Clinical Governance in Primary Care

Tim Van Zwanenberg, Jamie Harrison

• Publisher: CRC Press
• Year: 2018
• eBook ISBN: 9781315344690
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Patient-Centered Care Series Series Editors: Moira Stewart Judith Belle Brown and Thomas R Freeman Primary care clinicians are often unfamiliar with new and effective methods for detecting substance abuse problems in their earliest stages and the majority of patients with substance abuse problems remain undiagnosed. Substance Abuse is written by primary care clinicians and focused to meet the needs of primary care providers demonstrating how the patient-centered clinical method can assist clinicians in learning how to diagnose this complex psychosocial disorder. This book describes how to use state-of-the-art screening techniques and how to understand and motivate patients to decrease or eliminate harmful use of alcohol and drugs. It presents the latest scientific findings and gives examples of using a patient-centered approach as well as describing specific communication skills with samples of dialogue illustrating their use in helping substance-abusing patients. This is essential reading for all family doctors paediatricians gynaecologists psychiatrists nurses social workers psychologists and all clinicians whose practices include substance abusing patients. It will also appeal to counsellors education personnel and all professionals working with substance abusing individuals. For more information on other titles in this series please click here

PART 1

Setting the scene

CHAPTER 1

Clinical governance: a quality concept

Sir Liam Donaldson

If you always do what you always did, you always get what you always got.

Granny Donaldson

This chapter defines clinical governance and describes its origins. Clinical governance involves ensuring that quality assurance, quality improvement and patient safety are part of the everyday routines and practices of every healthcare organisation and every clinical team. Recognising the importance of organisational culture to the success of clinical governance in the new primary care trusts is vital.

Introduction

Clinical governance was one of the central ideas in a range of proposals to modernise the National Health Service (NHS) contained in a White Paper produced by the incoming Labour government in the late 1990s.¹

From the post-war years at the beginning of the NHS, through the 1960s, to the periods of cost containment in the 1970s and 1980s, and into the era of health system reform of the early 1990s, concepts and methods of quality in healthcare underwent a quiet revolution.

In the early years of the NHS, quality was implied, assured by the training, skill and professional ethos of its staff. Standards of care were undoubtedly high for their time, and the nationalisation of health services and facilities brought about by the creation of the NHS undoubtedly improved many past inequalities in access and provision. However, quality was essentially viewed through paternalistic eyes, with the patient a passive recipient of care. The 1960s saw a growth in thinking about concepts of quality, much of it emanating from North America, notably Donabedian’s quality triad (structures, processes and outcomes),² which has endured over more than 30 years. Despite these more sophisticated notions of quality emanating from academics and health service researchers, the vision was seldom realised in practice.

By the 1980s, management was beginning to become established within the health systems of many parts of the world. In the NHS, accountability for the performance of a health organisation came as career general managers replaced health service administrators.³ Initially resented by many professional staff, management gradually extended to the running of clinical services with the creation of clinical directorates and budgets.

The desire to build on these trends led, in the late 1980s and early 1990s, to attempts to design incentives for efficiency and quality into the NHS system itself. The resulting internal market for public healthcare in the UK split responsibility for the purchasing and provision of healthcare between health authorities and general practice fundholders (which were allocated budgets to purchase) and NHS trusts (which competed to provide services and gained a share of these budgets).⁴ The theory was that the internal market would simulate the behaviour of a real market and drive up quality while reducing costs. This concept of quality improvement remained controversial, and many professional staff working within the NHS were not confident that it could or did work.

During the 1990s, a series of high-profile instances of failed care among NHS service providers caused widespread public and professional consternation and sustained media criticism. During this time, incidents and events within local health services became public in a way that would not have been conceivable in the early years of the NHS. Traditional deferential attitudes towards doctors and others in positions of authority were changing as UK society became more consumer orientated. This was reflected in the way in which the media challenged and accused health service providers that had been responsible for incidents involving poor standards of care in which patients had been harmed or had died. Many such events in the past would not have seen the light of day at all, or if they did would have been explained away in general terms and quickly forgotten.

In the media climate of the late twentieth century, patients’ deaths were no longer mishaps or unfortunate accidents. They were scandals in which, although the plight of the victim was highlighted, as much emphasis was placed on identifying those perceived as responsible.

The watershed in public and professional attitudes towards serious failures in the standards of healthcare was undoubtedly the events which took place in the Bristol children’s heart surgery service during the late 1980s and early 1990s. Bristol appeared to be a statistical outlier for mortality after surgery, particularly in relation to one type of operative procedure. Despite concerns within the hospital, attempts to address and resolve the problems of clinical performance were inadequate. It was left to a ‘whistleblower’ – an anaesthetist – to bring the matter to external attention. At one point the surgeons were asked not to proceed with a heart operation on a particular child, but they judged the risks to be acceptable and proceeded, only for the child to die post-operatively.

What led to particular outrage when these events became public through disciplinary hearings and media reports⁵ was the extent to which clinical decisions were being made on behalf of parents rather than with them. A major public inquiry into the Bristol affair⁶ drew attention to a ‘club culture’ which was detrimental to high-quality care.

This and other cases of failed care^7,8 gave the impression of an NHS culture which at times subordinated patient safety to other considerations, such as professional loyalty, an unwillingness to challenge traditional practices and a fear of media exposure. However, they did pave the way to major reform in the way in which quality and safety were managed within the NHS.

Organisations and people

The NHS underwent a major process of reform, beginning in 1998,¹ which focused on developing primary care as the organisational locus for assessing and meeting local health needs and for commissioning and funding health services for their populations.⁹

NHS reform has also placed an emphasis on modernisation – of facilities and infrastructure, of professional practice, of organisational systems and ways of working and of attitudes towards the patient as a consumer of care.

At the heart of the process of reform has been the establishment and implementation of a clear framework for quality. This has involved setting clear standards for the NHS as a whole, formulated through a variety of mechanisms, but most importantly a National Institute for Clinical Excellence (NICE)¹⁰ and a series of National Service Frameworks covering priority areas of care (e.g. coronary heart disease and mental health).^{11, 12 and 13}

It has created robust mechanisms of inspection. The Commission for Health Improvement (or, from 2003, the Commission for Health Audit and Inspection) visits local NHS organisations, reviews quality and makes public reports.^14,15

The quality framework also requires healthcare organisations to fulfil a statutory duty of quality.¹⁶ This means implementing satisfactory ‘clinical governance’ arrangements. The concept of clinical governance^17,18 has been the driving force behind improvement in local NHS services. It seeks to establish in every healthcare organisation the culture, leadership, systems and infrastructure to ensure that quality assurance, quality improvement and patient safety activities are part of the everyday routines of every clinical team. A national clinical governance development team has undertaken a major programme of change management to fulfil this aim.^19,20

Clinical governance is essentially an organisational concept. This is made clear by the way in which it was first defined, as ‘a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish’.¹⁶

The elements of accountability, of ensuring that positive outcomes are delivered and of creating the right environment for good practice to flourish are all organisational features. Organisational culture – what it constitutes, what determines whether it is beneficial and how to change it – has not on the whole been studied systema...

Table of contents

• Cover
• Title Page
• Copyright Page
• Dedication Page
• Contents
• Foreword
• Preface
• List of contributors
• About this book
• Acknowledgements
• Part 1 Setting the scene
• Part 2 Clinical governance in practice
• Part 3 Exploring the future
• Index