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Improving quality and safety – Progress in implementing clinical governance in primary care: Lessons for the new Primary Care Trusts

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.

"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."

Sir John Bourn, head of the National Audit Office

Notes for Editors

  1. The main components of clinical governance can be grouped as follows:
  2. 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).
  3. 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.
  4. Press notices and reports are available from the date of publication on the NAO website, which is at Hard copies can be obtained from The Stationery Office on 0845 702 3474.
  5. 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.


PN: 01/07