Some National Service Frameworks are more equal than others: Implementing clinical governance for mental health in primary care groups and trusts

This paper reports the findings of a study concerned with the way in which Primary Care Groups (PCGs) and Primary Care Trusts (PCTs) engaged with the Mental Health National Service Framework (NSF) as part of their remit to implement clinical governance. A qualitative multiple case study is reported which used semi-structured interviews and documentary analysis in a purposive sample of 12 PCG-Ts in England. The study found a general awareness of and support for the Mental Health NSF among PCG-Ts. In some localities the NSF acted to reinforce existing local developments in primary care mental health. However, compared to the NSF for Coronary Heart Disease a number of difficulties in responding to the Mental Health NSF were identified. These related to the perceived clinical status and complexity of managing mental health problems at practice level (e.g. familiarity with and competence of General Practitioners (GPs) in managing the conditions), inter-agency working, clinical governance training and the feasibility of producing clear demonstrable mental health outcomes as part of performance management. While the NSF for mental health presents opportunities for establishing the principles of quality assurance and improvement in the area of mental health, it is in danger of being marginalized in the clinical governance agendas of new PCTs, because of an inability to compete on an equal footing with other clinical priorities. While the partial demedicalisation of mental health is increasingly recognised as desirable for policy and therapeutic reasons the corollary is that it is harder to implement non-medicalised forms of care through the essentially medicalised apparatus of clinical governance. In order to deal with the complexities and challenges posed by the mental health agenda targeted support and resources are needed to promote clinical governance developments within primary care organisations.