Published: 31/10/2002, Volume II2, No. 5829 Page 21

I read with interest the article on clinical networks ('Sum of the parts', pages 24-25, 17 October) in which a clinical network was tested via a simulation exercise.

We are halfway through a twoyear pilot of three managed clinical networks in specialist orthopaedics.

A number of the points raised in the article are very valid; in particular, the problem of cutting across existing patterns of service delivery and mechanisms of decision-making.

We have overcome this by appointing a project manager and involving chief executives from an early stage. We have a steering group with representation from both primary care trusts and acute trusts at chief executive level.

This group feeds information in to and out of the clinical networks and regularly updates the three strategic health authorities on its activities and key issues.

There are benefits to crossreferral. It is not necessary to create new organisations, as pointed out in the article. The organisation currently exists.

Our managed clinical networks are based on group clinical governance of surgeons with similar interest, but not necessarily similar experience.

The governance includes group audit, personal development, peer review of practice and formulating agreed outcomes for surgery.

The day-to-day organisation is done by our project manager and three lead clinicians. We have now agreed the minimum data set to be collected to provide governance and audit.

Our model has proved to be a unifying force, as described in the article. It has established the pattern of work.

Audit of the waiting lists has defined the work to be done and an ongoing audit has identified the likely cross-referral of patients from trust to trust. Joint appointments have been undertaken and protocols are being developed.

We are now agreeing clinical governance arrangements across our networks. There is an understanding by the PCTs that specialist orthopaedics does require cross-referral and movement of both patients and surgeons to provide a high-level, even quality across the region.

JK Stanley Lead clinician Consultant hand surgeon, Wrightington, Wigan and Leigh trust Professor of hand surgery Manchester University, Eileen Streets, Project manager Managed clinical networks