With the introduction of clinical governance to primary care, general practice teams will, for the first time, become answerable to each other for the quality of their clinical decision-making and service organisation. This move away from their status as independent small businesses to membership of a corporate primary care group represents a fundamental change in accountability, presenting special challenges.
In their first year, PCGs were required to appoint a lead for clinical governance, to undertake a baseline assessment of local capability and capacity to implement clinical governance, and to decide on an action plan and publish a report by the end of March 2000.1
How are they getting on? In May we used a two-page postal questionnaire to investigate progress with clinical governance in London PCGs - to discover who the leads were, the support they were receiving and who they were working with. We also wanted to know how they were getting colleagues on board, what enthused them and what worried them most.
We surveyed the clinical governance leads in all 66 London PCGs, receiving responses from 57 (86 per cent) by mid-June. In 25 PCGs, one person took the lead for clinical governance; the remaining 32 were jointly led by two people.
Three-quarters of the respondents were GPs and a quarter were nurses (some from practices, most from community trusts). In almost all cases where there were joint leads, one was a GP and the other a nurse. Three- quarters of clinical governance leads were nominated by their board or volunteered, while a quarter were elected or selected by interview.
Most leads, especially nurses, had some experience of working on quality issues, but in a fifth of responding PCGs, the clinical governance leadership had no experience. For those leads who did have experience, the most common source was membership of a primary care audit group.
We were especially interested in the degree of support the leads were getting from external bodies such as their health authority, university departments, local trusts or primary care audit groups. We ranked their ratings on a three-point scale: poor/none, moderate and good/very good.
Our results are shown in the table opposite. The most common external sources of support were HAs and primary care audit groups. HA support was described as moderate or good/very good by 63 per cent of responding PCGs. Given the audit experience of many clinical governance leads, it is surprising that similar support from primary care audit groups was reported by only 54 per cent. University departments provided little or no support to the majority (70 per cent) of responding PCGs, and support from trusts was rated only slightly higher.
The most common contacts were the HA or other clinical governance lead (61 per cent each), followed by lay people (40 per cent), colleagues in trusts (39 per cent) and social services departments (18 per cent). None of the PCGs was working with a finance manager, and only five (9 per cent) were working with an information manager - a low proportion given that the management of information may be critical to work on clinical governance. The leads told us that other collaborators included members of clinical audit groups, educationalists, medical advisers, PCG chief executives and board members.
Most clinical governance leads have already agreed one or more priority areas for work. Clinical areas are the most common. The most frequently cited is coronary heart disease and stroke, chosen by almost 72 per cent of responding PCGs. Next is diabetes (30 per cent), followed by mental health (16 per cent). Although prescribing is sure to be an important topic once PCGs get into the work, as a specific issue it is seen as a priority by a minority of PCGs (9 per cent), and only a handful have prioritised care of elderly people, asthma, teenage pregnancy or women's screening.
Clinical governance covers the quality of service delivery as well as clinical decision-making. But organisation and service issues barely feature as major topics so far: only four PCGs are considering primary care development and organisation as a clinical governance priority, with two looking at the quality of data recording and information technology. Most PCGs (86 per cent) are beginning to assess resources available for clinical governance, and three-quarters have developed a preliminary action plan. Only 10 PCGs (in seven of the 16 health districts) had agreed a clinical governance budget.
A lead for information management has been agreed in 70 per cent of responding PCGs, usually a GP. Managing knowledge will be crucial for clinical governance, not only to build a local picture of variations in clinical and service quality, but to promote evidence-based practice and share experience.
Time will tell whether the GPs who lead on managing information are able to obtain the support they need to be effective, especially as so few clinical governance leads are currently working with an information manager. Getting local practice teams on board is clearly an early task for all PCGs, although 10 PCGs told us they were not yet ready to do this. Over 80 per cent of PCGs have decided to identify a clinical governance lead in each practice.
Asked what was the most positive aspect of clinical governance, most leads (72 per cent) stated improvement in quality, equity or standards of care. Multidisciplinary teamwork, collaboration and accountability were also seen as important. Some leads were enthusiastic about the chance to alter the culture of learning in which they work and the potential to transform primary care.
All the clinical governance leads had serious concerns. What worried them most was lack of resources - especially money and time. This issue was raised by half the leads. Of the 10 PCGs that had allocated a budget for clinical governance, leads from six said that they were still worried about resources.
Many leads expressed anxieties about clinical governance. Worries included fear of failure, lack of knowledge and the size of the task. One lead feared he might lose the respect of his colleagues.
Leads are also concerned about apathy, hostility, suspicion and non co- operation from colleagues, how to get all practices engaged and how to deal with poor performers. Others were concerned about the imposition of rules from above, including the setting of standards, or that the initiative could become a 'number-crunching' exercise.
Our survey can only give a snapshot impression of the state of clinical governance in London PCGs. They are at different stages of development and the answers we received may reflect this. Nevertheless there are some clear messages from the results of our survey, and a few surprises.
On the negative side, only a minority of clinical governance leads felt they had good external support. If this continues, the viability of clinical governance might be threatened. Knowledge of epidemiology, measures of clinical effectiveness and skills to assess quality of practice and service delivery will be vital, yet these are areas in which few GPs have skills or time to use them.2 Expertise can be found in universities, public health departments and HAs, but the university departments of general practice or nursing appear to be almost disengaged, and most clinical governance leads rated HA support as moderate, poor or none.
A surprising finding was that so many PCGs are already working with lay people to develop clinical governance. More of a surprise was the apparent lack of joint work with pharmaceutical advisers, since managing the prescribing budget, understanding local variation and the use of incentives to promote quality are major clinical governance tasks for any PCG.
On the positive side, the leads are committed to the objectives of clinical governance, and much progress has been made: co-leads have been appointed, links to practices have started and priority areas have been agreed.
The biggest risk to clinical governance in PCGs is probably lack of resources. For clinical governance to be effectively launched across a PCG, practices must be visited, clinical teams must find time to discuss initiatives, and guidelines need to be adapted. Networks must be created, information gathered, analysed and disseminated. Above all, protected time must be reserved for education, to practise new skills and for reflection.
All of this will cost money and none of it is 'bureaucracy'. The recent allocation of£1m by the London regional office to support clinical governance in PCGs this year is welcome.
Beyond money, will HAs face up to the inevitable transfer of power to PCGs and devolve the people, skills, knowledge and infrastructure to enable them to rise to this new challenge? If clinical governance really does represent the most exciting thing to have happened to general practice in decades, it would be a tragedy for it to fail because the wide range of resources which exist to support its implementation could not be effectively harnessed.
John Hayward is a specialist registrar in public health medicine in the King's Fund primary care programme, and was a GP principal for more than 15 years. Rebecca Rosen is fellow, primary care programme, and Steve Dewar is fellow, effective care programme, King's Fund.
Clinical governance is being led by two people, usually a GP and a nurse, in most of the PCGs that responded to the survey.
A fifth of the leads for clinical governance had no experience of working on quality issues.
Nearly a third of respondents felt that their health authority had provided poor support or none at all.
Only 10 PCGs had identified a clinical governance budget.
No PCG was working with a finance manager to develop clinical governance and only five were working with an information manager.
1 Clinical Governance: quality in the new NHS (HSC 1999/05). NHS Executive, 1999.
2 McColl A, Smith H, White P, Field J. General practitioners' perceptions of the route to evidence based medicine: a questionnaire survey. BMJ 1998; 316: 361-5.