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Following serious concerns about clinical and organisational failures in the NHS during the 1990s (such as Alder Hey, the Bristol Royal Infirmary and Shipman), the Government identified the need for a more systematic approach to improving quality and safety in healthcare. In response, the Department of Health introduced a ten year programme to improve the overall standard of clinical care. Its centrepiece is clinical governance; a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care.
The Health Act 1999 (and 2003) introduced a statutory 'duty of quality' for services commissioned and provided by all NHS Trusts, for which trust Chief Executives are accountable. The Department expects this duty of quality to be discharged, at trust level, through the implementation of clinical governance. The Health Act 1999 also gave the Department the authority to establish Primary Care Trusts (PCTs) which are responsible for providing primary care services and commissioning services on behalf of their local health economy. In all some 303 PCTs were established between 2001 and 2002.
In July 2005, the Department identified the need for significant organisational change to enable primary care to respond more effectively to key national initiatives such as patient choice, payment by results and practice-based commissioning. The Department therefore announced that the number of PCTs would be reduced and reconfigured to 152, with effect from 1 October 2006.
On the basis of a report by the Comptroller and Auditor General,[1] we examined the Department's progress in implementing clinical governance in primary care; the lessons learned; and the risks that will need to be managed if quality and safety are to be embedded in the new PCTs. We took evidence from the Chief Executive of the NHS, the Deputy Chief Medical Officer and the NHS Director General of Commissioning.
We found that clinical governance is not as well established in primary care as in secondary care, largely because of the complexity of PCTs role in both commissioning and providing care; and the independence of contractors delivering healthcare, particularly General Practitioners (GPs). Primary care has also been slower in adopting a structured approach to quality and safety, evident for example in the lack of compliance with national systems reporting of clinical incidents. There is a lack of clarity between PCTs and their contractors as regards accountability for ensuring quality and safety, and scope for greater involvement of patients and the public in ensuring that primary care services are safe and of high quality.
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