Exit, voice, governance and user-responsiveness: the case of English primary care trusts

Hirschman contrasts exit and voice as 'recuperation' mechanisms for making organisations responsive to users. However, the emergence of health-care quasi-markets and of network governance structures since Hirschman necessitate revising his theory, for they complicate the relationships between governance structures and recuperation mechanisms. Using a case study of nine primary care trusts (PCTs), this paper analyses the recuperation mechanisms, governance structures and relations between them in primary care in England. User voice can be exercised through dedicated networks besides hierarchies. As well as the 'user exit' described by Hirschman, two new 'exit' mechanisms now exist in quasi-markets. Commissioner exit occurs when a third-party payer stops using a given provider. Professional proxy exit occurs when a general practitioner (GP) fund-holder (or analogous budget-holder) behaves similarly. Neither exit mechanism requires the existence of mechanisms for user exit from healthcare purchasers, provided strong voice mechanisms exist instead to make commissioners responsive to users' demands. Establishing such voice mechanisms is not straightforward, however, as the experience of English PCTs illustrates.     

Implementing continuous quality improvement in primary care: implications for preventive services

The implementation of CQI must be done in a manner that capitalizes on the challenges of primary care, including the professional autonomy of the physician, the availability of data, issues of cost and efficiency of service, and the expanding role of patient expectations in quality care. Analysis of these factors is based on an ongoing study designed to help community-based primary care practices increase the utilization of prevention and early detection services offered to patients.     

Implementing practice guidelines through clinical quality improvement

The American health care delivery environment is changing. As provider-at-risk payment strategies become increasingly dominant, they will force health care providers to replace old strategies that measured and managed revenues with new strategies that measure and manage costs. Quality improvement (QI) theory provides a set of tools to do exactly that--to understand, measure, and manage health care delivery processes and their associated costs. As a methodology for process management, QI theory merges case management, practice guidelines, and outcomes research into a single coordinated effort. It appropriately redirects management focus to care delivery processes, rather than to physicians. It also defines and illustrates a set of principles by which health care administrators can constructively team with physicians to find and document the best patient care outcomes at the lowest necessary cost, using QI-based practice guidelines as a decision support and measurement tool.     

A subtle governance: 'soft' medical leadership in English primary care

In many countries governments are recruiting the medical profession into a more active, transparent regulation of clinical practice. Consequently the medical profession adapts the ways it regulates itself and its relationship to health system managers changes. This paper uses empirical research in English Primary Care Groups (PCGs) and Primary Care Trusts (PCTs) to assess the value of Courpasson's concept of soft bureaucracy as a conceptualisation of these changes. Clinical governance in PCGs and PCTs displays important parallels with governance in soft bureaucracies, but the concept of soft bureaucracy requires modification to make it more applicable to general practice. In English primary care, governance over rank-and-file doctors is exercised by local professional leaders rather than general managers, harnessing their colleagues' perception of threats to professional autonomy and self-regulation rather than fears of competition as the means of 'soft coercion'.     

Organization and financing of British primary care groups and trusts: observations through the prism of US managed care

There are many parallels between the UK's new primary care commissioning organizations and the managed care organizations and integrated delivery systems that have evolved in the USA over the last three decades. Those building primary care groups and trusts (PCG/Ts) can learn from the American experience with health maintenance organizations and other similar entities. These lessons should also be relevant to those in other countries interested in establishing innovative primary care led organizations within the broader structure of a socialized health care system. Following an overview of US managed care and an update of the progress of the UK's PCG/Ts, we go on to suggest how new consortia of PCG/Ts might be developed and how budgets and provider incentives could be structured. This international comparison suggests that the resources needed to support the development of effective PCG/Ts will be considerable, as will the need to maintain organizational flexibility. If primary care organizations are to thrive, it will be essential to develop truly integrated budgets for primary and secondary care.     

Methodological issues in the development of a national database for primary care groups and trusts

At the National Primary Care Research and Development Centre (NPCRDC) we have constructed a national database for all primary care groups (PCGs) in England. At its core, the database links information about population socio-economic and demographic characteristics to generic health status and to the organisation, resourcing and activities of general practice. In this paper we describe and discuss the problems with linking these data, and with defining the boundaries and the local populations of PCGs, given that they have been established on the basis of administrative expediency rather than geographical coherence. We then consider the implications of these difficulties for needs assessment in primary care groups.     

The dangers of managerial perversion: quality assurance in primary health care

The promotion of primary health care (PHC) at the Alma Ata conferencehas been followed by a variety of managerial initiatives insupport of the development of PHC. One of the more promisingvehicles has been the implementation of quality assurance mechanisms.This paper reviews recent examples of this genre and arguesthat the thrust of both primary health care and quality assuranceare in danger of being distorted by a rather antiquated approachto management.     

Impact on health authorities of the introduction of primary care groups and trusts.

The National Tracker Survey of Primary Care Groups (PCGs) and Trusts (PCTs) in the UK has provided evidence about how PCGs and Health Authorities managed the transition to PCTs. This was a major challenge for both organizations. Devolution of responsibilities was dependent on the capacity and readiness of PCGs to take on their new roles. The development of good working relationships between the principal parties was critical to this process. Health Authorities started to let go and all put in place basic mechanisms for holding PCGs to account in their first year. However, a number of PCGs regarded their Health Authority as authoritarian. Most Health Authorities were found to have started to provide information to support PCGs in their core functions, but resources were frequently problematic. It will be important for Health Authorities and PCG/Ts to negotiate a shared view of their respective roles and responsibilities. The future role of Health Authorities in providing strategic leadership for their local health economies was not sufficiently well defined or understood.     

Beyond the limits of clinical governance? The case of mental health in English primary care

Background  

Little research attention has been given to attempts to implement organisational initiatives to improve quality of care for mental health care, where there is a high level of indeterminacy and clinical judgements are often contestable. This paper explores recent efforts made at an organisational level in England to improve the quality of primary care for people with mental health problems through the new institutional processes of 'clinical governance'.     

Clinical governance in primary care groups: the feasibility of deriving evidence-based performance indicators

OBJECTIVES: To test the feasibility of deriving comparative indicators in all the practices within a primary care group. DESIGN: A retrospective audit using practice computer systems and random note review. SETTING: A primary care group in southern England. SUBJECTS: All 18 general practices in a primary care group. MAIN OUTCOME MEASURES: Twenty six evidence-based process indicators including aspirin therapy in high risk patients, detection and control of hypertension, smoking cessation advice, treatment of heart failure, raised cholesterol levels in those with established cardiovascular disease, and the treatment of atrial fibrillation. Feasibility was tested by examining whether it was possible to derive these indicators in all the practices; the problems and constraints incurred when collecting data; the variations in indicator values between practices in both their identification of diseases and in the uptake of various interventions; the possible reasons for these variations; and the cost of generating such indicators. RESULTS: It was possible to derive eight indicators in all practices and in three practices all 26 indicators. The median number of indicators derived was 12 with two practices able to generate eight. There was considerable variation in the use of computers between practices and in the ability and ease of various practice computer systems to generate indicators. Practices varied greatly in the identification of diseases and in the uptake of effective interventions. Variation in identification of ischaemic heart disease could not be explained by a higher prevalence in practices with a more deprived population. The cost of generating these indicators was 5300 Pounds. CONCLUSION: Comparative evidence-based indicators, used as part of clinical governance in primary care groups, could have the potential to turn evidence into everyday practice, to improve the quality of patient care, and to have an impact on the population's health. However, to derive such indicators and to be able to make meaningful comparisons primary care groups need greater conformity and compatibility of computer systems, improved computer skills for practice staff, and appropriate funding.     

Soft governance and attitudes to clinical quality in English general practice

OBJECTIVES: English primary care organisations (primary care groups and trusts - PCGs, PCTs) were, and are, responsible for the quality of general practice but lack hierarchical structures and, frequently, contractual relationships through which to influence it. The theory of soft governance describes how managers can influence professional practice by other means. This study examines the hypothesis that PCG/Ts have used 'soft' clinical governance. METHODS: Survey in 2000/01 of general practitioners' (GPs') attitudes, opinions and self-reported activity in six PCGs and six PCTs using a semi-structured mailed questionnaire. To assess how representative respondents were of English GPs generally, four questions from a national sample survey of English GPs were included and the results compared. RESULTS: Responses were obtained from 437 (52%) GPs. They most often mentioned the technical aspects of clinical governance. Managerial, policy and resourcing implications were next most frequently mentioned, usually in unfavourable terms. Most GPs reported that their clinical practice had changed because of clinical governance activities, although nearly 40% also reported little difference in the quality of care provided. The National Service Framework for coronary heart disease influenced practice independently of PCG/T activities. CONCLUSION: English primary care organisations are exercising soft governance (although not by that name) over some but not all aspects of GPs' clinical practice. However, this soft governance is complex, not easy to sustain and appears hard to extend beyond essentially clinical domains.     

Quality assurance in primary care

We describe an outcome-based approach to quality assurance in primary care and present data from an initial study made to explore its usefulness. A questionnaire, which asked patients to report on the status of their problem in terms of the amount of symptoms, activity limitation, and anxiety it caused, was mailed to adults who had been seen a month previously for upper respiratory tract infection, sore throat, or urinary tract infection. Outcome standards developed for these conditions indicated that patients should report no symptoms, activity limitation, or anxiety. Of the 127 patients who responded, 17% failed to meet these standards. A review of their medical records was conducted to test the value of using substandard problem-status outcome as an indicator of important deficiencies in care. Definite deficiencies in care were found for 57% of those with substandard outcomes and for 2% of those with acceptable outcomes. Corrective action was judged likely to benefit 95% of the cases with substandard outcome and 7% of those with acceptable outcomes. Data from the medical records were insufficient to explain the reasons for substandard outcome in all cases, thus emphasizing the need to examine also patient- and system-related variables not evident in the medical record. An approach to quality assurance that is based on measuring outcome and then determining the reasons for poor outcome is useful for uncovering correctable errors in the delivery of primary care. In order for the approach to be effective in improving care, the outcome measures used must be sensitive to the role of primary care in assisting patients to resolve health problems.     

Understanding team-based quality improvement for depression in primary care

OBJECTIVE: To assess the impacts of the characteristics of quality improvement (QI) teams and their environments on team success in designing and implementing high quality, enduring depression care improvement programs in primary care (PC) practices. STUDY SETTING/DATA SOURCES: Two nonprofit managed care organizations sponsored five QI teams tasked with improving care for depression in large PC practices. Data on characteristics of the teams and their environments is from observer process notes, national expert ratings, administrative data, and interviews. STUDY DESIGN: Comparative formative evaluation of the quality and duration of implementation of the depression improvement programs developed by Central Teams (CTs) emphasizing expert design and Local Teams (LTs) emphasizing participatory local clinician design, and of the effects of additional team and environmental factors on each type of team. Both types of teams depended upon local clinicians for implementation. PRINCIPAL FINDINGS: The CT intervention program designs were more evidence-based than those of LTs. Expert team leadership, support from local practice management, and support from local mental health specialists strongly influenced the development of successful team programs. The CTs and LTs were equally successful when these conditions could be met, but CTs were more successful than LTs in less supportive environments. CONCLUSIONS: The LT approach to QI for depression requires high local support and expertise from primary care and mental health clinicians. The CT approach is more likely to succeed than the LT approach when local practice conditions are not optimal.