Kieran Walshe's thought-provoking piece on the NHS Executive consultation paper on quality (Open Space, pages 18-19, 9 July) states that 'the establishment of the Commission for Health Improvement can also be seen as an implicit criticism of the Audit Commission for failing to tackle issues of clinical performance and sticking to less controversial territory in its national and local studies'. Such a perception would be wrong.

In the eight years since the Audit Commission began assessing value for money in the NHS, its work has increasingly considered effectiveness as well as efficiency.

It has tried to capture the patient's perspective as well as measures of clinical quality. Studies have, for instance, looked at the communication between clinicians and patients in hospitals, rates of day surgery for particular procedures, the appropriateness of GP prescribing, and women's satisfaction with maternity services.

These studies have often been controversial, posing difficult questions for policy makers (for instance, the GP fundholding study), for managers (the viability of accident and emergency departments) and for clinicians (the potential for using nurse anaesthetists). Work that involves both local government and health sectors, such as our studies of elderly people and community care, have in themselves highlighted organisational weaknesses which are now being addressed at a national policy level.

The proposed Commission for Health Improvement is a welcome step. But quality issues must always be considered alongside efficiency and value for money in the public sector. We in the Audit Commission therefore look forward to working with the Health Improvement Commission.

Jonathan Boyce

Director

Health studies

Audit Commission