Learning by heart: An interview study in general practice during the advent of the National Service Framework for coronary heart disease
Meal A., Wynn A., Pringle M., Cater R., Hippisley-Cox J.
Background. In 1998 the government created primary care groups, later to become primary care trusts, in England and established clinical governance. These changes were designed to enable the delivery and monitoring of standards, alongside developments in clinical health informatics. The National Service Framework (NSF) for coronary heart disease, published in March 2000, identified clinical governance and advances in information technology as central to delivering its standards. Objectives. To discover the preparedness of general practices to implement the NSF for coronary heart disease. Design. A qualitative study using two sets of semistructured interviews, one year apart. Setting. Nineteen general practices from 19 primary care organisations (PCOs) within Trent Region, all of whom were users of clinical computer systems. Participants. Key informants nominated by each of the participating practices as being their clinical governance lead. Sixteen practices nominated general practitioners (GPs) (in one of these, two GPs shared the role), one practice nominated a practice nurse co-ordinator, and another nominated both a practice nurse and practice manager to be interviewed. The remaining practice nominated a GP, practice manager and two practice nurses to be interviewed. Results. In the first interviews, practices were already addressing some of the issues in the NSF, but were doing so based on existing activity in their own practices: PCOs had not yet begun to exert much influence. The informants felt that PCOs, however, had prioritised coronary heart disease (CHD) because of influences from government, including the NSF. By the second interviews, the NSF and PCOs were beginning to exert some influence on the perceived priorities of the practices, but local issues were still seen as important. Practices in this study were concentrating mostly on secondary prevention. Primary prevention was being undertaken, but secondary prevention was seen to be more effective and evidence based. We found some early evidence of multi-agency working that is identified in the NSF as a way to implement primary prevention, but this did not yet appear to be widespread. Informants indicated an overall positive attitude to computers and data quality, and could envisage a wide range of potential future uses for computers. Lack of time and expertise, and inconsistent clinical coding are problems that may impede progress in computerisation and data quality. Conclusions. Practices in this study recognised the importance of CHD and were already active in many areas of primary and secondary prevention. They seemed ready to embark on the prevention targets contained in the NSF, and were making progress particularly in secondary prevention, but primary prevention is the area where most work is required to meet the specified targets. We found some early evidence of multi-agency working, and we suggest that this needs to be encouraged, especially in primary prevention and data quality, if the targets in the NSF are to be met. © 2004 Radcliffe Publishing.