of severe pain. Is the pain to be measured at rest or on movement? Is the severity of pain to be judged according to regular individual measurements or scored as an average over 24 h? Does the target include all operations (including minor operations performed in the outpatient department)? Within the generally accepted meaning of the target, the figures for 1997 could be achieved without resource to complex methods of pain relief [4], but to achieve the 2002 target would surely require the more widespread use of regional techniques. In order to achieve the target, the report recommended that all hospitals should have an acute pain service, but gave no indication as to its specification. The Association of Anaesthetists has a long record of providing invaluable guidance booklets that contain clear standards on subjects such as monitoring during anaesthesia and recovery [5]. In 1997, in collaboration with the Pain Society, a document on the Provision of Pain Services was published [6]. It covered all aspects of pain services and, of necessity, each section was brief. The recommendations with regards to acute pain services largely mirrored those of previous reports, though some mention of the cost implications of providing acute pain services was touched upon.