Robin C Fraser

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:

Model for directly assessing and improving clinical competence and performance in revalidation of clinicians

It is now clear that revalidation and clinical governance will drive continuing professional development in medicine in the United Kingdom. 1 2 Thus patients, society, and the profession are to be assured that individual doctors not only are fit to practise but are providing high quality care for patients. The focus of professional revalidation is rightly moving from the requirement that practitioners merely provide evidence of participation in continuing education towards the requirement that they provide evidence that better reflects their clinical practice. 3 4 Nevertheless, the primary screening procedures that have been proposed for revalidation are indirect (see box).4 If used at all, tests of clinical competence come much later in the process, but few tests include direct observation of practice. We present the case for the primacy of obtaining direct evidence of clinical competence of any doctor being revalidated; discuss the essential attributes of any process of obtaining such evidence; describe the ways in which such evidence can be gathered; explore the limitations of review tools currently available; and suggest an appropriate model for performance review. #### Summary points The measures currently proposed for assessing competence in clinician revalidation are mainly indirect or proxy As the consultation is the single most important event in clinical practice, the central focus of revalidation should be the assessment of consultation competence Such assessment should be by direct observation and satisfy five criteria—reliability, validity, acceptability, feasibility, and educational impact Assessment of consultation competence would be followed by assessment of specific skills and regular performance review Such an assessment procedure is recommended for use in the revalidation of all clinicians #### Recent proposed components of revalidation in United Kingdom Indirect …

Development of review criteria: linking guidelines and assessment of quality.

Review criteria are designed to enable clinicians and others to assess care. However, there is no established method for developing criteria, and they are often confused with guidelines. Criteria should comprise measurable activities that are appropriate for the setting in which they are to be used. They should also be based on research evidence and prioritised according to the strength of that evidence and effect on outcome. Good criteria can be used to aid implementation of guidelines by providing a standard against which to monitor performance and enabling clinical audit.

Formative assessment of the consultation performance of medical students in the setting of general practice using a modified version of the Leicester Assessment Package

To evaluate the use of a modified version of the Leicester Assessment Package (LAP) in the formative assessment of the consultation performance of medical students with particular reference to validity, inter‐assessor reliability, acceptability, feasibility and educational impact.

High Risk of Coeliac Disease in Punjabis

The purpose of this study was to measure the incidence of coeliac disease in different ethnic communities and investigate the hypothesis that the incidence is decreasing in most European countries and

Strengths and weaknesses in the consultation skills of senior medical students: identification, enhancement and curricular change

Introduction  This paper seeks to describe the consultation strengths and weaknesses of senior medical students, the explicit and prioritised strategies for improvement utilised in student feedback, and curriculum developments informed by this work.

Student perceptions of a new integrated course in clinical methods for medical undergraduates

In line with recent General Medical Council recommendations a new, 8‐week integrated course in clinical methods has been introduced into the undergraduate curriculum at Leicester University.

Teaching the teachers at Leicester: the general practice approach

This article describes a systematic induction programme devised for newly appointed lecturers in general practice. The programme aims to help them develop skills in both teaching and assessment and to encourage self-appraisal. The progress of participants is monitored by direct observation and video-recording with the regular provision of feedback a prominent characteristic. All the lecturers have found participation in the programme an effective way of developing their teaching capabilities.

The relationship between measures of patient satisfaction and enablement and professional assessments of consultation competence

The authors examined the extent of the relationship between a Consultation satisfaction questionnaire and Patient enablement instrument scores and professionally assessed consultation competence scores of senior medical students. Three analyses were performed: (i) linear regression with mean overall competence score as response variable; (ii) sensitivity and specificity calculations using patient scores to classify competence; (iii) a repeated measures model with consultation-specific competence score as response variable. One hundred and nineteen students and 388 patients took part. Consultation satisfaction and enablement scores were weakly correlated with overall and consultation specific competence scores (correlation coefficient 0.16 to 0.44). ‘Satisfaction with professional care’ had a sensitivity of 0.68, specificity of 0.72 and positive and negative predictive values of 0.32 and 0.92 respectively. It is concluded that patient and professional assessments may complement, but do not replace, each other. Levels of patient satisfaction should not be used as proxy measures of the quality of consultation competence.

Devising and establising the face and content validity of explicit criteria of consultation competence in UK primary care nurses

AIM The aims of this study were (a) to devise a set of prioritised criteria of consultation competence which primary care nurses need to acquire and (b) to determine the face and content validity of these criteria. METHOD The criteria of consultation competence as contained in the Leicester Assessment Package (LAP) were modified for use with primary care nurses and sent to a stratified sample of UK primary care nurses (n=1126) to determine their face and content validity. RESULTS Support for the seven categories of consultation competence varied from 93-98% and for the 39 component competences from 88-98%. There was no consensus for alternative or additional categories or components. CONCLUSIONS; We have established the face and content validity of the derived competences. These are suitable for the teaching and assessment of consultation skills of primary care nurses, at all stages of their professional development, when incorporated within an educational package.