Clinical governance and primary care in the English National Health Service: Some issues of organization and rules

Abstract

New Labour's concept of 'clinical governance' is an essentially bureaucratic strategy in that it places great emphasis on controlling the behaviour of NHS clinical professionals via a web of rules, including clinical guidelines and National Service Frameworks, supported by new external agencies such as NICE and CHI. In the context of primary medical care, however the classic organizational means for implementing such rules, the bureaucratic hierarchy, is largely absent. Despite the current development of new forms of primary care organization (PCGs, PCTs and PMS Pilots) which display some hierarchical characteristics, these remain highly attenuated and a priori unfitted to implement bureaucratic rules. This paper explores the validity of such doubts through three sources of evidence: research into 'total fundholding' (many of whose characteristics are shared by the new organizational forms), contemporary Internet user group discussions between GPs in PCGs, and some pilot interviews of GPs in a northern PCG. The latter two data sources are not presented as representative, but rather to highlight the apparent lack of fit between central components of New Labour health policy and the need for empirical research on the topic.