Published:25/04/2002, Volume II2, No. 5802, Page 19

Patricia Day and Rudolf Klein ('Who nose best? , cover feature, 4 April) point out that Commission for Health Improvement reviews are diagnostic, and are not, in themselves, sufficient to achieve change.

This will depend on many factors, not least the attitudes to the learning achieved by key trust staff such as the chief executive and clinical governance lead.

Our research has followed all West Midlands trusts over threeand-a-half years. Data from 32 of the 40 trusts sampled so far included comment on the impact of star ratings, Dr Foster and CHI on clinical governance.

The Dr Foster data was the least well received, being too easily misinterpreted and not taking account of the organisation of care across organisations - for example, the absence of a hospice could skew hospital mortality. These criticisms were also made of CHI's use of data.

The focus on structure and policies, on quantity rather than quality, left all respondents critical of the review process, which failed to capture and describe outcomes adequately.

Of the 11 trusts reviewed by CHI, all were largely positive about the views reflected of the trust. But only two felt the review had helped clinical governance. Their reasons were not about specific undetected problems or learning achieved from the review team. Rather, it was the process of having staff focus on clinical governance for a concentrated period. This effect was similar to that found for the regional office visiting team process. Trusts in the West Midlands were visited by a three or four-strong team led by a consultant in public health.

One could ask, therefore, whether a re-engineered and more developmental review might not achieve more learning, better clinical governance and better outcomes.

Professor Louise Wallace, Matthew Boxall Health services research centre, Coventry University Professor Peter Spurgeon, Tim Freeman, Health services management centre Birmingham University