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Dear Editors

Ayres, Cooling and Maughan outline an ambitious Clinical Governance programme for the Nelson Primary Care Group (PCG) in their article in Public Health Medicine (October 1999).1 They are clearly aware of the scale of the task and they have chosen a dissemination method – practice visits – for which there is good evidence of benefit. Their project is in an early stage and inevitably there is no evidence yet of success, but they quote an early result which could signal a problem of practice compliance that could cause the whole project to fail: only 27% of practice team members returned their analysis sheets prior to the practice visits.

The East Sussex, Brighton and Hove Multi-professional Audit Advisory Group (MAAG) is assisting four PCGs in East Sussex with their Clinical Governance programmes by visiting each practice. We too are aware that collaboration with each practice is essential and have taken an approach that has a different feel from that of the Nelson PCG. In those visits our striking impression is that, frustrated and exhausted by the changes in primary care over the last decade, general practitioners and their fellow professionals have little enthusiasm for another set of requirements imposed on them from above, which they see as getting in the way of the business of looking after their patients. This realisation has led us to take a more bottom up approach. Rather than looking for indicators which can be monitored across the PCG, we say to each practice that it is for them to identify what the quality issues are for that practice, and to decide how to tackle them and how to monitor them. The role of the MAAG is to facilitate this process by giving each practice dedicated time during the practice visit and by describing processes which the practice might want to use to achieve its aims (adverse event meetings, risk management etc.). So far this is similar to the Nelson approach. What happens, however, if a practice identifies issues which do not coincide with PCG targets? We take the line that that is acceptable; any attempt at that stage to corral practices into attending to issues that they have not identified as important would reveal our bottom-up approach to be a fraud.

Like the Nelson PCG we do not yet have evidence that this approach will lead to improvements in health care. But our early impressions are that this way of working brings on board a number of practices who would be put off by a more managed approach. Furthermore, as practices develop their action plans during the hour and a half of our visit, they tend to raise the very issues that the PCG Clinical Governance Sub-committee would have chosen had it adopted a more top-down stance.

This leaves the question of what action should be taken if a practice was clearly failing its patients and did not intend to address that failure. This, in our view, is a matter for the Poorly Performing Doctor procedures which operate independently from our educational approach to clinical governance.

Reference:

1. Ayers, R Cooling, H Maughan. Primary Care Groups and Clinical Governance. Public Health Medicine 1999;1:47-52.