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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
Competing interests:
No competing interests
06 July 2001
Alan Maynard
Director, York Health Policy Group, MRC Research Fellow
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
Competing interests: No competing interests