clinical governance

GPs' understanding of the scope and responsibility of clinical governance is poor, and highlights the need for expert guidance according to a survey. Gill Malbon and colleagues explain

Total purchasing pilots were established in England and Scotland in 1995 as a three-year experiment. The pilots comprised either one standard fundholding practice or a group of standard fundholding practices. Each received a delegated budget from their health authority to purchase potentially all the hospital and community health services for their registered populations.

This group of GPs is likely to be more advanced in commissioning and managing a budget across practices than most. Because of this, we thought it was important to explore their understanding of the emerging issue of primary care group clinical governance.1

A questionnaire was sent out to the lead GPs in all 87 pilots in June 1998 at the same time as A First Class Service - quality in the NHS was published.2

The questionnaire asked:

What is your understanding of the term clinical governance?

How do you think clinical governance should be implemented at the PCG level?

How do you think this will affect your day-to-day work as a GP?

Sixty-four GPs (74 per cent) completed the questionnaire.

Results

A third of the GPs considered clinical governance to be a commitment to agreed standards and to setting a level of clinical practice below which doctors should not fall. Most answers covered how clinical governance might work: through auditing, peer review, sharing information and monitoring activity. The Bristol case was mentioned by two GPs, who implied that the child heart deaths tragedy at Bristol Royal Infirmary could have been avoided if a better system of clinical governance had been in place.

Little was mentioned about the wider implications of clinical governance, such as its overall purpose for the NHS in terms of good practice and improving clinical quality.

The GPs interpreted clinical governance as exclusively a medical concern, with more emphasis on self-regulation than clinical improvements. Very few mentioned public health input, although one GP said he did not want clinical governance in his PCG run by the HA's public health consultants. Only a few GPs talked about clinical governance in relation to risk management, corporate responsibility, peer pressure or leadership.

Accountability was mentioned by 15 GPs (23 per cent) as being a function of clinical governance. But there was no consensus among them about the particular attributes of accountability to which they were referring. A third mentioned clinical accountability; just over a quarter mentioned financial accountability, some talked about corporate accountability, and one GP indicated that clinical governance would mean working to local and national standards.

Accountability arrangements in total purchasing pilots had been relatively informal. Public accountability was not a priority. Almost half the respondents reported that they had done nothing to inform or consult patients about the development of the project or changes they wished to make to local services.5

But with the advent of PCGs, this situation is likely to be addressed more explicitly.

Implementing clinical governance in PCGs

Twenty-three GPs (36 per cent) thought that implementation should be GP-led, with a lead GP developing standards which would then be agreed by local consensus in the PCG (see figure 1). Equally, there was a feeling among 31 per cent that clinical governance would largely be a matter of building on existing systems.

A quarter of the GPs acknowledged that sharing information and co-operation were important for clinical governance, and there was a sense that this ought to happen in an educative environment rather than one of blame.

This approach is similar to that of Scally and Donaldson, who argue that 'an organisation that creates a working environment where ideas and good practice are shared, where education and research are valued, and where blame is used exceptionally is likely to be one where clinical governance thrives'.3

Other GPs talked more about the practicalities of implementing clinical governance in their PCG. Ten mentioned the idea of having a sub-group in their PCG, comprising GPs and a lead nurse, which would be responsible for setting up clinical governance frameworks for specific disease areas. The sub-group would ensure that all clinicians were aware of such frameworks and see that recommendations and guidelines were being followed: this would involve a large amount of training.

Only two GPs mentioned the idea of corporate governance or corporate responsibility. Yet if clinical governance is to succeed, it must be underpinned by clinicians sharing a sense of identity with the wider organisation.

The effect of clinical governance

Scally and Donaldson view clinical governance as a positive developmental opportunity.3 But more than two-thirds (44) of the respondents viewed it in a negative light.

Almost half were concerned about administrative costs, the additional time required to implement clinical governance plans, the proliferation of committees that would result and the reduction in time available to see patients.

Other concerns were restrictions on clinical freedom (14 per cent), increased working to local and national targets (6 per cent), and more protocol- driven work (9 per cent).

Some GPs commented on the collective and convergent nature of clinical governance, such as an increased understanding that each GP's actions can affect others in a group, and a recognition of how practices compare with one other.

A minority talked about how clinical governance would improve care for their patients and clinical outcomes; for example, making possible the use of evidence to promote better patient care or setting up frameworks for achieving quality improvement. However, most respondents viewed clinical governance more as a mechanism to control clinical behaviour through peer pressure than as a tool which would improve overall quality and consistency in primary care.

Implications for the development of PCGs

The GPs tended to talk about clinical governance as a series of tasks concentrating on areas which were familiar to them. There was little discussion of the wider implications and strategic purpose, although some had picked up on the implications for control of professional behaviour. GPs tended to view it more as an elaborate version of peer review and audit.

There was growing awareness among the GPs of the impact their actions had on other GPs and how they compared with their peers. This is an essential part of participating in PCGs and may mark the beginning of a more corporate approach to clinical work and resource management.

Clinical governance was also described as something which GPs would develop and then use. There was little mention of the involvement of others in the primary care team or how it could be developed with clinicians in secondary care.

Risk management and corporate governance were also relatively unexplored.

The GPs' main understanding of clinical governance was concerned with preventing other GPs falling below a certain 'minimum standard': this would be monitored through a system of sub-groups and frameworks run by GPs and a lead nurse in each PCG. For these GPs, clinical governance did not appear to relate to improvements in patient care. Rather the emphasis was on being managed and restricted by a series of protocols and guidelines. Unfortunately, NHS Executive guidance has compounded this perception.6

The GPs' descriptions included 'upward' accountability for delivery of local and national targets, accountability to peers and corporate accountability to the wider organisation, including financial management arrangements.

None of the GPs surveyed mentioned accountability to patients or the wider public. The lack of appreciation of the relevance of public involvement was also apparent in responses to other parts of the questionnaire.

Our findings suggest that GPs are only starting to recognise the implications of clinical governance.

More explicit guidance will be required on what is expected of GPs and other clinicians in the PCG in relation to clinical governance; how members of a PCG ought to assess and tackle variations in the quality of care among practices; and who would be the most suitable people in the PCG for the task.

Furthermore, clinical governance must be seen in an educative environment.