Rapid Responses to:

PRIMARY CARE: Stephen Campbell, Martin Roland, and David Wilkin Primary care groups: Improving the quality of care through clinical governance BMJ 2001; 322: 1580-1582 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

The need for evidence based clinical governance

Alan Maynard, Karen Bloor   (6 July 2001)

The need for evidence based clinical governance 6 July 2001
Alan Maynard, Director, York Health Policy Group, MRC Research Fellow University of York, Karen Bloor Send response to journal: Re: The need for evidence based clinical governance	Dear Sir Improved clinical governance in primary care is important for patients, and a considerable managerial challenge. However, the article by Campbell, Roland and Wilkin1 offers remarkably little help to challenged managers in Primary Care Groups and Trusts. The authors fail to define quality, and offer few evidence-based insights into better management of processes and outcomes. They refer to 'an increasing move towards making information about quality of care more widely available' without telling us what 'information about quality' is. They cite evidence of greater investment in education and information sharing, but do not address the issues of its costs and benefits, ignoring systematic review evidence demonstrating 'small to moderate' benefits of audit and feedback, 2 'mixed effects' of local opinion leaders', 3 and no convincing evidence of the effectiveness of interprofessional education. 4 The authors appear to welcome the further development of financial incentives despite the uneven quality of earlier attempts to incentivise GPs (the 1990 contract introduced by Ken Clarke). Fees for service and other financial incentive schemes should only be used where the activity likely to be encouraged is demonstrably cost-effective. Whilst management of process in primary care is important - who wants grumpy GPs5 and unpleasant premises? - the key challenge for clinical governance in primary care is to establish integrated packages of care over time, with systematic measurement and evaluation of the functional status of patients wherever they are in the NHS. Primary care is largely a data-free environment. The activities described in Campbell et al may be encouraging to some, but for most should raise anxieties about rigour and the evidence base. As Lenin remarked: committees talk! Please can we move to cut the chat, and instead set simple goals for PCG/Ts, to be pursued by evidence-based interventions. Yours faithfully Professor Alan Maynard York Health Policy Group Karen Bloor MRC Research Fellow Department of Health Sciences And Clinical Evaluation University of York 1. Campbell S, Roland M, Wilkin D. Improving the quality of care through clinical governance. BMJ 2001;322:1580-2. 2. Thomson O'Brien MA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL. Audit and feedback: effects on professional practice and health care outcomes (Cochrane Review). In: The Cochrane Library, Issue 2, 2001. Oxford: Update Software. 3. Thomson O'Brien MA, Oxman AD, Haynes RB, Davis DA, Freemantle N, Harvey EL. Local opinion leaders: effects on professional practice and health care outcomes (Cochrane Review). In: The Cochrane Library, Issue 2, 2001. Oxford: Update Software. 4. Zwarenstein M, Reeves S, Barr H, Hammick M, Koppel I, Atkins J. Interprofessional education: effects on professional practice and health care outcomes (Cochrane Review). In: The Cochrane Library, Issue 2, 2001. Oxford: Update Software. 5. Di-Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. Lancet 2001; 357: 757-62