User involvement in clinical governance.

This paper reports the findings of a study concerned with the way in which Primary Care Groups (PCGs) and Primary Care Trusts (PCTs) engaged with the Mental Health National Service Framework (NSF) as part of their remit to implement clinical governance. A qualitative multiple case study is reported which used semi-structured interviews and documentary analysis in a purposive sample of 12 PCG-Ts in England. The study found a general awareness of and support for the Mental Health NSF among PCG-Ts. In some localities the NSF acted to reinforce existing local developments in primary care mental health. However, compared to the NSF for Coronary Heart Disease a number of difficulties in responding to the Mental Health NSF were identified. These related to the perceived clinical status and complexity of managing mental health problems at practice level (e.g. familiarity with and competence of General Practitioners (GPs) in managing the conditions), inter-agency working, clinical governance training and the feasibility of producing clear demonstrable mental health outcomes as part of performance management. While the NSF for mental health presents opportunities for establishing the principles of quality assurance and improvement in the area of mental health, it is in danger of being marginalized in the clinical governance agendas of new PCTs, because of an inability to compete on an equal footing with other clinical priorities. While the partial demedicalisation of mental health is increasingly recognised as desirable for policy and therapeutic reasons the corollary is that it is harder to implement non-medicalised forms of care through the essentially medicalised apparatus of clinical governance. In order to deal with the complexities and challenges posed by the mental health agenda targeted support and resources are needed to promote clinical governance developments within primary care organisations.

In April 1999, 481 English Primary Care Groups (PCGs) were created. The National Primary Care Research and Development Centre is leading a three year longitudinal study, in conjunction with the King’s Fund, to track the development of PCGs. The implementation of clinical governance is an important responsibility of PCGs. This survey aimed to describe initial progress in implementing clinical governance in primary care, and to describe barriers to change. Data were collected in autumn 1999, using a questionnaire to clinical governance leads, in a random sample of 72 PCGs. PCGs have put considerable effort into the development of clinical governance and an extensive range of activities were planned for tracking quality of care. However, PCGs face barriers in implementing clinical governance and they must foster a culture of engaged participation by practices and practice staff. PCGs must also be given the time and resources needed to implement clinical governance.

This is the last of five articles The new requirements of clinical governance are a challenge for everyone working in the NHS. If the quality of health care is to...

PurposeThe purpose of this article is to investigate acceptability, dissemination and use of a multidisciplinary audit toolkit to monitor evidence‐based care for acute low back pain and to identify barriers to implementation of the RCGP evidence‐based LBP guideline and associated audit process.Design/methodology/approachA survey was carried out of 707 clinical governance leads (CGLs) and 336 clinical audit leads in English/Welsh Health Authorities, NHS Trusts, Primary Care Groups and Primary Care Trusts. Subsequently, structured telephone interviews with 50 CGLs and 22 CALs in 72 Primary Care Trusts were qualitatively analysed.FindingsSubstantive barriers specific to implementation of the RCGP LBP guideline and associated audit toolkit could not be identified. Issues were raised pertaining to the wider healthcare system, which itself may restrain implementation of evidence‐based health care for LBP sufferers. Qualitative analysis revealed six categories responsible for poor clinical governance. Results suggest that LBP is not a priority area and that without National Service Framework status this is unlikely to change.Research limitations/implicationsResponse to the initial survey was only 37 per cent; thus results may not be representative of all relevant UK NHS organisations. It coincided with a particularly busy period of change and ongoing reform, making it difficult to reach relevant personnel. This problem was accentuated by frequent change of persons in the post of clinical governance lead. All of this may have impacted on the response rate. In addition, some organisations/individuals were reluctant to be identified for the purpose of this study.Originality/valueThis study identifies the practical difficulties of delivering the clinical governance agenda, particularly in non‐priority areas, as reported by those responsible for doing so.

In many countries governments are recruiting the medical profession into a more active, transparent regulation of clinical practice. Consequently the medical profession adapts the ways it regulates itself and its relationship to health system managers changes. This paper uses empirical research in English Primary Care Groups (PCGs) and Primary Care Trusts (PCTs) to assess the value of Courpasson's concept of soft bureaucracy as a conceptualisation of these changes. Clinical governance in PCGs and PCTs displays important parallels with governance in soft bureaucracies, but the concept of soft bureaucracy requires modification to make it more applicable to general practice. In English primary care, governance over rank-and-file doctors is exercised by local professional leaders rather than general managers, harnessing their colleagues' perception of threats to professional autonomy and self-regulation rather than fears of competition as the means of 'soft coercion'.

Clinical governance is no longer in its infancy. Although introduced 3 years ago into the National Health Service (NHS) through the Government’s paper ‘‘The new NHS—modern . dependable’’ [1], it has not reached its final objective in becoming the essential habit of everyone who works in the health service and so it is not yet mature. It is in those terrible teenage years! It is now accepted that clinical governance is the local part of the Government’s national initiative on clinical quality in the NHS, aimed at setting and maintaining standards of clinical care. Since its inception, the principles of clinical governance have been further developed in subsequent papers from the NHS: ‘‘A first class service: quality in the NHS’’ [2] and ‘‘Clinical governance: in the new NHS’’ [3]. The quotation from these documents that I think is most relevant to the understanding of clinical governance is ‘‘the new NHS will have quality at its heart, without it there is unfairness. Every patient who is treated in the NHS wants to know that they can rely on receiving high quality care when they need it. Every part of the NHS and everyone who works in it should take responsibility for working to improve quality’’. Since 1997 we have seen the development of the national framework for clinical quality in the form of the National Institute for Clinical Excellence (NICE), the National Service Frameworks and the Commission for Health Improvement (CHI). Some progress has also been made in identifying patients’ views on the service. The now well recognized diagram (Figure 1) shows clinical governance sitting between the NICE and the CHI, but alongside professional self-regulation and lifelong learning. The fundamental elements of clinical governance (Figure 2) were first enunciated in 1997 and were not unfamiliar to professional staff working within the NHS. However, this reminder of good clinical practice was accompanied by significant organizational change associated with ‘‘governance’’. The concept of governance is now widespread throughout society and originated in relation to the principles of corporate governance in the Cadbury Report of 1992 [4]. Under governance guidance, Trusts are required to ensure that there are mechanisms in place to facilitate high standards of practice. Until clinical governance arrived, governance in the NHS largely related to financial affairs. The responsibility of Trust Boards has been clarified and in particular the Chief Executive has been made fully responsible for ensuring that controlling

This is an up to the minute book on a relevant subject for community nurses. It is well referenced, clearly set out and incorporates headings, boxes and diagrams. The authors set out to examine some of the facets of clinical governance such as quality, accountability, transparency and continuous improvement. After explaining the meaning of clinical governance and placing it squarely within primary care groups and trusts, aspects such as humane care, clinical effectiveness, risk management and personal and professional development are outlined. The book concludes with a critique of possible future developments. Whilst the authors acknowledge that the implications of clinical governance apply equally to all members of the primary care team, this is not borne out in the text, which appears to have been written almost exclusively for general practitioners. In the entire book, only five pages refer to issues relating to nurse members of the primary care team. Although this text would make a useful addition to nursing libraries, it is not one that individual nurses are likely to purchase. They could suggest, however, that each of their GP colleagues buys a copy, as the book contains many useful guidelines for continuously improving the quality of medical services.

Current policy places great emphasis on the development of “partnerships”, particularly between NHS and local authority services, with the aims of increasing service coordination and delivery and improving health. To this end, primary care groups (PCGs), at the forefront of NHS organizational developments, are required to include a social services representative on their governing boards; similarly, primary care trusts (PCTs) have a social services representative on their executive committees. Drawing on a representative longitudinal national survey of English PCGs, the paper evaluates the contribution of these new governance arrangements to the development of inter‐agency partnerships. Despite poor histories of collaboration and some major organizational barriers, there are some signs of progress, with social services representatives playing an active part in PCG affairs and having clear lines of communication about PCG matters with their employing authorities. Equally significantly, PCGs have also quickly established a wide range of contacts directly with other local authority services and departments. However, these early gains risk being limited by traditional professional inequalities between social work and medicine and, in particular, by the prospect of further organizational upheaval as PCGs merge with each other and/or acquire trust status.

AimTo find out understanding and usefulness of clinical governance among trainees in a NHS trust where clinical governance meeting is held each month and subsequently to implement measures to make...

PurposeTo report on the clinical governance work of the NHS Clinical Governance Support Team's, Primary Care Team.Design/methodology/approachThe review describes the formation of the NHS Clinical Governance Support Team's Primary Care Team and the development of a range of national clinical governance activities, drawing on a case study example.FindingsThe Team have been developing appraisal, and revalidation for general practitioners across the UK, supporting front‐line staff in primary care to improve patient experience by embedding principles of clinical governance into day‐to‐day practice, and are providing an online education and training programme to develop primary care managers. It has established links, and worked collaboratively with a range of partners in its activities.Originality/valueThe article provides a summary of the activities of the Primary Care Team and its activities to date. An example of supporting clinical governance in primary care is given in a case study of facilitating an influenza vaccination campaign.

Multi–sectoral approaches to health improvement in its broadest sense have entailed an emphasis by the British government upon partnership working in and around community involvement in planning processes. New service planning and delivery organizations in the health service—primary care groups and primary care trusts—thus have to ensure that public and patient involvement strategies reflect a coordinated, if not integrated, multi–sectoral approach to such involvement. But how are these enforced partnership arrangements shaping the approach taken by primary care groups and trusts to the issue of public and patient involvement? More particularly, is the traditional dominance of health service managers and the medical profession in decision–making processes under challenge? This article draws on a study of primary care groups and trusts in three districts in order to gauge perceptions and calculations with regard to partnerships for involvement. Results appear to suggest that health service managers and practitioners continue to exercise considerable influence in comparison to that of patients and citizens. But, if the findings are viewed in the broader contexts of government managerialist strategies of surveillance and accountability and the growth of service–user and advocacy organizations, partnerships may offer significant scope for “lay” challenges to managerial and medical power.

Background: Individuals with serious mental illness face challenges in managing their health, leading to the need for integrating their needs and preferences in care decisions. One way to enhance collaboration between users and providers is to improve clinical governance; a shared responsibility between managers and providers, supported by healthcare organizations (HCOs), policies, and standards. We applied the concept of clinical governance to understand (1) how managers and providers can enhance the involvement of users in mental health, (2) the contextual and organizational factors that facilitate user involvement in care, and (3) the users’ perceptions of their involvement in care.Methods: We conducted two, in-depth case studies from two clinical teams in Canada offering outpatient care for users with acute mental illness. A total of 25 interviews were carried out with managers, and four focus groups were held with providers. A measure of patient-reported experience was used to evaluate the users’ perceptions of their involvement in care.Results: The providers used two methods to involve users in the care planning process: encouraging users to identify their life goals and supporting them to define recovery-oriented objectives. To encourage the adoption of collaborative practices, the managers used various practices such as revising care protocols, strengthening providers’ knowledge of best practices and integrating peer-support workers (PSWs) in the team. Compliance with organizational and external commitments/requirements for user involvement, access to specific training and the institutionalization of a culture promoting user involvement facilitated the adoption of collaborative practices. We found that mental health teams that adopt recovery and collaborative practices with users show a high degree of user-perceived involvement in care.Conclusion: This is the first study to apply the concept of clinical governance to understand how managerial and clinical practices, and other organizational and contextual factors, can enhance the involvement of mental healthcare users.

The challenge of governance: achieving quality in diagnostic imaging

This paper reports on a study to ascertain the development needs in terms of clinical governance of 220 health service staff across all the key professions from primary and secondary care, including chief executives and clinical governance leads. Interviews suggested that the development of clinical governance was progressing through the structures created by the leads, and that there was considerable goodwill shown towards it in most of the interviews conducted. Of the participants 69 per cent had heard of clinical governance, though detailed knowledge was rare. The author suggests that development overall needs to be carried out using a multi-disciplinary and multi-agency approach where possible, perhaps using pathways of care. It needs also to take account of the expressed fears from medical staff of discussing their care in a multi-disciplinary setting, and of the two potential conflicting themes that are apparent to chief executives of change towards no-blame cultures, while encouraging account-ability and the recognition of risk.

Primary care groups have been with us in England for a year. In that time we have also had a winter bed crisis; a general practitioner serial killer; a new...