Bob Nicholls - Associate Consultant for Health Management
The British Council
The main emphasis in the Labour government's plans to modernise and develop the British National Health Service (NHS) is improving the quality of clinical care available to all patients. 'The new NHS will have quality at its heart' 1. One of the main methods by which this is to be achieved is the introduction of a statutory duty on NHS bodies for quality from April 1999 through the introduction of 'clinical governance'.
Clinical governance has been defined as a 'framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish' 2.
The term 'clinical governance' has been attributed to Professor Liam Donaldson, the newly appointed Chief Medical Officer for England, which may ensure that it is rather more than a current political fad and that its implementation and development will be sustained. Also it appears to many commentators that it is an entirely appropriate focus on what should be the NHS's 'bottom line' - clinical care. Until now NHS Boards and Chief Executives could be sacked for failure to manage their finances but not for a preventable breakdown in clinical care. 'Clinical governance' will extend the statutory responsibility from finance to clinical activity.
'Clinical governance' also neatly extends the concept of 'corporate governance' - imposing a duty on Boards to conduct their business in a proper manner and to take corporate responsibility for it. This notion of collective responsibility at the highest level in the organisation extended for the first time into the clinical field is the key feature of the new proposals. Although clinicians will play a key role in developing evidence based standards and protocols, the government and their agents - the NHS Boards and Chief Executives, will drive the quality agenda on behalf of patients.
The roots of the change
The need for a shift from a focus on measuring activity and cost to a focus on quality and effectiveness is the result of the increasing evidence of wide variations in clinical practice, the disappointing results from clinical audit, the alarming rise in complaints against doctors and in clinical negligence claims (up to over £200 million in 1996/7), and a series of recent high profile scandals culminating in the Bristol children's cardiac surgery disaster. This has brought into sharp relief what Donald Light describes 3 as the age-old problem of the major funder of care being accountable for services over which it has little control - 'the doctrine of clinical autonomy reigning supreme'. Perhaps more significantly, clinical leaders are recognising the need for fundamental change in the relationship between the role of physician and society. As Sir Cyril Chantler, Chair of the GMC's standards committee, put it recently:
'medicine used to be simple, ineffective and relatively safe. It is now complex, effective and potentially dangerous. The mystical authority of the doctor used to be essential for practice, now we need to be open and work in partnership with our colleagues in health care and with our patients.'
The government's proposals
There is to be an extensive national framework for performance management with evidence based standards and levels of service, clinical guidelines and performance reviews. The government wants clinical decisions to be based on the best possible evidence of effectiveness and national service frameworks will lay down standards of care for different groups of patients. Responsibility for delivery will be local but driven by the organisation's responsibility for clinical governance backed by consistent monitoring arrangements.
'Clinical governance will be the process by which each part of the NHS quality assures its clinical decisions...it will introduce a system of continuous improvement into the operation of the whole NHS' 2.
It will be backed by lifelong learning for staff to update their skills and knowledge and by the improved models of professional self regulation being developed by licensing bodies like the General Medical Council and United Kingdom Central Council for Nurses, Midwives and Health Visitors. Basic clinical governance requirements will be introduced by NHS trusts early in 1999 and they will be required to produce their first clinical governance reports in Spring 2000.
Clear lines of responsibility and accountability for the overall quality of clinical care - Chief Executive carrying the ultimate responsibility; designated senior clinician responsible for ensuring systems in place and for monitoring their effectiveness; Trust Board to be closely involved through a clinical governance committee and regular clinical care reports to the Boards; annual report on clinical governance.
Comprehensive programme of quality improvement activities - full participation in internal and external audit by clinicians and in national confidential enquiries like CEPOD (Confidential Enquiry into Perioperative Deaths); ensuring clinical standards of national service frameworks and of NICE (National Institute for Clinical Effectiveness) are implemented;
Clear policies aimed at identifying and managing risks.
Procedures for all professional groups to identify and remedy poor performance - critical incident reporting; open complaints procedures; professional performance reviews; clear procedures for staff to report concerns about colleagues' conduct and performance; etc.
Similar procedures are to be developed in primary care settings through the new Primary Care Groups.
Although the principal of clinical governance is relatively simple and has been widely welcomed, it is a complex concept open to many interpretations and involving major system and cultural changes which will be difficult to implement. There is increasing concern that considerable resources will be required for strengthening information systems and for the training and development of staff. Also time and care will be required to develop robust and sustainable systems and it may well reveal quality deficits that will require resources to redress. Given the failure of the internal market to accelerate the quality of data collection and analysis, one of the main barriers to implementation of clinical governance may be access to relevant information. The new NHS Information Strategy 4 points in the right direction but it is likely to be many years before it is fully completed. Meanwhile, the danger of any serious quality failure being attributed to a failure of clinical governance will need to be resisted - a blame culture will need to be avoided.
The new arrangements for ensuring quality are claimed as part of Labour's new 'third way' - 'rejecting the grey uniformity of central control as irreconcilable both with clinical judgement and with individual patient needs. Equally it dismisses laissez-faire local competition as inefficient and incompatible with the drive to ensure all patients...have access to the same high quality care' 2.
Clinical governance is a key part of this new approach and while it appears to give government endorsement to local collective responsibility for quality care, it may mark a significant shift away from clinical autonomy and towards more central government control. Nevertheless it is potentially one of the most important developments in the history of the NHS.
1 'The new NHS: modern dependable' HMSO White Paper Cmnd.3807. Dec.1997
2 'A first class service: quality in the new NHS' DHSS Consultative Document July 1998.
3 'Effective commissioning: lessons from purchasing in America' Donald Light OHE 1998.
4 'Information strategy for the NHS' Department of Health July 1998.
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