Clinical governance for public health professionals

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1 Journal of Public Health Medicine Vol. 21, No. 4, pp Printed in Great Britain Clinical governance for public health professionals J. A. G. Paris and K. M. McKeown Summary This paper examines the issues specific to clinical governance for public health professionals. It highlights three levels at which public health is capable of promoting clinical governance: within the specialty of public health, across other National Health Service (NHS) organizations and as part of the public health responsibilities of health authorities. Current work is reviewed, and its focus on hospital and community NHS Trusts is noted. Current thinking on the introduction of clinical governance into clinical practice is interpreted to provide a framework for its development in public health professional practice. Keywords: Public health, clinical governance Introduction The election of a Labour Government in 1997 signalled the start of another period of change for the National Health Service (NHS). One aim of the new administration is to deliver a new approach to quality. 1 The Government has called the approach clinical governance and defined it as a framework through which National Health Service (NHS) organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care can flourish. 2 There are a number of publications that summarize aspects of clinical governance. 3 9 Some offer an exploration of the ideas, perspectives and concepts behind clinical governance, whereas others provide tools, instruments or guides to the implementation of clinical governance. Interestingly, although some of the authors are public health trained, the current literature says little about the application of clinical governance to public health practitioners as either members of a specialism or employees of a health authority. This paper attempts to begin rectifying that omission. Current policy in the United Kingdom The Government s view is that progress on delivering clinical governance within the NHS must be judged against six criteria. 1 These can be posed as questions: Is there an open and participative culture in which education, research and the sharing of good practice are valued and expected? Is there a commitment to quality that is shared by staff and managers and supported by local resources? Is there a tradition of active working with the public? Is there an ethos of multi-disciplinary working at all levels? Is there regular board level discussion of all major quality issues and strong leadership from the top? Is good use made of information to plan and assess progress? These six questions will be used to help guide the discussions in this paper. Most current British studies concentrate on the potential impact of clinical governance on NHS Hospital and Community Trusts. There has been relatively little discussion of the implications of the Government s statement that clinical governance will apply to all Health Authorities, Primary Care Groups, Primary Care Trusts, and to NHS Trusts. 1 Although clinical governance is the responsibility of all managers within the NHS, public health specialists have a particular interest. This is consistent with their responsibilities to maintain and improve the health of the population. 10 If this general duty is to be met, public health specialists must enhance the determinants of health and improve the quality of interventions for ill-health. This latter responsibility should operate at different levels: to develop clinical governance within the specialty of public health (level one); to support the clinical governance strategies of other NHS organizations (level two); and to promote an appropriate approach to clinical governance within health authorities (level three). Work at levels one and three could provide experience and enhance credibility for work at level two. Level one: clinical governance within the specialty of public health At level one, there is much on which to build. Forsythe has North West Lancashire Health Authority, Wesham Park Hospital, Derby Road, Wesham, near Kirkham PR4 3AL. J. A. G. Paris, Consultant in Public Health Medicine K. M. McKeown, Health Development Manager Address correspondence to K. M. McKeown. Faculty of Public Health Medicine 1999

2 CLINICAL GOVERNANCE FOR PUBLIC HEALTH PROFESSIONALS 431 commented on how to deal with a public health doctor whose performance gives cause for concern. 4 Procedures for dealing with poorly performing doctors have already been defined by the General Medical Council 11 and interpreted for public health physicians. 4 The General Medical Council, at the time of writing, is due to publish Management in health care the role of doctors (J. O Brien, personal communication, 1999) as an addition to their recent publications, The duties of doctors 12 and Maintaining good medical practice. 13 The General Medical Council s advice will concentrate more on aspects of doctors in management than on the broader range of responsibilities of public health practitioners. The current system of public health audit, organized by consortia of public health departments within health authorities, and continuing professional development, organized by the Faculty of Public Health Medicine, could be developed. Professional colleagues would be enabled to keep up-to-date, have access to information on clinical effectiveness, be supervised appropriately and be subject to an appraisal system with other staff. Audit and continuing medical education are just two of 11 key elements identified, within clinical governance, by the British Association of Medical Managers. 5 The others, presented for clinicians, are: effective management of poorly performing clinical colleagues; risk management; evidence-based clinical practice, developing guidelines and protocols; development of clinical leadership skills; audit of consumer feedback; health needs assessment; managing the performance of colleagues, developing guidelines and protocols; accreditation of hospitals, community providers and primary care practices; continuing professional development for all staff. It would seem sensible therefore to combine and expand the existing public health structures within a holistic approach to clinical governance. Such a structure would exist under the auspices of the Faculty of Public Health Medicine and be accountable through the regional advisers to the Faculty Board as part of professional self-regulation. Clinical governance guidance emphasizes multi-disciplinary team working at all levels in the organisation 1, and many public health directorates now employ a wide range of clinical and non-clinical professionals. There is a clear need for the inclusion of representatives of public health professionals and groups not at present represented within the Faculty. For these other public health professionals individual professional selfregulation would be provided either by their own professional organization or, where this is absent, through a strengthened Multi-disciplinary Public Health Forum. This arrangement alone may not be enough. It is important to ensure that those common values underpinning effective multi-disciplinary team working at all levels in the organisation are reflected in the structures, formal and informal, used to support public health clinical governance. To this end it is vital that all public health organizations, including the Faculty, co-operate. Level two: clinical governance strategies of other NHS organizations Work at level two is beginning, and there are already useful frameworks and tools. Four examples illustrate this. First, the National Primary Care Research Centre has produced a handbook for Primary Care Groups and others in general practice. 14 This provides a framework for the introduction of clinical governance into practice, including standards and the General Practice Assessment Survey, a tool for assessing patients perceptions of the service. Second, the Royal College of General Practitioners has issued its own booklet offering advice, on clinical governance and the use of quality markers, for primary care in England and Wales. Third, a workshop, attended by one of the authors at the 1998 Clinical Audit in the National Health Service Conference for Primary Care, identified three key areas of peer appraisal essential to establishing and maintaining a high-quality service; namely, those that are patient centred, service centred and organization centred. The equivalent for public health departments would be the appraisal of individual public health professionals, the public health department as a whole and the Health Authority. Fourth, in North West Lancashire a research team, including one of the authors, has developed a model of nurse-based service development in primary care, which reflects the principles of clinical governance. This COPE model has four key areas of activity to promote sustainable service development, namely: clinical to cover the development and maintenance of clear clinical guidelines; organizational to ensure that the needs of the organization match the clinical demands made on it; professional to support the education, training and development required by staff providing the service; economic to secure the appropriate use of available resources including determination of priorities. These models and approaches can be adapted for use in public health practice. Level three: clinical governance within health authorities Although there is clarity about the scope of the work of public health practitioners and the nature of their responsibilities, 10

3 432 JOURNAL OF PUBLIC HEALTH MEDICINE there is limited guidance about their new professional and organizational responsibilities in relation to clinical governance. In particular, there are, as yet, no publications describing what approaches, methods and instruments public health professionals could use in their clinical governance work, including that of promoting effective clinical governance within health authorities. The rest of this paper includes a consideration of this aspect of public health s clinical governance agenda. A general framework for public health specialists The sheer scope and complexity of clinical governance can cause confusion. The work of Scally and Donaldson 3 is helpful in this regard, as they identified six integrating approaches (see Table 1). Within each of these six dimensions, there are a number of aims around which standards can be developed. They offer a framework for the development of clinical governance within the specialty whether the work is related to performance at the individual professional, public health departmental and/or organizational levels. At the individual public health professional level, Forsythe has developed seven methods or instruments for reviewing the work of a public health physician. 4 They include portfolios, correspondence and files, site tours, third party (independent) interviews, report presentations, observations in practice and summary reviews of performance. Most of these instruments are transferable to a routine system of clinical governance. In place of third party interviews, a standard quality based questionnaire, for use with third parties, could be developed. These instruments would facilitate self-assessment. The next stage of development would be peer assessment within and between departments. Use could be made of methods developed elsewhere. For example, North Yorkshire Health Authority has a self-assessment workbook for general practices that focuses on quality within practice, 15 including the issues of waiting times, repeat prescribing, management methods and complaints procedures. It is working well and is popular with practices (Kathleen Swann, personal communication, 1999). The method is transferable to public health practice. The output of each element of public health practice within a department would need to be identified, standards created and methods of assessment defined. The final stage of development is for public health specialists to play a full part in enabling health authorities to assess their decision making and organizational competence. At present, this takes place at regional review meetings and, on occasion, in the courts! New less formal methods are required. At this corporate level, the focus would be not only on the decision-making structures and systems but also on the ways in which the people in the organization are trained, up-dated, organized, developed and supported. Public health specialists could play a key role in ensuring that NHS organizations support the health of their workforce as well as their community. The evidence that good management positively benefits the health of employees 16 confirms the value of clinical governance at corporate level. The immediate task Understanding the need for, and benefits from, clinical governance is not enough. Public health practitioners must make progress by applying clinical governance to their own work. To do this, it is necessary to identify the various elements within clinical governance and the ways in which they can be addressed. Table 1 shows how this task can be undertaken. It builds on the six approaches of Scally and Donaldson, 3 linking each approach with a set of aims and key ideas for the development of workbook elements. It makes the general concept of clinical governance tangible, manageable and specific. If real progress is to be made, the whole endeavour must be based upon unifying values and agreed ground rules. The values must include mutual trust and esteem if people are to participate actively, positively and fully in the scheme. The ground rules should include agreements about the confidentiality of individual appraisals, the sharing of information and the limitations to be placed on what individuals can say and do. Once this framework is in place, action can be taken within the framework set out in the table. For appraisal of the department as a whole, the workbook approach appears to be best suited to the task. To this could be added a site visit from another public health department, at which an agreed set of quality standards would be assessed. Such standards would need to be developed and agreed locally within a framework of national standards. The Faculty of Public Health and other public health organizations have important roles at national and local levels. Conclusions Public health professionals have a dual role in relation to clinical governance. They have a general duty to ensure that the challenge of clinical governance is appropriately taken up throughout the NHS and a specific professional responsibility to apply clinical governance to public health within their own specialism, department and organization. The credibility of public health practitioners in relation to their general duty may depend somewhat on how they discharge their specific professional responsibility. This paper has directly tackled this new and important professional issue and suggested that there must be a properly supported and fully integrated system of continuing individual, directorate and organizational assessment as outlined above. The Faculty of Public Health is a key player in this development. It is also important that other public health professionals working within the NHS participate. This would be consistent with the interim findings of the Chief Medical Officer s project

4 Table 1 Operational aspects of clinical governance for public health practitioners Approach Aims and values Workbook elements to be developed Risk avoidance 1. Well-trained staff Set standards for training of public health directorate staff 2. Clear procedures and guidelines Set standards of training for the organization 3. Safe environment Identify standards and document for key departmental tasks Monitor and evaluate outcomes Identify potential environmental hazards and document, e.g. visual testing for computer users Coherence 1. Goals of individual, team and organization aligned Identify and document individual, team and organizational goals 2. Excellent communication Agree methods for measuring communication quality 3. External partnerships forged Question partners on quality of contact with department Infrastructure 1. Access to evidence Set standards for access to evidence 2. Time allowed to plan Agree measures of effective time management 3. Training and development strategies Agree defined training and development strategy within standards set 4. Information technology supports practice Set standards for IT support Culture 1. Open and participative Question members of other departments on quality input from 2. Good leadership public health directorate 3. Education and research valued Monitor standards of training and check whether educational goals achieved 4. Effective patient partnerships Apply methods for open and participative review of departmental working 5. Ethos of teamwork Quality methods 1. Good practice spread Set standards for development of clinical policies 2. Clinical policies evidence based (guidelines and protocols) 3. Lessons learned from failure Select and use methods for identifying and reviewing failure 4. Improvement processes integrated Select and use methods for establishing improvement processes Performance 1. Early recognition Apply official guidance (GMC) 2. Decisive intervention Establish ground rules and systems 3. Effective self-regulation Offer peer review 4. Feedback on performance Deliver appropriate training and development CLINICAL GOVERNANCE FOR PUBLIC HEALTH PROFESSIONALS 433

5 434 JOURNAL OF PUBLIC HEALTH MEDICINE to strengthen the public health function in England. 17 A genuine multi-disciplinary dialogue is recommended. It is now up to all public health professionals to develop and prove the structures and processes by which they can improve the quality of their work. References 1 Department of Health. Clinical governance: quality in the new NHS. HSC 1999/065. London: NHS Executive, Secretary of State for Health. The new NHS, a first class service. Department of Health. London: HMSO, Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. Br Med J 1998; 317: Forsythe M. Poorly performing public health doctors. Public Hlth Physician 1998; 9(2): British Association of Medical Managers. Clinical governance, a document for consultation. Cheadle: British Association of Medical Managers, Carroll L, Sullivan FM, Colledge M. Good health care: patient and professional perspectives. Br J Gen Pract 1998; 48: Murray TS. William Pickles Memorial Lecture, the vision of a poet. Br J Gen Pract 1998; 48: Anon. Clinical governance in North Thames a paper for discussion. London: Public Health Department, NHSE North Thames Region Office, Royal College of General Practitioners. Clinical governance: practical advice for primary care in England and Wales. London: RCGP, Department of Health. Public health: responsibilities of the NHS and the roles of others. HSG(93)56. Health service guidelines. London: Department of Health, General Medical Council. Performance procedures: a guide to the new arrangements. London: GMC, General Medical Council. Duties of a doctor: good medical practice. London: GMC, General Medical Council. Good medical practice. London: GMC, Roland M, Holden J, Campbell S. Quality assessment for general practice: supporting clinical governance in primary care groups. Manchester: National Primary Care Research and Development Centre, University of Manchester, Anonymous. Primary care development: an aid to practice development, self-assessment handbook. York: North Yorkshire Health Authority, Bosma H, Marmot MG, Hemingway H, et al. Low job control and risk of coronary heart disease in Whitehall II (prospective cohort) study. Br Med J 1997; 314: Department of Health. An interim report of a project to strengthen the public health function in England. A report of emerging findings, from Sir Kenneth Calman, Chief Medical Officer. London: Department of Health, Accepted on 29 June 1999

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