Clinical Governance in the UK National Health Service.

In 1991, the Conservative Government under Mrs. Thatcher, realising that there were cost inflation pressures within the NHS for which there was no mechanism for control or accountability, designed the 'Internal Market'. The whole service was divided into notional 'purchasers', Area Health Authorities and larger family doctor practices, who would control their own defined budget on behalf of their population by commissioning services, and 'providers', hospitals and community services designated 'Trusts' from whom care would be 'bought'. Funding would, in theory, follow the patient who would go where services were best and cheapest. This experiment was at best a partial success but served to define areas of deficiency of provision and to begin a process of accounting total work against total cost. The NHS has recently been restructured again so that commissioning is undertaken by new 'primary care groups' (PCGs) but remains a paragon of fiscal control in healthcare.

A number of healthcare scandals, particularly the institutionally concealed very poor paediatric cardiac surgery results from Bristol, and failures of breast and cervical screening programmes elsewhere exposed inequalities of standards, provision and access to services. In 1997 the current Labour government initiated a framework endorsed by all the medical and paramedical professional bodies aimed to raise standards and prevent future system failures - Clinical Governance. It has national and local elements.

In 1999 the national elements, two statutory bodies, were established. The first, the National Institute for Clinical Excellence (NICE) evaluates treatments for effectiveness and cost and recommends optimal treatment in a given circumstance so that its recommendations become treatment standards. The second, the Committee for Healthcare Improvement (CHI) evaluates the outcomes being achieved. A recent evaluation of care provided by all UK hospitals allocated a rating of 0-3 stars. Results of cardiac transplant centres have been assessed and one with poor results has been closed.

Local elements are:

. Continuous (personal) professional development

2. Professional revalidation

3. Involvement in audit and implementing the audit cycle

4. Risk management processes including a 'no blame' culture

5. Evidence based practice - setting, delivering and monitoring standards

6. Patient and carer experiences - accountability to patients

In order to implement the above, all departments have identified individuals responsible for each of the elements of Clinical Governance and all elements are considered during the annual appraisal of each employee.

Problems encountered have included:

. Shortage of time, resources and skills necessary for the new tasks

2. Use of new managerial language and ideas - perceived shifting of power from doctors to managers

3. 2 perceived as threatening - failure to engage some individuals

4. Perceived distance between language and reality of process, i.e. Clinical Governance often does not affect how patients are treated

5. Implies culture change

Conclusions:

Clinical Governance is the framework for the implementation of a national strategy to improve quality of care in the UK NHS. It is a large and ambitious programme to be implemented over 10 years. Good early progress has been made but success requires a major change in culture and behaviour throughout the organisation.