Safeguarding

Safeguarding Patients 37
– even the local police force – were unable to entertain the possibility that a respected GP could
be capable of deliberate harm to his patients, even when the warning signals were so clear. Local
clinical governance systems therefore have to be resilient enough to identify such cases, rare as
they are, and ensure that effective action is taken.
4.29 All primary care practices are required, as noted above, to have a clinical governance lead and
clinical governance systems. But it is not always easy for practice partners to appreciate that a
colleague’s performance is becoming unsafe, and even if they see the warning signs they may be
reluctant to take action. And a minority of GPs, some 6.6% in England in September 2005, still
practise as single-handers. PCTs therefore have a key role, as explained in Chapter 2, both for
promoting and supporting clinical governance in individual contractors and for providing the
ultimate “safety net” of assurance that contractors are safe and fit for purpose.
4.30 Recent developments in the NHS, as summarised in Creating a patient-led NHS and
Commissioning a patient-led NHS, have impacted on PCTs in three main ways:
• the number of PCTs have been reduced by about 50% since the Shipman Inquiry report was
written (from 303 to 152), and they cover much larger populations (typically populations of
500,000 or more rather than the previous 100,000 to 200,000). This could result in PCT officers
becoming more “distant” from practices and having less direct local knowledge. It will however
have the major advantage of enabling PCTs to build up specialist expertise in handling
performance issues;
• there is a continuing development programme to strengthen PCTs’ structures, systems,
processes and capacity for commissioning services. There could be useful synergies between
the skills and processes needed to commission for quality in secondary care and the
management of primary care contracts;
• more services will be provided in primary and community care settings and there will be an
increasing variety of types of provider organisation, including new types of private and voluntary
sector providers. These will include nurse-led community services, specialist out-of-hours
providers, and community health centres and community hospitals offering a mix of primary and
secondary health services. PCTs will need to ensure comparable standards across these
different kinds of provider. This may require new approaches to performance management,
including the use of new PCT contractual freedoms such as those announced in Our health, our
care, our say 58 to drive up quality and responsiveness through contestability. The Department
will provide support and guidance as needed, for example recent guidance on clinical
governance safeguards for practice-based commissioning 59 and guidelines to be
published shortly on accrediting GPs and pharmacists with special interests.
These and other significant developments both increase the scale of the challenge facing PCTs
and strengthen their capacity to meet that challenge.
Accountability of GPs to PCTs
4.31 Good doctors, safer patients recommended that
Further attention should be paid to ensuring the formal and personal accountability of individual
general practitioners to their primary care trust, through use of standard contracts and other
mechanisms. In particular, primary care trusts should be guaranteed unfettered access to all
patient records. 60