Press Release - Improving quality and safety - Progress in
implementing clinical governance in primary care: Lessons for the
new Primary Care Trusts
11 January 2007
The National Audit Office has urged the NHS to ensure that a
focus on quality and safety is at the top of the agenda in primary
care.
In a report out today, the NAO says that almost all primary care
trusts (PCTS) have clinical governance structures and processes in
place that should assure quality and safety of patient care. But
progress in the implementation of these structures and processes
varies within and between trusts. More needs to be done to provide
assurance about GP performance and protect patient safety.
In 2005-06 Primary Care Trusts (PCTs) spent £23 billion on
commissioning primary care and providing health care. All PCTs have
a statutory ‘duty of quality’ which the Department of Health
expects them to discharge largely through implementing its clinical
governance initiative.
The concept of clinical governance was introduced in 1998 as the
centre-piece of the Government’s 10-year programme to improve
continuously the overall standards of clinical care. The key
principles of clinical governance are: a coherent approach to
quality improvement, clear lines of accountability for clinical
quality, and effective systems for identifying and managing risk
and addressing poor performance. The various components of clinical
governance include ensuring effective clinical leadership,
maintaining the capacity and capability to deliver services, the
ability to learn lessons from complaints and patient safety
incidents and improving patient and public involvement and the
patient experience.
Today’s report shows that, in the four or so years since the
establishment of PCTs, implementation of clinical governance has
delivered clear benefits to the quality of patient care and has
helped some PCTs to achieve improvements in efficiency. Eighty two
per cent of PCTs considered there had been benefits to patient
care. Twenty per cent considered that there had been efficiency
savings: for example,e a reduction in the number of patient safety
incidents and near-misses and, in consequence, less litigation.
However, progress has not been uniform, particularly where PCTs
have to work with others to deliver services. A major challenge is
the independence of primary care contractors, such as GPs,
community pharmacists, dentists and practice nurses, and the need
to engage them in the clinical governance agenda. The fact that
PCTs do not have direct line management authority over individual
contractors means that the PCTs may be unwilling or unable to
remedy concerns about conduct or performance.
Independent contractors felt that they had received only limited
support from PCTs in helping them to embed clinical governance.
Where complaints about GPs were reported to their PCT, just over
half were routinely informed of the outcome by the PCT.
The report also found patient and public involvement as one of
the least well developed components of clinical governance, despite
the Department’s NHS Reform agenda confirming it as one of the most
important given the drive towards a patient-led NHS. The lack of
patient and public involvement is one of the greatest risks to
progress in improving quality and safety.
Patients and carers reported feeling excluded from aspects of
patients’ care. The most frequent complaint was that clinicians
were often insensitive or lacked appropriate knowledge about the
condition with which they were dealing. It was felt that they
tended to dispense treatment rather than care.
The NAO found some key barriers to future progress in
implementing clinical governance. PCT Chief Executives considered
the main risks to sustaining progress in clinical governance to be
lack of training in evidence-based practice; inability to benchmark
commissioning; the need for more effective joint working; and
leadership development. At the same time, front-line staff reported
day to day pressures including a lack of time, financing and staff
as barriers to implementing clinical governance.
Among the NAO’s recommendations are that the Department of
Health should explicitly address quality as a requirement in
developing its guidance for PCT commissioning. Strategic Health
Authorities should put in place effective oversight of
accountability arrangements so that clear lines of accountability
for quality and safety are in place throughout the system,
including the handling of potential conflicts of interest.
The new PCTs need to develop a strategy for engaging their
independent contractors in improving quality and safety. They
should provide leadership skills training and development for PCT
staff; seek the views of patients and demonstrate clearly that they
have built those views into the design and delivery of services;
and require all providers to have an incident reporting system
alongside an effective complaints handling process.
Sir John Bourn, head of the National Audit Office, said
today:
"Good clinical governance is essential if patients and
the public are to have greater confidence in the NHS. Whilst
Primary Care Trusts have made good progress in getting structures
and processes in place, there has been less progress in actually
implementing the fundamental components of clinical governance,
particularly patient and public involvement.
"Our recommendations provide a clear steer to enable the
new Primary Care Trusts to create a professional culture within
their organisations that accepts and promotes as the norm
accountability, the learning of lessons and the pursuit of high
quality, safe care for patients."
Notes for Editors
- The main components of clinical governance can be grouped as
follows:
- a. learning mechanisms
(clinical risk management, clinical audit, adverse incident
reporting, learning networks, continuing professional
development);
b. patient empowerment (better information, patient
complaints, patients’ views sought and patients involved throughout
the NHS); and
c. knowledge management (information and information
technology, research and development, education and
training).
- In July 2005 the Department announced, in Commissioning a
patient-led NHS a radical reconfiguration of PCTs with the aim
of aligning them more clearly with local authority social services
boundaries and changing them from providers of services towards
being patient-led and commissioning-led organisations. Alongside
this, the Government proposed the alignment of Strategic Health
Authorities (SHAs) with those of Government Office boundaries, with
a new role for SHAs in support of PCT commissioning and contract
management. Following consultation the number of SHAs was reduced
from 28 to 10 from 1 July 2006 and the number of PCTs was reduced
from 303 to 152 with effect from 1 October 2006. This report was a
unique opportunity to evaluate progress some four years after the
establishment of the first PCTs and identify the issues that the
new PCTs will need to focus on.
- Press notices and reports are available from the date of
publication on the NAO website, which is at
www.nao.org.uk. Hard copies can be obtained from
The Stationery Office on 0845 702 3474.
- The Comptroller and Auditor General, Sir John Bourn, is the
head of the National Audit Office which employs some 850 staff. He
and the NAO are totally independent of Government. He certifies the
accounts of all Government departments and a wide range of other
public sector bodies; and he has statutory authority to report to
Parliament on the economy, efficiency and effectiveness with which
departments and other bodies have used their resources.
Press Notice 01/07
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