Accountability for clinical governance: developing collective responsibility for quality in primary care

Pauline Allen's excellent article 1 highlights the vital goal of
clinical governance in primary care 'to foster a new sense of collective
responsibility for the quality of care' provided by all practitioners.
She also warns that 'establishing and maintaining horizontal and upwards
accountability' in new Primary Care Trusts is 'likely to be costly'. We
would like to share our recent learning curve with general practitioners
for a mental health quality improvement project, because it may hold
lessons for other primary care initiatives. For four years Barking and
Havering Health Authority has been conducting an investigation of
deliberate self-harm (DSH) in two boroughs, identifying cases through
their contacts with Accident and Emergency departments and tracing these
patients' involvement with other services, including general practice,
before and after self harm.

We are currently tracing the clinical needs and interventions for a
cohort of 60 local young people presenting with DSH. These young and
vulnerable people are tracked through many treatment settings. Relative
to all other settings, investigation of general practice care required
much more assertive and time-consuming effort for limited quality data.
In five months (January-May 2000) information could only be obtained for
30/60 children (50%) using a frequently repeated cycle throughout this
period, of letters, phone calls, faxes, visits and the use of
intermediaries like practice managers and the director of Public Health.
This effort was put in by an experienced community researcher who was
already familiar with the 'territory'.

Potentially important Public Health findings could have been produced
by an efficient collaboration with general practitioners. Out of 30 young
people eventually traced, some information on primary care appointments in
the year before A&E attendance for DSH (index episode) was available
for 24 (20 females and 4 males, age range 9-16 with a median of 15 years).
Seventy six attendances and five did-not-attends were recorded in some
form (handwritten notes, of variable legibility) for the 12 months before
the index episode. The doctors involved rarely described the mental
health state in these young patients- only two out of 76 appointments
mentioned any psychological problems. Yet we knew from other sources that
at least seven out of these 24 had previous histories of DSH and five had
been treated by the child and adolescent mental health service.

General practitioners need to be informed about DSH and the mental
health needs of young people. They see these patients and their families
over many years (median 14.7 years' history for these children). They
also share the care of these patients with many other colleagues, so
'horizontal accountability' really is 'the bedrock for effective clinical
governance' 1 . Health events linkage in primary care provides a window
into widespread problems of assessment, quality of records, access and
sharing that currently limit service development for PCTs.

1. Allen P. Accountability for clinical governance: developing
collective responsibility for quality in primary care. BMJ 2000; 321: 608-
611.

TOM CLARKE

Research Fellow

Primary Care and Population Sciences,
Royal Free Hospital, London NW3 2PF.

CHRIS WATTS

Director of Public Health

Barking and Havering Health Authority,
Barking IG11 8EY

WOODY CAAN

Public Health Specialist in Research and Development

Barking and Havering Health Authority,
Barking IG11 8EY.

LORRAINE SHERR

Reader
Primary Care and Population Sciences,
Royal Free Hospital, London NW3 2PF.

(No competing interests)