Mayur Lakhani

A model for clinical governance in primary care groups

Clinical governance is the core component of the new quality programme for the NHS (see box on next page) announced in the consultation document A First Class Service .1 It is described as “a framework through which 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 will flourish.” It will be the central focus for assuring the quality of care and addressing the issue of providing accountability through the Commission for Health Improvement.2 The activities of the commission will reflect national and local priorities as identified by the National Institute of Clinical Excellence and health improvement programmes respectively. Although A First Class Service included details about the structure and functioning of clinical governance in health service trusts, arrangements for primary care groups were not specified. In this paper, we suggest a possible model for clinical governance in primary care groups. Clinical governance is central to the NHS quality programme, but how it will operate in primary care groups remains unclear Although many activities included in the new concept of clinical governance are already being undertaken, these need to be coordinated A model of governance that addresses the core tasks of defining, accounting for, and improving quality and incorporates evidence on effective methods of changing performance is suggested This model can improve professional, practice, and primary care group performance It shows how groups can introduce and develop clinical governance and how health authorities and the Commission for Health Improvement can monitor progress The model is based on three underlying precepts:

Best care for the dying patient

Why do so many people die badly when we know how to care for them well?

Never the right time: advance care planning with frail and older people

> ‘ ... the doctor has the map and the patient does not. In fact the doctor not only has the map but drives the vehicle and the patient may not know that they have reached a crucial crossroads, or that they have reached the end, until they get there and it is too late.’ 1 Care of the dying is inadequate in many developed countries, and its improvement is an important national and international challenge. Around 500 000 people die in England every year, of whom 53% die in hospital even though 63% indicate a preference to die at home.2 Although palliative care services have been available for many years for people with cancer, most people do not die of cancer. Other conditions, including multimorbidity and extreme old age, tend to have a less predictable course and such patients are less likely to be found on a GP’s palliative care register. Do older patients really have a voice when it comes to planning their future care? In the first ever systematic review of attitudes of the public and healthcare professionals to advance care planning, Sharp et al find there are some critical barriers to be overcome if we are to translate the concept of ‘advance care planning’ from its origins in palliative care for cancer to frail older people who are dying.3 We know what we ‘should be doing’. Why aren’t we doing it? In this editorial we examine the opportunities and challenges of advance care planning in the context of a much needed national conversation about death and dying.4 Advance care planning is defined as the ‘voluntary process of discussion and review to help an individual who has the capacity to anticipate how their condition may affect them in the future and if they …

Let’s talk about dying

Imagine a situation where most people with a common condition do not have it diagnosed. Where opportunities are repeatedly missed to identify the problem and to offer structured evidence based care. Where people are too often denied a chance to influence their care in a planned proactive way. This area of healthcare generates 54% of all hospital complaints. What is this condition? Dying. Despite huge advances and successes in end of life care in the United Kingdom, of which we should be rightly proud, we have not yet managed to transform care. Someone in Britain dies every minute, yet many of us are afraid to discuss dying, leaving many people unprepared and unable to plan. All of us must do more to talk about this if we are to give patients the best chance of a good death. Even people with advanced progressive illness who are admitted to hospital are often not identified for end of life care, meaning that many patients who could benefit from palliative care never have that opportunity. Too many people still die in distress with uncontrolled symptoms, are inappropriately …

Palliative care for everyone with advanced progressive incurable illness.

In a 2008 poll BMJ readers voted “palliative care in conditions other than cancer” as the intervention that would make the “greatest difference to healthcare.” If I ruled the NHS I would make this a reality. All people with advanced progressive incurable illnesses would receive palliative care regardless of diagnosis or postcode. By doing this, we would make good care for all at the end of life the norm. People in the last years of their life or with life limiting diagnoses would be encouraged to think ahead and make advance care plans. Quality and value would improve dramatically. Moreover, it could tackle the problem of …

Consider advanced care planning in functional assessment of older people

When assessing older people it is important to consider an advanced care plan if appropriate,1 especially when comorbidity is the rule in this group with a high prevalence of dementia. It is therefore worth …

Time to legalise assisted dying?: RCGP is not neutral: it opposes a change in legislation

EDITOR—Delamothe states that the Royal College of General Practitioners (RCGP) has a neutral stance on the issue of assisted dying.1 This is no longer correct. At a meeting of the college council in June 2005 it was decided, by a …

Drug points: Complete heart block induced by hyperkalaemia associated with treatment with a combination of captopril and spironolactone

references on a disk and use the remaining space for the index and text files which I described in my paper. When I need to look for references which are stored on many floppy disks, I copy them on to the hard disk and use it to locate the data required more quickly. I am delighted to state that well over 500 readers have sent requests for listings of the program. I am doing my best to dispatch them and to answer individual questions about hardware and software requirements. Detailed instructions on how to incorporate this program into other computer systems are also included. DAVID P SELLU Department of Surgery, Dudley Road Hospital, Birmingham B18 7QH