Development of Clinical and Health Governance: Primary Health Care in the Lisbon and Tagus Valley Region

Abstract

The Clinical and Health Councils (Conselhos Clínicos e de Saúde - CCS) became responsible for implementing Clinical and Health Governance (Governação Clínica e de Saúde - GCS) in primary health care (PHC) in Portugal. However, this project suffered political abandonment, although there are cases of continuity due to the dedication of CCS professionals. Considering the lack of evidence on the impact of GCS concerning the horizontal integration of the Functional Units of Health Center Groups (Agrupamentos de Centros de Saúde - ACES), the present study sought to identify micropolitical elements that could enhance this horizontal integration. The modified Delphi technique (Policy Delphi) was used as a methodology involving a group of ten experts with experience in academia, in administrative structures, and in the CCS, who shared their experiences to answer the research questions. The results revealed, on the one hand, a general tendency, on the part of the experts to accept that the CCS fulfilled the competences that were assigned. On the other hand, they identified economic and social limitations in the development of the project, as well as the fragmentation of care and tensions generated by disparities between the Functional Units. This study also made it possible to suggest a set of micropolicies capable of promoting the integration of GCS in PHC.

Key words:
Primary Health Care; Clinical and Health Governance; Horizontal Integration; Micropolicies

Resumo

Os Conselhos Clínicos e de Saúde (CCS) tornaram-se responsáveis pela implementação da Governação Clínica e de Saúde (GCS) nos cuidados primários em Portugal. Contudo, este projeto sofreu abandono político, embora existam casos de continuidade devido à dedicação dos profissionais dos CCS. Considerando a ausência de evidências sobre o impacto da GCS na integração horizontal das Unidades Funcionais dos Agrupamentos de Centros de Saúde (ACES), a investigação buscou identificar elementos micropolíticos que pudessem potencializar essa integração horizontal. Como metodologia foi utilizada a técnica Delphi modificada (Policy Delphi) envolvendo um grupo de 10 especialistas com experiência acadêmica, nas estruturas administrativas e nos CCS, que compartilharam suas vivências para responder às questões da pesquisa. Os resultados revelaram uma tendência geral, por parte dos especialistas, para aceitarem que os CCS cumpriram as competências que foram atribuídas. No entanto, identificaram limitações econômicas e sociais no desenvolvimento do projeto, bem como a fragmentação dos cuidados e as tensões geradas por disparidades entre as Unidades Funcionais. A pesquisa possibilitou ainda sugerir um conjunto de micropolíticas capazes de promover a integração da GCS na APS.

Palavras-chave:
Atenção Primária à Saúde; Governação Clínica e de Saúde; Integração Horizontal; Micropolíticas

Resumen

Los Consejos Clínicos y de Salud (CCS) pasaron a ser responsables de implementar la Gobernanza Clínica y Sanitaria (GCS) en la atención primaria en Portugal. Sin embargo, este proyecto sufrió un abandono político, aunque hay casos de continuidad por la dedicación de los profesionales de la CCS. Considerando la falta de evidencia sobre el impacto de GCS en la integración horizontal de las Unidades Funcionales de los Grupos de Centros de Salud (ACES), la investigación buscó identificar elementos micropolíticos que podrían potenciar esta integración horizontal. Se utilizó como metodología la técnica Delphi modificada (Policy Delphi) involucrando a un grupo de 10 expertos con experiencia académica, en estructuras administrativas y en CCS, quienes compartieron sus experiencias para responder las preguntas de investigación. Los resultados revelaron, por un lado, una tendencia general, por parte de los expertos, a aceptar que la CCS cumplía con las competencias asignadas. Por otro lado, identificaron limitaciones económicas y sociales en el desarrollo del proyecto, así como la fragmentación de la atención y las tensiones generadas por las disparidades entre las Unidades Funcionales. La investigación también permitió sugerir un conjunto de micropolíticas capaces de promover la integración de las GCS en la APS.

Palabras clave:
Atención Primaria de Salud; Gobernanza Clínica y Sanitaria; Integración Horizontal; Micropolíticas

Introduction

The World Health Organization (WHO), as set forth in the Declaration of Alma-Ata in 1978, understands that Primary Health Care (PHC) can cover the majority of a person’s health needs throughout one’s life¹. In Portugal, in 1971, the first network of health centers was created, which were primarily dedicated to preventive activities and the promotion of maternal and child health². Over time, health centers have undergone several changes, and between 2005 and 2010, a major boost was given to the transformation of PHC, with the creation, in 2006, of the Family Health Units (FHUs), which develop their activity based on the contracting of objectives, making financial and institutional incentives correspond to their fulfillment, and based on Health Center Groups (ACES) in 2008^3,4.

The reconfiguration of health centers followed a twofold movement. The approximately 360 health centers, which had a pyramidal hierarchical organizational structure, now have an organization of multidisciplinary teams with varying degrees of technical autonomy and self-organization capacity. In this sense, the health centers gave rise to approximately 1,300 multidisciplinary teams with their own “identity” differentiated by type of unit: person-centered and family-centered comprehensive and longitudinal general care (FHU/Personalized Health Care Units (Unidades de Cuidados de Saúde Personalizados - UCSP)); selective care for groups with special needs and interventions in the community (Community Care Units - CCUs); diagnosis and monitoring of the health status of the population, as well as the coordination of programs to protect and promote the health of the general population (Public Health Units - PHUs); health care, participation in common health projects, and consultancy services provided to other units, composed of psychologists, nutritionists, physiotherapists, social workers, among others (Shared Assistance Resource Units (Unidades de Recursos Assistenciais Partilhados - URAP))⁴.

This “decentralization” process was accompanied by a process in the opposite direction - concentration of resources and management structures, that is, of devices for clinical governance and organizational management, to allow scales of epidemiological analysis and action results, as well as to achieve economies of scale to maximize resource management. The approximately 360 health centers gave way to 70 ACES, later restructured into 55.

Health systems have always been complex, and difficult to understand and change, but due to limited resources, most countries seek ways to improve the efficiency of their health systems^5,6. In this context, the Mission for PHC (2005-2010) established three axes of action in its Strategic Plan for the three-year period of 2007-2009: quality and organizational change; clinical governance (CG); and knowledge management, sustainability, and development⁷.

Clinical and Health Governance Devices

Governance comes from the Greek word kubernân, which means ‘to pilot’. Using the metaphor of a journey, it is assumed that its purpose is to pilot the ship to reach the desired destination safely and economically. It is a comprehensive, multidimensional system that aims to achieve specific objectives by improving common practices^8-10.

The concept of CG was imported to Portugal in 2001 and was further developed in the PHC, where it gained relevance with the term Clinical and Health Governance (Governação Clínica e de Saúde - GCS), bringing together the WHO concept of Health Governance with that of CG from the British system, and combining two ideas: improving health levels, and obtaining clinical results at an individual level (each person) and health results at a group or population level (in this case, ACES). The latter is the responsibility of the Clinical and Health Council (Conselho Clínico e da Saúde - CCS, a GCS device in each ACES, in the legislation that was in force until December 31, 2023)^11,12.

The GCS in the PHC had the following dimensions: focus on people, professionals, innovation, assessment (accountability), continuous improvement of processes, adequacy of care, patient safety, and health results/gains (Figure 1)¹².

Figure 1
Dimensions of Clinical and Health Governance.

This network organization model would enable the development of collective and collaborative intelligence in ACES. The appropriation by professionals of this new paradigm required more than a mere transformation of the organization. It implied a change in thinking and in the pattern of institutional relations. To this end, focus was placed on the development and qualification of a GCS culture in the PHC, by: defining the conceptual and technical-scientific framework of reference; training new leaders; creating the CG community, involving all the CCS and a monitoring device through a matrix of indicators.

With limited evidence in the PHC, the first indicators were initially developed in the MCSP, for the FHU and UCSP. Performance evaluation efforts often focused on process indicators rather than outcome indicators, which is one of the main limitations highlighted in this study. However, they did allow for the analysis of data that appears to show consistent progress in more than four dozen performance indicators.

In 2017, the BI-PHC portal was created, with public access and different access profiles¹³. In addition to other features, it has supported the contracting process and the development of the GCS culture. It provides a matrix of performance indicators that considers the GCS areas, enabling the monitoring of the various dimensions of Figure 1. This assessment resulted in the Global Performance Index (GPI), which in 2024 was replaced by the TPI (Team Performance Index), which includes the disruption index (professional-user ratio, absences, user complexity, sociodemographic conditions).

Clinical and Health Governance in the Lisbon and the Tagus Valley Region

In December 2008, the Regional Health Administration of Lisbon and Tagus Valley, I.P. (ARSLVT), developed a project to promote the CCS (DiCCA Project), carried out by a multidisciplinary working group that, with the participation of professionals, developed guidelines and procedures for each strategic axis, developed meetings/workshops/discussion groups, which subsequently favored the creation of a community (Network) of practices with the sharing of documents, experiences, methodologies and innovative strategies.

During the years that followed, there was a lack of continuous training for CCS at a national level, in addition to the frequent change of its members, which contributed to the gradual loss of knowledge of the role of CCS and the relevance of GCS. Thus, ARSLVT, in 2017:

• a) revived the DiCCA (II) project;

• b) designed and implemented the Oncology Screening Programs (Programas de Rastreio Oncológicos - PRO), Cervical Cancer (cancro do colo do útero - CCU), and Colon and Rectal Cancer (CRC) from the GCS perspective, in close connection with the CCS, through their integration with the projects worked on in DiCCA II.

At ARSLVT, there had already been two decades of unsuccessful attempts to implement PROs, with much resistance crystallized in various points of the system (health centers and hospitals). Thus, ARSLVT invested in their design and implementation, now from a GCS perspective, in order to maximize the effects of these interventions in terms of individual and collective health, with positive impacts on organizational and systemic development^14,15.

Between 2017 and 2024, the annual population coverage rate went from 0% to 16.6% (97,815 people invited and 73,544 of them screened) in the case of RCCR and from 0% to 51.4% of women screened for CC (100,998 invited and 98,245 screened). These results exemplify what could be good public health intervention practices and how GCS can be implemented at a local level, on a population scale of 10⁵.

c) created the instrument to support the organizational development of all UFs (FHU, UPHC, CCU, URAP, and PHU) - the DORA manual. A qualitative instrument that emphasizes dimensions such as teamwork, people-centeredness, community, openness, cooperation, adaptive capacity, learning culture, and achievement of health results. The motto was “May each Team be a master and disciple of itself, a master and disciple of its peers (other teams), and a master and disciple of the recipients/partners of its services” (quote from Victor Ramos)¹⁶.

The current moment of GCS

On January 1, 2024, the National Health Service (NHS) was reorganized again with the abolition of the ARS and the creation of 39 Local Health Units (LHUs), which integrate hospitals and ACES^17,18. This merger involves organizations providing different levels of care with a view to improving the quality of life of a given population (vertical integration). The risk of prioritizing the allocation of resources to immediate needs (almost always curative hospital care activities) to the detriment of health promotion and disease prevention activities must be considered. On the other hand, the existence of very different cultures may lead to the dominant culture being that of the largest organization, that is, the hospital. The vertical integration that exists in hospital units may constitute a threat and obstacle to the horizontal integration achieved in PHC.

Societal changes, which are associated with changes in a health system that is moving towards increasingly decentralized structures, have required an evolution in GCS models.

The present study was intended to answer the following research questions (a) What is the perception of a panel of experts about the role of the CCS in the development of GCS and what impact did this have on the application of performance indicators in clinical practice; and (b) Which micropolicies would best serve GCS in the new LHU organizational model.

Methodology

An exploratory, descriptive, cross-sectional, and qualitative study was designed to obtain the perceptions of a panel of experts on the development of GCS and its impact on performance, as well as which micro-policies could contribute to GCS in the new LHU model.

The Policy Delphi technique is a method for structuring a group communication process around a complex problem, exploring areas of consensus and dissent among experts^19-23. The sample was considered heterogeneous, since the members did not work in the same places, belonged to different professional groups, and dealt with GCS at different levels.

The selection of experts was intentional, as it was intended that they would have prior and direct contact with the development of GCS in PHCs, both at the academic level and at the level of the central, regional, and local structures of the health system.

Ten experts were invited, of whom seven were doctors, one senior health technician, one physiotherapist, and one nurse. Although seven of these experts were family doctors (the profession with the greatest role in implementing GCS), the roles they played were at different levels. Five experts worked at the central and regional levels of the health system, two at the academic level, and three worked on implementing and developing GCS at the local level.

Participation in the study was voluntary and informed consent was obtained from all participants. This study complied with the World Medical Association’s Declaration of Helsinki and the Personal Data Protection Act, which transposed the Regulation (EU) 2016/679 of the European Parliament and of the Council, from April 27, 2016, into national law.

In this study, we used three rounds over three months. The questionnaire (comprised of a Likert scale, with the possibility of expressing comments and open-ended responses) was created in Google Forms and the link was sent individually. The first submission took place on September 27, 2024. We obtained responses from all those invited. These in turn gave rise to many nuances about the problems under study, which allowed for a constructivist approach, to which the phenomenological approach was associated, in the sense that the relationships discussed in the study (between people, groups, institutions) are processes that are inaccessible to what appears to the senses, allowing for the deduction of empirically observable consequences. It also served for the inductive analysis of the data, which was accompanied by the inclusion of many of the experts’ responses in the article, common in the phenomenological analysis of practices experienced by the subjects²⁴. Approaches were maintained in the following round.

The second questionnaire contained three open-ended questions on topics that had not been fully clarified in the previous round. It was sent on November 10, 2024, using the same format and platform, and all participants responded. The questionnaire was accompanied by a narrative summary of the responses received in the previous round, highlighting areas of consensus and disagreement. The link to the first questionnaire was also sent, and the possibility of changing the initial positions was given, as was a copy of the respective responses from the previous round. None of the experts made any changes.

At the end of the two rounds, material for the construction of the decision matrix had been gathered and was sent to the panel for the next round, which began on November 25, 2024. This next round focused on micropolicies aimed at integrating GCS, resulting from the analysis of all previous responses. Only 6 participants responded (60.0%).

Our research followed studies that used mixed methods^25,26. A Likert scale was used and the most recent studies on productivity, access, and effectiveness in PHC, from official sources, were used to triangulate the data. The research group had previous experience in qualitative and quantitative research and professional experience in CAPS, as well as direct contact with GCS, which enabled them to understand the responses in context.

Data analysis followed a constructivist approach, since the study is structured around “truths” freely shared by experts, resulting from their social interactions, i.e., situated knowledge, which is thus produced and shared. The analytical work used a thematic analysis^27,28. This type of analysis is referred to as a method and not as a methodology. The sequence of stages were: transcription and familiarization with the data; identification of key words in the responses; and selection of codes, thematic development, and development of the conceptual model. No computer programs were used in the data analysis, with each analytical phase being developed by the research team.

Results

Descriptive statistics

The sociodemographic characteristics of the members of the expert panel indicated the weak representation of the “non-physician” group, which may represent a weakness of the study.

The results of the Likert scale, whose questions summarized the competencies of the CCS, were analyzed (Table 1)^29,30. The distribution of responses shows polarization, with a concentration of positive responses (Agree and Strongly agree), but also a significant number of negative responses. The answer in all categories indicates the diversity of opinions among professionals.

Table 1
Likert scale results.

Likert scale questions	Strongly Agree		Agree		Neither agree nor disagree		Disagree		Strongly disagree		Total
	N	%	N	%	N	%	N	%	N	%	N	%
P1 - CCS supported the units so that they could achieve health gains.	2	4.0	2	4.0	2	4.0	3	6.0	1	2.0	10	20.0
P2 - professionals were involved in a shared and participatory management of GCS.	3	6.0	4	8.0	1	2.0	2	4.0	0	0.0	10	20.0
P3 - cooperation and complementarity between units and the technical interconnection of ACES with other health services were promoted.	2	4.0	2	4.0	3	6.0	3	6.0	0	0.0	10	20.0
P4 - units were guided towards compliance with technical standards and promoting continuous improvement of processes and procedures	4	8.0	3	6.0	2	4.0	1	2.0	0	0.0	10	20.0
P5 - contributed to the development of an organizational culture of training. quality. humanization. critical spirit. and scientific rigor.	5	10.0	3	6.0	1	2.0	1	2.0	0	0.0	10	20.0
Total	16		14		9		10		1		50	100.0

• Note: P1 and subsequent participants correspond to the questions described above.
• Source: Authors.

The mean of 2.93 indicates a slightly positive core tendency in the answers, suggesting a general inclination towards moderate agreement. The mode shows that “Agree” was the most frequent response, demonstrating a general tendency towards approval of the statements contained in the scale. The standard deviation of 1.34 suggests considerable dispersion in the answers. Although there is a positive core tendency, there is significant variability in the opinions of the participants. The value of the standard deviation suggests that there is a lack of clear consensus among the participants, which may reflect differences in the experiences or perspectives of the experts. The predominance of positive responses (65% - Agree and Strongly agree) suggests that, despite the divergences, there is a general tendency to accept that the CCS fulfilled the responsibilities that had been assigned to them.

The questions showing the greatest polarization were: 1) that referring to the support of the CCS regarding the achievement of health gains and 2) the issue of complementarity and cooperation between functional units and between levels of care.

Results of iterative dialogue

The main ideas identified and their respective examples are summarized in Chart 1.

Chart 1
Main results of the interactive dialogue.

Study Question 1 - What are the experts’ perceptions about the role of CCS in the development of GCS and its impact on the application of performance indicators in clinical practice?
Theme	Textual excerpts	Inductive analysis
The CCS were the GCS bodies of excellence	R2 “understanding the CCS as the body of excellence for GC and health”	The experts referred to a support structure for clinical services, capable of enabling them to respond to the challenges of continuous quality improvement to ensure high standards of service31.
	R8 “the CCS ensured a global vision in ACES, promoting everyone’s commitment to building and implementing quality care”
The motivation of professionals to drive the GCS	R1 “The will of the professionals in the teams, who were following their path alone”	According to the experts on our panel, the commitment of the teams was crucial to driving change, given the difficulties experienced, together with the investment made in training the first CCS. Later, the DiCCA II and the DORA16 manuals were developed at ARSLVT.
	R2 “The motivation of professionals for change; The involvement of everyone; The ability to break with the historical legacy of a verticalized governance culture”
	R4 “Workforce capacity, with increased competence in the management area”
	R6 “The implementation of GCS by teams benefited from the technical and organizational/functional autonomy of the Functional Units, which required commitments from professionals”
	R7 “initial motivation aroused by the organizational model implemented in 2008”
	R10 “Investment in the initial training of Clinical Councils, and their motivation for change and for the involvement of professionals”
There was no culture of shared and participatory management of GCS	R1 “In my experience, few ACES have involved professionals in shared and participatory management of clinical and health governance”	Experts have also focused on the need for change at this level. Successful implementation of SCM requires a shift in organizational culture and forces changes in the roles that managers at all levels and healthcare professionals play in ensuring the safety and quality of care provided. How leaders understand, enact, and implement these responsibilities is recognized as a key determinant of an effective GCS program32.
	R4 “There is an asymmetry in the involvement of different professional groups”
	R6 “There is still no culture of participatory management in the Functional Units regarding GCS”
	R3 “The importance that professionals and managers recognized for this task despite the lack of sufficient legislative and financial recognition. A lack of clear policy and support for these professionals who were sometimes financially disadvantaged in carrying out this activity”
Social and political context influenced the development of GCS	R9 “I am aware that it was/is not an easy process, essentially due to the size of the ACES and the organizational, political, economic constraints, among others”	The GCS was a project that began during a period of economic and, consequently, political and social crises. The first period was a recession (2002-2003), and then, between 2008 and 2009, the international financial crisis hit Portugal. While Portugal was still recovering from this crisis, another one hit between 2010 and 2013. These crises were always accompanied by a reduction in public investment and the abandonment of ongoing projects, especially if they were seen as expenses.
	R9 “without adequate and continuous supervision, monitoring, support, guidance, training and evaluation, the behavior of the various CCS was erratic, heterogeneous, as if adrift, if we consider the ACES as a whole”
	R9 “The Clinical and Health Councils did not have adequate support, monitoring, ongoing training, recognition, or reward. The supplements provided for by law were never regulated and applied. A technical committee created for the development of the GCS was interrupted shortly after it had begun (that is, in the same political cycle) - the political signals were, predominantly, of non-recognition and devaluation of this strategic function essential for the technical-scientific steering of the PHC and the NHS as a whole. The members of the CCS were appointed, but then left to fend for themselves”
A path was built for GCS with multidisciplinary teams	R2 “The proximity and involvement of professionals”	It is understood that a path for GCS was built based on one of the central pillars of the PHC reform, which was teamwork. From the outset, the establishment of USF and GCS methodologies are examples of the PHC’s transformation culture33.
	R3 “GCS was developed in a context of multidisciplinary teamwork, which had not happened until now.”
	R7 “the successful organizational model with participation of all professional groups and with probable replication in hospital care”
	R10 “teamwork, within and between units”.
	R2 “A path that has been built and promoted since 2008, intra and inter-units, in multidisciplinarity, with a growing focus on the person, humanization, and safety of care, with a view to continuous improvement of quality”
	R10 “clues were laid and a horizon was envisaged, albeit very imprecise/diffuse”
Punctual cooperation and complementarity	R2 “internal strategies in ACES, [...] with external health and social units (hospitals, IPSS, City Councils, schools, universities, among other services)”	These comments reflect a strong polarization, as they address the issue of horizontal cooperation between CSP units, with other health organizations and with local authorities and community partners. It should be noted that it would be the responsibility of the CCS to develop a culture of cooperation and complementarity.
	R6 “punctually [...], far below what was desired”
	R9 “the subjective perception obtained through various conversations was that this cooperation and complementarity was promoted in a structured and systematic way in less than 5 ACES”
	R7 “One of the objectives of the CCS was to promote greater coordination between the CSP and the Hospital Centers”
Overvaluation of performance indicators, asymmetries, and inequalities	R6 “Functional Units are essentially geared towards meeting contractual targets”	The issue of performance indicators has always been controversial. The experts' words are in this sense. The experts understood that medical work, in this context, is essentially focused on meeting performance indicators, even going as far as a “laborious ‘engineering of indicators’”. The main criticism is that meeting indicators is not reflected in the results and affects the doctor-patient relationship and the relationship with the team's professionals. In addition, the experts stated that there are “asymmetries between USF and UCSP” and mentioned that the focus on developing indicators was, above all, numerical, forgetting local realities and the user needs.
	R3 “asymmetry and inequality in the quality of teams and in the results obtained”
	R6 “performance of its professionals on how to achieve results, sometimes in a laborious “engineering of indicators”
	R8 “the existence of asymmetries between USF and UCSP despite all UF participating in the GC and all assuming the care commitment. The UCSP maintain a level of inequality, with fewer resources and more constraints at the organizational level”
	R2 “little cohesion between ACES functional units”
	R6 “I believe that a significant proportion of healthcare professionals and Functional Units focus their activities on the results of performance indexes [...], which does not always translate into health gains”
	R9 “We fell into an “indicatoritis”. Anecdotally, there was talk of an “Indicator-centered practice” that dramatically harmed a true “person-centered practice”
	R4 “organizational model places system access failures under less developed units [UCSP] generating unacceptable inequity processes within the same community”
	“Unbalanced financial return model and only accessible to one functional unit out of four possible.”
	R8 “The existence of asymmetries between FHU and UCSP despite all UFs participating in Clinical Governance and all assuming the care commitment. UCSPs maintain a level of inequality, with fewer resources and more constraints at an organizational level.
	R8 “The asymmetry in the contractual process between the USF and the remaining units, without achieving the same level of analysis and organization capacity with information and registration systems embedded in the FHU model and trying to replicate the same in other units such as the CCU, URAP, and PHU.”
Tension between indicators and quality of service	R1 "The focus is on the numerical nature of the goals and not on the discussion of the scope of the measuring instruments, centered on the users and their needs"	The detailed analysis shows that clinical governance strategies and practices have a decisive influence on the selection and application of performance indicators in PHC. Despite notable progress in the development of these indicators, which now place greater emphasis on health outcomes and excellence in care, substantial challenges still need to be overcome. Thus, although clinical governance practices have provided advances in the selection and development of performance indicators, there is still a considerable distance to be traveled to ensure that these instruments are implemented and interpreted in a way that effectively promotes quality in primary health care.
	R5 "Given the insufficient culture of clinical governance, and the poverty of its practices and instruments used, the influence was negative - focus on production and process, and not on results"
	R6 “In my experience, performance indicators in PHC often negatively influence consultations, imposing a heavy schedule on the doctor, motivated by the need to meet targets, which is not in the patient's interest, namely it does not represent health gains and strongly conditions the patient's schedule.”
Quality Improvement as a Success of GCS	R2 “development and implementation of a contracting reference framework supported by healthcare performance, organizational quality and care safety”	The philosophy of quality in PHC, led by the CCS, emphasizes the integration of quality of care as one of the fundamental components in achieving universal health coverage. For this to happen, the involvement of professionals is necessary, as a critical factor for the success of the organization39, being a state in which professionals identify with their organization and its objectives, wishing to remain affiliated with it in order to achieve their personal goals34.
	R3 “strong involvement in quality and its multiple dimensions”
	R6 “some continuous quality development activities”
	R7 “continuous improvement of quality of care”
	R10 “creation of a “philosophy” of continuous improvement, aimed at improving the provision of health care”
Autonomy of ACES, in relation to ARS	R8 “the lack of autonomy of the ACES in relation to the ARS, leading to the view of the units and the CCS being often distorted in the GC process, to the detriment of the ARS guidelines/model. The centralization of decision-making in the ARS, conditioned the ACES to intermediate management, with little room to maneuver”	The lack of autonomy, professionals, and units, in relation to the guidelines issued by central services is a recurring theme.
The weight of bureaucratic relationships as a reason for organizational fragmentation	R5 “Evaluate to judge and not to improve”	The analysis of the experts' responses reveals a series of obstacles that hindered the implementation of GCS in PHCs, with one of the most commonly mentioned being the burden of bureaucratic relationships.
	“A command and control, vertical, highly centralized governance model.”
	“A predominant focus on health care ‘production’ data and bureaucratic culture centered on ‘processes’ and compliance with ‘regulations’”
	R4 “The spirit of the initial framework law for the reform and subsequent updates never provided for an integrated view of the different areas of knowledge in primary health care.”
	“Professional and associative corporatism.”
	“An overly complex contracting model based on exhaustive registration processes far from health indicators has converted clinical governance into bureaucratic processes, distant from the user and demotivating for the professional.”
GCS as a facilitator of care integration	“the assumptions of GCS based on the participation of all, on the design of efficient and effective processes, and on the continuous improvement of practices that meet the needs of citizens” “a cooperative network with active and regular participation of the various teams at the levels of care” “foster the integration of care with the citizen at the center”. “it is mandatory to have information systems that guarantee knowledge management. Need for tools that facilitate integration” “overcoming challenges is done through communication”.	Although criticism focuses on the idea that the GCS is a top-down initiative, the common idea among this panel is that the GCS assumptions should be valued32. The experts' view is also that of creating a cooperative network that facilitates integration. Other experts believe that there is no past history of “promoting the exchange of information, common protocols, established pathways, or joint assessment of results”. This past will be important for what will happen in the future in order to achieve consensual and peaceful integration through open and direct communication. For the GCS to facilitate the integration of care, the experts felt it necessary to invest in improving the information system. Given that 87.0% of all citizens in mainland Portugal have a family doctor assigned to them, in order to be able to follow the path of these citizens in the health system, proper interoperability with the other integrated services would be enough.

• Source: Authors.

Based on the set of factors that influenced the development of GCS summarized in Chart 1, three questions were asked in the second round about the recommendation of micropolicies that would promote GCS in the LHU model. From this set of ideas, the following themes were organized, which are presented in Chart 2.

Chart 2
Micropolicies that promote GCS in the ULS model.

Study question 2 - Which micropolicies would best serve clinical and health governance in the new ULS organizational model?
Theme	Textual excerpts	Inductive analysis
Technological connectivity	R1 "Technological connectivity. Integration of care seems essential but the standardization of information systems”	Governance has driven the digital transformation of health systems, with the aim of improving access, quality, safety, and efficiency of care. This will always be a changing process, not only due to technological advances, but also because the priorities of citizens and professionals tend to be changing.
Incentives for participation	“Incentives for participation: A lot of work will be needed in fair and equitable people management and an incentive system that values joint work, prevention, access, and quality”	Working at GCS requires dedication, protected time and specific skills.
Definition of roles and responsibilities	R2 “The definition of roles and responsibilities: Clinical and health governance will always have to facilitate, promote, develop, and innovate processes of continuous improvement and excellence in care, based on the needs of the population, knowing how to identify priorities very well and assigning roles and responsibilities at each moment”	It is essential that each of the professionals involved understands the roles assigned to them, as well as their responsibilities. This clarity ensures a harmonious approach to the defined strategic priorities.
Face-to-face dialogues	R3 "Face-to-face dialogues: The policy must involve clarity and transparency of GCS actions, which must be based on the best evidence and experience to achieve health gains for users”	Fragmentation of care is well-known and multifaceted. One factor may be latent or perceived conflicts between professionals and institutions. Mistrust and stereotypes are common. Face-to-face meetings will aim to build consensus and trust, mutual respect, and shared commitment.
Strategic alignment	R4 “Strategic alignment: if the clinical management matrix has sequential planning between the ULS Action Plan, which integrates the Hospital Action Plan and the CSP, which in turn integrates the Action Plans of the USF+UCSP+UCC+URAP, and of the different Hospital services, it offers to Clinical Governance the necessary robustness, organization, and structure that facilitate its business monitoring.”	This alignment is recommended here to improve organizational performance.
Minimum requirements for GCS	R5 “Minimum requirements for GCS: Real accessibility to health services with the allocation of family teams and essential shared services as a gateway to the NHS.	These appear to be the basic criteria of a CG project, executable and achievable, to ensure that the project meets the needs and objectives of the organization.
	- Integration of care between the 2 levels of care, avoiding unnecessary costs and improving efficiency.
	- Shared and participatory leadership for decision-making and solutions to common problems.
	- Participatory management to ensure balance and compliance with the specific needs of both institutions.”
Culture of trust	clinical governance, it would have the following: Essential axes: - Pathway management/Qualifying access - Human resources - Knowledge management/Information system - Qualifying governance Values: - Empowering/Including/Sharing/Transparency Essential principles - (Re)designing processes - Simplifying/Debureaucratizing Change Management Plan - A strategic vision - public and shared commitment - Leadership - multidisciplinary, "led" by health professionals, with a "face" - An operational plan - transparency and accountability - Creation of collaborative networks (several units, etc.) to build these different processes	The contributions of different experts aligned in this creation of a common organizational culture where different professionals, teams, and units feel valued, respected, and able to contribute to common goals.
Establish metrics and measurement strategies	R7 “Establish metrics and measurement strategies: it is the responsibility of clinical governance to demonstrate that quality improvement projects and methodology fit appropriately into the business management model.”	The GCS is a system through which healthcare organizations are held accountable for continually improving the quality of their services and safeguarding high standards of care.
Communication, training and investigation	R8 “Communication, training and research: A GC that promotes, jointly, developed training and research and the sharing of results and good evidence-based practices.”	This proposal involves the efficient transmission of information, structured meetings, and ensuring that each UF is capable of learning, innovating, and evolving, which stimulates the motivation, involvement, and responsibility of all professionals, placing emphasis on continuous professional development.
Transparência de processos	R9 “Process transparency: Improve the overall efficiency of the institution, focused on people/needs and results	Stresses the importance of accountability, which implies means of evaluating and monitoring actions and their impact. This could promote greater credibility and, consequently, greater trust and commitment to the GCS process. The literature suggests that simple and clear rules and transparency of processes are important features of the GCS and care integration project.
	Commitment of the professionals involved and satisfaction of users and professionals. The fact that the factors that can directly and indirectly impact the results of the GCS is evaluated; Culture of transparency and accountability of the team involved”
Context	R10 “Context: In addition to the CA, there must also be two semi-autonomous bodies: a Clinical and Health Council and a Local Health Council”	This refers to the importance of citizen involvement in the design and provision of services and in adapting responses to the particularities of a community. Initially provided for in the ACES legislation; the creation of the Community Council was practically non-existent.

• Source: Authors.

Expert decision on micro-policies for GCS in the LHU model

In accordance with the recommendations of the Policy Delphi technique, a decision matrix was organized with the items resulting from the iterative debate, in which the experts were faced with a set of situational criteria: desirability, feasibility, importance, trust (in the validity of the argument or premise), and simplicity of implementation¹⁹.

Values between 1 and 4 were assigned to each criterion, with 1 being the least important and 4 the most important. The weighting of each criterion also varied from 1 to 4, with the corresponding percentage. Each expert filled out a table and the score for each criterion corresponded to its mode¹⁹. Finally, a single table was organized with all the valid responses and the mode of the scores obtained was calculated again. The mode obtained for these values shows that which was most frequent, as well as a general tendency to approve the micropolicy options presented to the experts.

As can be seen in Table 2, there was no micropolicy option that received unanimous values, although only one (Actions Based on the Best Scientific Evidence) received a value of 3. For this reason, we considered that all the remaining ideas could include our proposal for micropolicies that will contribute to an integrated CG.

Table 2
Experts' decision on policy components to be adopted for the implementation of Integrated Clinical Governance.

Micropolicies	Experts						Mode
	1	2	3	4	5	6
	Attributed score
Technological connectivity	4	4	4	3	4	4	4
Incentives for participation	3	4	4	4	3	4	4
Definition of roles and responsibilities	4	3	4	3	4	4	4
Face-to-face dialogues	3	3	4	3	4	4	3
Strategic alignment	4	3	4	4	4	4	4
Minimum requirements	4	4	4	3	4	4	4
Culture of trust	4	4	4	3	4	4	4
CG and quality assessment strategies	4	3	4	3	4	4	4
Communication	4	4	4	3	3	4	4
Transparency of the processes	4	4	4	3	4	4	4
Context	4	4	3	3	4	4	4

• Source: Authors.

Discussion

The legislation that was created successively recognized the strategic importance of CCS in the implementation and development of a GCS culture in PHC. In general, the experts recognized that CCS assumed this importance through their commitment to the skills that were assigned to them. However, despite the revisions to the law that governs the organization of ACES, the legal and regulatory framework for the exercise of CCS functions, their responsibilities, rights, and guarantees was never reviewed and improved, which may have contributed to a turnover of CCS teams, with the loss of acquired knowledge and experience. The low financial recognition does not seem to have overcome the internal motivation of some to seek a role that was perceived as important. The experts understood that it was the CCS that played a significant role in the development of GCS, since it was a project that became dependent on the motivation of the professionals involved, which began when it no longer had the support that had been guaranteed in the beginning. Several participants acknowledged that these were interested and dedicated professionals who carried out their responsibilities.

Changes cannot be seen only in terms of intentions. GCS requires a transformation at the level of the entire organization, for which clinical leadership and organizational cultures are particularly important. Organizational culture is the social glue that holds the entire organization together³⁵. However, in order to introduce changes, we must always consider, on the one hand, the rationalizing pressure of the state and, on the other, the technical-scientific aspect and the health professionals³⁶.

Experts understand that the development of GCS in the PHC was greatly conditioned by political drifts, which created discontinuity in the process, but they still voted for the initiative to be abandoned. Peering into the institutions, we can discuss strategic priorities, as is the case with CG|, but it will also be important to look at the context outside the organization. The impact of crises on health has been highly debated, particularly the 2010-2012 crisis, when Portugal was forced to sign a Memorandum of Understanding, with more than 50 measures and actions to be implemented in the health sector alone³⁷. With regard to budgetary policy, Portugal had to control costs in the sector, aiming to achieve savings of 550 million euros³⁸. The reinforcement should be in PHC, with the aim of reducing an unnecessary use of hospital consultations and emergencies.

It is in this context of discontinuing investments in CCS that ARSLVT, in 2017, took measures to frame and support CCS in their mission, as explained in the introduction.

Another essential aspect in this regard was highlighted by the experts when they stated that, although political choices did not prioritize GCS, a path was opened that could continue, largely at the expense of the culture of the interprofessional teamwork that had been created, which also influences the satisfaction of professionals. Interprofessional work is defined as a partnership with a collaborative, participatory, and coordinated approach, often focused on by experts, for shared decision-making on citizens’ social and health issues, tends to achieve better results and greater satisfaction when compared to multidisciplinary teams³⁹.

Health organizations are “complex adaptive systems” and for there to be a true integration of care, it is necessary to set up multidisciplinary teams that are sufficiently flexible and open to continually adapt and respond to the needs of individuals and families⁴⁰.

The PROs implemented in the ARS-LVT, from a GCS perspective, continue to be considered among the best examples of care integration, since, among other features, through a single IT platform, they are able to integrate all of the answers that people need, from screening to future treatment^14,15.

Despite this good example, the relationship between ACES, functional units, and ARS (PHC) was identified as a constraint on the integration of care. These were created as intermediate regional structures with the aim of obtaining greater gains in efficiency and productivity at the local level⁴¹. Since their creation, they have become the intermediate level of management intended for the implementation of health policy at the regional level. This role was often understood as a hindrance to the development of local projects and a hierarchical level, which could be abolished, especially because, since their inception, the autonomy of ACES was a legislative designation.

The concept of autonomy in health care is evolving from an individualistic approach to one that emphasizes relational responsibility, which promotes collaboration and shared decision-making between caregivers and users. This shift is essential to creating a more integrated and agile health system⁴². Portugal is currently facing a major organizational change that could negatively impact this issue. On January 1, 2024, the ARS (PHC) and respective ACES were extinguished with the creation of the LHU, merging the PHC with the hospitals¹⁷. Although it could be an opportunity to bring hospital and PHC professionals closer together, and therefore facilitate more integrated clinical practices, the new organizational model does not provide for a clinical and health governance device (the CCS of the former ACES have disappeared), and is structurally organized by professional hierarchies (clinical medical directors, nursing directors) and not by multidisciplinary teams to treat the needs of people and families, which could become an obstacle and even a setback with regard to the desired integration of care.

The experts reported that there was no collaboration or complementarity between UFs and organizations outside the ACES, which was evident both in the first round in response to a set of closed questions and in the second round, which allowed the experts’ ideas to emerge through open questions. Person-centered care is based on mutual respect and understanding, as well as on the promotion of the patient’s right to self-determination, which requires collaboration between professionals and between different structures⁴³. The increasing specialization of professionals and services represents, on the one hand, an opportunity for efficiency in the continuum of care, but, at the same time, a growing difficulty in coordination and integration⁴⁴. It is in this context that the experts understand that there has been specific cooperation. When multiple organizations are involved in the healthcare continuum, the limits to care integration are defined by policies, laws, regulations, cost assumptions, and cultural differences⁴⁵. Process management is nothing more than a methodology dedicated to creating horizontal management structures to facilitate the flow of value within and between organizations. We recognize that it is difficult to combine vertically oriented management with horizontal process management in health care. From the testimonies gathered, we understand that this incompatibility is the biggest problem facing CG.

The experts highlighted the issue of overvaluing the indicators and the consequences of the asymmetries and inequalities that emerged from this. It is important to note that although the initial idea was to cover the entire country with FHUs, only partial coverage (around 67%) was possible until 2024, which has generated inequalities that have continued over time for professionals and users^13,46. The FHU (voluntary membership by professionals) began to have a “controlled” population with incentives for performance, while the UCSP had to bear the pressure of users without a family doctor, proportionally with fewer professionals, without incentives for performance and, in general, with access to less investment in working conditions. These inequalities added even more challenges to the work of the CCS in supporting the UF and the GCS’s goals.

Although these types of indicators provide an objective and quantifiable means of assessing performance, reliance on quantitative data can introduce problems, such as reductionism (indicators reduce the complexity of facts to simple numbers) and potential misalignment with real objectives. Measurement will always depend on the quality of the recording^47,48.

These difficulties led to the search for indicators that assessed the overall performance of PHC (as in the case of IDG), a multifaceted concept that involves metrics and frameworks to assess the quality, access, and effectiveness of PHC in many countries⁴⁹.

However, in terms of overvaluing indicators, it is important to note that the comparison of international quality indicators revealed that Portugal performs above the average of the countries of the Organization for Economic Cooperation and Development (OECD), both in terms of indicators related to avoidable hospital admissions and in the indicator related to hospital admissions due to major lower limb amputations in diabetic patients (year 2022)⁵⁰. This creates internal tension between those who claim that the results of the indicators do not always correspond to better health outcomes for citizens and the positive results obtained in comparative studies.

Incentives, particularly financial incentives, serve as mechanisms to stimulate improvements in the quality of care provided in PHC, as demonstrated by the results obtained, in order to respond effectively to the changing health needs of the population⁵¹.

The micropolicy components that were presented to the experts were given equal emphasis, with the exception of actions based on the best scientific evidence. Compliance with the minimum requirements describes what is the starting point for the project to begin, without which results will not be achieved. Citizen and community participation should be the starting point, as it will guarantee relevance and responsiveness. The digitalization and integration of information systems, in close conjunction with the learning organization, facilitate the adaptive process, creating rapid responses to new situations and challenges. The valorization of work in the area of GCS should be negotiated with all stakeholders and is intended to guarantee integration. The definition of roles and responsibilities deserves emphasis, as it ensures that all stakeholders are aware of their responsibilities. Ensuring strategic alignment requires sequential planning of responsibilities and contributes to the creation of trust. A culture of trust is centered on a shared and dynamic understanding of the group’s stories and values. Quality assessment strategies should also be aligned with the national strategy, recognizing that any intervention to improve quality will have an impact on the quality perceived by the user.

Study limitations

An exploratory, cross-sectional, qualitative study conducted with a group of 10 experts has important limitations to consider. The number of participants, even if adequate, may not encompass the full range of views and perceptions on the subject¹⁹. There is a possible sampling bias, since the selection of experts may not represent the relevant community, possibly omitting significant views. As it is an exploratory study, it does not offer conclusive answers, but only indicates paths for further studies. The qualitative methodology works with the subjectivity of the statements, which reflect participant experiences. The final agreement may result from the wear and tear of a process divided into three distinct stages, each with several dissertative questions.

Conclusions

Despite its limitations, the study represents an initial analysis of GCS in PHC.

The panel’s experts identified the importance of CCS in advancing GCS. They also highlighted economic and sociopolitical obstacles to the project’s progress, recognizing that the dispersion of care and the disparities between the UFs that make up the system create real difficulties for horizontal integration in PHCs. They agreed that clinical activities, especially in FHUs, are geared towards performance indicators.

The generalization of LHUs needs to be accompanied by the development of a new model of clinical and health governance that frames, interconnects, and guides all teams in health centers and hospitals (vertical integration).

The socioeconomic limitations highlighted in this study do not justify unfinished projects, since they do not always depend on financial resources, but rather on effective leadership.

Acknowledgements

The authors would like to thank the review board, whose contributions were essential to producing this article.

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• Chief editors:
  Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva

Publication Dates

• Publication in this collection
  11 Aug 2025
• Date of issue
  July 2025

History

• Received
  06 Dec 2024
• Accepted
  24 Feb 2025
• Published
  26 Feb 2025