In our era of “assessment and accountability” in health services it is important to be able to assess quality. Much has been written about measuring quality and quality assessment,^1,2 and there are some valuable and well known frameworks available for doing this.^3,4 Quality frameworks tend to include a number of different dimensions. It is clear that the concept of quality must be multidimensional but it is surprisingly difficult to map the frameworks onto each other.

Maxwell³ offers us an apparently comprehensive six dimensional framework (effectiveness, efficiency, equity, acceptability, appropriateness, and accessibility) which can be used to assess the quality of health services but, in Maxwell’s framework, certain key and essential elements such as (Donabedian’s) structure and process⁴ or attention to a more holistic approach to anticipatory health care offered to the individual are omitted.

Toon’s framework⁵ for conceptualising quality in the primary care setting in the UK is less well known. It includes four dimensions of quality: biomedical, business, teleological, and anticipatory. The biomedical dimension relates to the …