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GENERAL PRACTICE: Martin N Marshall Improving quality in general practice: qualitative case study of barriers faced by health authorities BMJ 1999; 319: 164-167 [Abstract] [Full text]

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Tackling data quality

Sheila Teasdale   (16 July 1999)

Organisational Culture

Dave Young   (18 July 1999)

SENSITIVITY OF PRACTITIONERS MAY BE A FUNCTION OF INSENSITIVITY OF MANAGERS

Diane Barnes   (19 July 1999)

Illuminating the Health Care Facade

David Kernick   (3 August 1999)

Barriers in the NHS - is there a pattern?

Alicia O'Cathain   (9 August 1999)

Tackling data quality 16 July 1999
Sheila Teasdale, CHDGP Team Manager Division of General Practice, University of Nottingham Send response to journal: Re: Tackling data quality	Martin Marshall's paper (Improving quality in general practice: qualitative case study of barriers faced by health authorities) in today's BMJ identifies one of the barriers for health authorities as the poor quality of clinical data available from general practices, especially data stored on the clinical computer system. It is important to recognise that data quality depends crucially on what use is made of it at its source. If data held on computer is used for the purposes of direct patient care, clinical audit, payment, and so on, those entering the data will pay attention to its completeness and accuracy. There are ways of tackling this particular barrier, however. The NHS Executive-funded CHDGP project (http://www.nottingham.ac.uk/chdgp) has been working on training local information facilitators over the last two years to help practices understand the benefits of improving data quality (and its effect on the quality of care), and also giving them practical help and guidance in better information management in the practice. It is hoped that this service will be rolled out to be available to all PCGs over the next two or three years. Sheila Teasdale CHDGP Team Manager Division of General Practice University of Nottingham
Organisational Culture 18 July 1999
Dave Young, GP Derby; CME Tutor Derby;NAGPT Sec. Derby Send response to journal: Re: Organisational Culture	Sir, I noted the seven barriers in Marshall's paper with interest. Sheila Teasdale picked up on data quality which is a relatively simple problem. It is the "sensitivity" of doctors that interests me and I feel that this issue is a good deal more difficult to resolve. It concerns power, defensiveness and professional autonomy. Coalface GPs have somehow to be persuaded that power sharing, appropriate delegation and performance review by peer reference is for the general good. Indeed how can any health authority strategic plan exist without this evolution? The literature on Organisational Behaviour places these problems in the domain of Organisational Culture* which may only change by stealth through experienced and respected leadership. Choose those health authority leaders with care, and with consultation, or we will merely end up as always with a new Organisational Structure failing to deliver real interprofessional collaboration. Sincerely David Young FRCGP *Organisational Behaviour Brooks (Pittman 1999)
SENSITIVITY OF PRACTITIONERS MAY BE A FUNCTION OF INSENSITIVITY OF MANAGERS 19 July 1999
Diane Barnes, GP medical adviser SANDWELL HA Send response to journal: Re: SENSITIVITY OF PRACTITIONERS MAY BE A FUNCTION OF INSENSITIVITY OF MANAGERS	One of the first things to strike me when starting in my post of GP Adviser was how little idea most health authority staff have of the realities of life as a practicing GP in Britain today. HA managers very rarely have a background in general practice and seem unaware of the clinical caseload or organisational burdens of running a practice. reading marshalls paper made me think that perhaps this lack of awareness contributes to the perceived sensitivity of practitioners by junior managers. As has been shown many times in patient studies, if you are not addressing their concerns, you are unlikely to get much of a response to whatever you are trying to do. No GP wants to provide a poor quality service to their patients. Perhaps a more in depth assessmnet of practitioners concerns and barriers to quality within the structure of primary care itself might contribute to reducing HA managers views of GPs as sensitive.
Illuminating the Health Care Facade 3 August 1999
David Kernick, Lead Research GP St Thomas Health Centre, Cowick Street, Exeter Send response to journal: Re: Illuminating the Health Care Facade	Dear Sir Illuminating the Health Care Façade Marshall's study of the barriers faced by Health Authorities in improving quality in general practice identifies a parallel track system which operates within the health care service. Its major characteristic is a dissonance between political/executive theory and practical reality. In theory, a linear, deterministic world based on the delivery of a structured health care system with an emphasis on targets and the measurement of outcomes. In practice, a world identified in this paper of "frantic activity; lack of skills and resources; little sense of team work or effective collaboration; considerable friction; apathy amongst a majority; tinkering around at the margins". Marshall's conclusion is "an over-riding impression of organisations under siege barely coping". Complexity theory is beginning to offer alternative perspectives and identify the adaptive and emergent properties of complex non-linear systems, an approach which may offer more relevant analytical and predictive insights. But until this new discipline evolves, Marshall must be congratulated for illuminating so succinctly the façade under which we operate as commissioners and providers of primary care. Yours faithfully Dr D P Kernick
Barriers in the NHS - is there a pattern? 9 August 1999
Alicia O'Cathain, Research Fellow MCRU, University of Sheffield Send response to journal: Re: Barriers in the NHS - is there a pattern?	Dear Editor Barriers in the NHS - is there a pattern? Marshall highlights seven barriers to improving quality in general practice (1). We used similar methods to study barriers to shiftiing services from secondary to primary care(2). It is worth highlighting the commonality of some of the barriers to these processes. We found that a lack of information about quality of care was a barrier but that this exists for secondary as well as primary care and for other issues such as the costs of services. Both hospital managers and general practitioners identified a lack of leadership from health authorities when attempting to shift services, echoing the theme running through Marshall's findings of a perceived lack of guidance from the NHS Executive to health authorities and from senior to junior managers. Finally, health authorities, hospital managers and general practitioners identifed the heterogeneity of general practice as a barrier to shifting services. Some of these barriers are real, for example the lack of relevant information in the NHS. However, some perceived barriers may need to be questioned. Is the NHS without leadership or do power distributions within the NHS make leadership impossible? Is heterogeneity in general practice a barrier or is the assumption of homogeneity the real barrier? 1. Marshall M. Improving quality in general practice: qualitative case study of barriers faced by health authorities. BMJ 1999;319:164-7. 2. O'Cathain A, Musson G, Munro J. Shifting services from secondary to primary care: stakeholders' views of the barriers. J Health Serv Res Policy 1999;4:154-160.