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

Linda Gask,Anne Rogers,Stephen Campbell,Rod Sheaff

doi:10.1186/1472-6963-8-63

Abstract

BackgroundLittle 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'.MethodsFramework analysis, based on the Normalisation Process Model (NPM), of attempts over a five year period to develop clinical governance for primary mental health services in Primary Care Trusts (PCTs). The data come from a longitudinal qualitative multiple case-study approach in a purposive sample of 12 PCTs, chosen to reflect a maximum variety of organisational contexts for mental health care provision.ResultsThe constant change within the English NHS provided a difficult context in which to attempt to implement 'clinical governance' or, indeed, to reconstruct primary mental health care. In the absence of clear evidence or direct guidance about what 'primary mental health care' should be, and a lack of actors with the power or skills to set about realising it, the actors in 'clinical governance' had little shared knowledge or understanding of their role in improving the quality of mental health care. There was a lack of ownership of 'mental health' as an integral, normalised part of primary care.ConclusionDespite some achievements in regard to monitoring and standardisation of prescribing practice, mental health care in primary care seems to have so far largely eluded the gaze of 'clinical governance'. Clinical governance in English primary mental health care has not yet become normalised. We make some policy recommendations which we consider would assist in the process normalisation and suggest other contexts to which our findings might apply.

Highlights

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
'they may be a perfectly competent general practitioners (GPs) but they just haven't got that level of training to know that, okay, that person may calm down if you just spend a bit longer with them, they maybe haven't got that level of skill, maybe they're frightened, may be they just don't want to do it, it's a mixture of things
'So we have a cohort of patients- service users who are too severe for the counselling service, don't meet the criteria for the CMHT specialist services and GPs are finding they don't quite know what to do with these patients...So some of our GPs have had training and they're very interested and they can do short-term interventions but the vast majority of GPs out there wouldn't have a clue.' [Site H mental health lead Primary Care Trusts (PCTs)]

Summary

Introduction

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'. One specific approach in the international 'quest for quality' in health care has been a standardization of practices in medicine. Less attention has been given to the organisational as opposed to the technical aspects of implementation or on implementation in clinical areas such as mental health where there is a high level of indeterminacy and contestability (i.e. the tacit private and less technical aspects of clinical judgement). The data come from the English National Health Service (NHS), the organisation of primary mental health care there is sufficiently similar to certain other health systems and to the provision of care for other care groups (see below) to give the findings wider relevance

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Conclusion