Managing governance programmes in primary care: lessons from case studies of the implementation of clinical governance in two primary care trusts

Abstract

This thesis applies a conceptual framework to determine the key insights that complex adaptive system theories provide to the novel challenges facing the introduction of clinical governance in two English Primary Care Trusts (PCTs). It presents empirical research on governance through qualitative case studies of the implementation of clinical governance arrangements within two North West PCTs, during a time of flux and change. The study is located within the English
National Health Service (NHS) between 1999 and 2005. The Department of Health (DH) describes clinical governance as an evolving organisational structure and process that: "Provides NHS service organisations and individual health professionals with a framework within which to build a single, coherent local programme for quality improvement." (Department of Health, 1998a p.33).
The thesis reviews the literature on governance models, quality improvement frameworks and complexity-based approaches to establish an appropriate theoretical base to the study. The literature relates to the nature of PCTs as a networked structure with autonomous parts. This approach contextualises the origins of clinical governance and related quality concepts. The study encompasses the introduction of the most recent contractual arrangements for primary care in 2004
(NHS, 2004). The research question posed is: "How can governance of quality improvement programmes be managed in a way that is appropriate to the characteristics of English PCTs?"
Detailed evidence demonstrates the nature of local clinical governance programmes and the implementation within two North West PCTs, from the perspective of those involved. The results of the analysis show that multiple perspectives were taken into account in the decisions made about the content and delivery of clinical governance programmes. It is suggested that the application of a complex adaptive system conceptual framework helped to provide insight and interpretation of
the accounts of those involved in the two case studies. The variation in clinical governance approaches across the two PCTs is explained in part by the strategic and policy orientation of each PCT. The results are consistent with the argument that the characteristics of quality improvement programmes in two PCTs go beyond linear based concepts, and can be thought of as real-world exemplars of the emergent properties of complex adaptive systems. In practice, the lessons learned
provide opportunities to inform future management approaches to quality improvement programmes in PCTs.