Intended for healthcare professionals

Rapid response to:

General Practice

New Zealand's independent practitioner associations: a working model of clinical governance in primary care?

BMJ 1999; 319 doi: (Published 20 November 1999) Cite this as: BMJ 1999;319:1340

Rapid Response:

Independent practitioner associations and primary care groups

Dear Editor,

In asking what lessons Primary Care Groups (PCGs) can
learn from New Zealand's independent practitioner associations Malcolm and
Mays appear to be underestimating the opportunities that PCGs bring and
the progress made so far.1

They correctly state that from April 1999 the Chief Executive of each NHS
Trust and the Chairperson of each PCG became accountable not only for the
financial health of the organisation, but also for the quality of the
clinical services it delivers. This is a fundamental change in the
delivery of healthcare in this country, which provides us with an
opportunity to change the culture of the NHS.
Through Primary Care Investment Plans PCGs have both an opportunity and an
obligation to place quality issues at the centre of primary care
development. As PCGs develop Care Pathways with secondary care providers
in the process of commissioning they can begin to set standards for
secondary care also. Rather than clinical governance being interpreted in
a restricted manner that excludes the management of resources, as the
authors suggest, the two areas are inseparable.

The authors also suggest that managers and clinicians are reluctant to set
priorities in the use of resources. The local Health Improvement
Programme (HImP) inevitably sets targets and priorities. The HImP allows
PCGs to improve the quality of clinical services in areas of particular
need for that locality.

Clinical governance is resulting in a change to a culture that emphasises
peer review, risk management, significant event analysis and personal and
organisational development.2 3 The organisation of PCGs facilitates this
change, for example the appointment of PCG Pharmacists and the development
of an IM&T infrastructure encourages and supports cross-practice
audit. A similar culture change appears to be taking place in New Zealand
and the lessons learnt in this process could be usefully shared.
Because the financial responsibility of a PCG is wider than that of an
independent practitioner association in New Zealand, the scope for
improving the quality of clinical services is also wider. In addition
PCGs work with other agencies such as Social Services, local councils and
the voluntary sector. This allows them to improve the health of a
population rather than being restricted to improving the health care of
that population.

PCGs are in a far stronger position to deliver the clinical governance
agenda and have made more progress than perhaps the authors appreciate.
Indeed, following the recent change in government in New Zealand, it might
be argued that PCGs could provide a new model of primary care for that

Huw Charles-Jones
General Practitioner

Upton Village Surgery, Wealstone Lane, Upton, Chester, CH2 1HD

Tom Butler
Chief Executive

Chester City PCG, 21a Garden Lane, Chester, CH1 4EN


1. Malcolm L, Mays N. New Zealand's independent practitioner
associations: a working model of clinical governance in primary care? BMJ
1999; 319: 1340-2.

2. Scally G, Donaldson LJ. Clinical Governance and the drive for
quality improvement in the new NHS in England BMJ 1998; 317: 61-5.

3. Baker R, Lakhani M, Fraser R, Cheater F. A model for clinical
governance in primary care groups. BMJ 1999; 318: 779-83.

Competing interests: No competing interests

03 December 1999
Huw Charles-Jones