The first step of this initiative has been taken with Lifting The Burden's proposal for the organisation of good quality headache services, in collaboration with the European Headache Federation. However, once these services exist there will also be a need to evaluate them.

Lifting The Burden is working with the Health Services Research Unit of the Department of Public Health, University of Oxford, to create a framework for evaluation and provide a means of benchmarking services, where they exist. This will allow comparisons between a local service and those offered in other parts of the world.

Currently, there are six proposed areas of a headache service that require evaluation:

• technical success, i.e. does the service work? This can include references to waiting times, throughput and efficient referral from primary to specialist care.

• uptake, i.e. is the service being used? This needs to measure the percentage of the population wanting access to the service and the number of patients treated within the service.

• clinical effectiveness, i.e. are outcomes for the patient as good as they can be? This should cover not only the success in treating those patients seen within the service but also any failure to reach people who would benefit from access.

• patient satisfaction. This may cover timely access to services, levels of staff interest, follow-up if needed.

• cost effectiveness, i.e. is the service affordable? The additional doctor- or nurse-time that is needed to run a headache service must be shown to be a cost-effective use of resources. While direct treatment costs will be part of this equation, other factors, such as reduced referrals to secondary care and recovery of lost productivity, must also be counted.

• success in tackling inequality, i.e. is access equally available for all? It is essential that headache services should be available fairly to everyone, and reach all groups within in society.

Benchmarking so many variables poses a number of challenges. How should these different aspects of service be prioritized, and from whose perspective, so that quality of services can be evaluated against them?

Lifting The Burden will undertake a review of the existing literature on health service evaluation to see what can be applied to headache. At the start of next year, focus groups will be held with patients in the UK, Germany and Denmark and, in the UK, separate focus groups among physicians and specialist nurses.

The findings from these will help show how headache services should be evaluated, and how these methods can be applied to the development of services being undertaken by Lifting The Burden.