Models for quality improvement and assurance in English and Welsh primary care

Abstract

Various initiatives have been tried to improve the quality of primary care in England and Wales in the last fifteen years. Such initiatives can be divided into quality improvement (QI) and quality assurance (QA). This paper looks at three contrasting models, drawn from data from 48 semistructured interviews with personnel from three primary care organisations (PCOs): two primary care trusts in England and one Local Health Board in Wales. The first model was collegiate, a voluntary doctor-led initiative begun during the period of GP fundholding. The second is clinical governance, a current government-imposed system administered by PCO officers, which has attracted limited engagement from GPs. The third is the Quality and Outcomes Framework of the new GP contract, which was generally described positively, although the process of administering it was experienced as bureaucratic. The three models correspond with three organisational types: networks (which use peer relationships to achieve goals), hierarchy (which use ‘top-down’ requirements and monitoring) and market (which use contracts). Although doctors have traditionally preferred network-style arrangements, the success of these arrangements in sustained QA and QI has been questionable. The importance of hierarchical arrangements is inevitable, given the functions and constitution of PCOs, and the risk that GPs will disengage is similarly inevitable. However, it is important that PCO officers find ways to engage GPs as much as possible in quality initiatives if patient services are to improve. © 2007, Cambridge University Press. All rights reserved.