Clinical Governance

A Guide to Implementation for Healthcare Professionals

Robert McSherry, Paddy Pearce

• Publisher: Wiley-Blackwell
• Year: 2011
• ISBN:
  9781118276020
• Edition: 3
• Topic: Medicina
• Subtopic: Tecniche infermieristiche

Clinical Governance: A Guide to Implementation for Healthcare Professionals provides a comprehensive overview of what is meant by clinical governance and how it can be implemented in practice. It explores the evolution of clinical governance, its key components, legal implications, the barriers to implementing it, and its impact.

Clinical Governance provides step-by-step practical advice, facilitating better understanding of the key principles of clinical governance. This third edition has been fully updated throughout to incorporate a more integrated approach to achieving clinical governance, with an additional chapter on education and training. Each chapter includes reflective questions, activities and case studies taken from clinical practice as well as a full list of references and further reading.

Chapter 1
Introduction and Background: Clinical Governance and the National Health Service

Rob McSherry and Paddy Pearce

Introduction

This chapter briefly describes the term ‘clinical governance’, identifying the key drivers for its inauguration into the National Health Service (NHS). The term ‘clinical governance’ became prominent following the publication of New Labour’s first White Paper on health, The New NHS Modern and Dependable (Department of Health 1997). Within this document the government sets out its agenda of modernising the NHS by focusing on quality improvements. Clinical quality is rightfully assigned centre stage by ‘placing duties and expectation on local healthcare organizations as well as individuals’ (DH 1997, p. 34) to provide clinical excellence. The vehicle for delivering clinical quality is termed ‘clinical governance’, which ‘is being put in place in order to tackle the wide differences in quality of care throughout the country, as well as helping to address public concern about well-published cases of poor professional performance’ (King’s Fund 1999, p. 1). We believe that a complicated series of multiple factors have contributed to the development of clinical governance agenda within healthcare. These can be distilled and categorised into three main drivers: political, professional and public demands, all attempting to revive a failing NHS and improve the quality of care that the public should rightfully expect in a modern society (McSherry 2004).

Background

Why the need for clinical governance?

The literature offered by Scally and Donaldson (1998), Harvey (1998) and Swage (1998) attributes the need for clinical governance because of a decline in the standards and quality of healthcare provision, a point reinforced by the government. ‘A series of well publicized lapses in quality have prompted doubts in the minds of patients about the overall standard of care they may receive’ (DH 1997, p. 5). Upon reviewing the early literature (Donaldson & Halligan 2001) on clinical governance we have noted that a key question had not been fully addressed in establishing why there was a perception in the decline of standards and quality. Possible reasons for this perception could be attributed to the following. Firstly, healthcare professionals and the public are better informed and educated and are interested in health-related issues, thus demanding high quality service provision. Secondly, quality and clinical standards have taken a back seat to other financial and resource management issues. Thirdly, political and societal changes have led to a consumerist society where patients and their carers expect to choose where and when they access healthcare. Fourthly, high quality care is seen as a prerequisite. Within this chapter it is our intention to explore the factors that may have contributed to the introduction of clinical governance.

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Activity 1.1 Reflective question.

Write down the factors that you feel may have led to the introduction of clinical governance.

Read on and compare your answers with the findings at the end of the chapter.

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No single factor has and transformation led to the government’s current position for modernisation, reform. We argue that patients’ and carers’ expectations and demands of all healthcare professionals have significantly increased over the past decade. In the 1980s and early 1990s, public awareness of healthcare provision was increased through target facilitation by the publication of significant documents; notably, The Patient’s Charter (DH 1992) and The Citizen’s Charter (DH 1993) both of which were readily and freely made available to the public. On the one hand, these charters may have increased patients’ and carers’ expectations of healthcare by offering information about certain rights to care. On the other hand, the responsibilities of the patients to use these rights in a responsible way have been over used, resulting in higher demands for care and services in an already busy organisation. Between 1990s and 2005, we have seen a huge emphasis placed on patient and public involvement (PPI) in the planning, delivery and quality assessment of care. Public and patient involvement has been targeted at both a national and a local level both directly and indirectly through the establishment of Patient Advisory and Liaison Services (PALS; DH 2000a) within every NHS organisations. Nationally, we have witnessed the establishment of the Commission for Patient and Public Involvement (DH 2003) resulting in the creation of Patient and Public User Involvement Fora. Similarly, the development of the Overview and Scrutiny Committees for Health (HMSO 2002) with the sole purpose of seeking and representing public opinion on the quality of healthcare. Between 2008 and 2009, further reforms have been introduced surrounding patient and public involvement. We have seen the demise of Patient and Public Involvement Fora and the introduction of Local Involvement Networks (LINks; DH 2008a) which embraces a joined up approach to patient, client, carer and/or user involvement within health and social care and local government. The aim of LINks as defined by the DH (2008a, p. 1) is

to give citizens a stronger voice in how their health and social care services are delivered. Run by local individuals and groups and independently supported – the role of LINks is to find out what people want, monitor local services and to use their powers to hold them to account.

In addition, other contributing factors such as changes in health policy, demographic changes, increased patient dependency, changes in healthcare delivery systems, trends towards greater access to healthcare information, advances in health technology, increased media coverage of health care and rising numbers of complaints going to litigation have influenced the need for a unified approach to providing and assuring clinical quality via clinical governance (Mc Neil 1998). These will now be debated in further detail under three broad headings and associated subheadings (Fig. 1.1).

Political

Political drivers for governance should be viewed with both a capital and a small ‘p’. The capital ‘P’ refers to those drivers resulting directly from government and policy. The small ‘p’ relates to organisation and personal factors that influence change and policy decision-making at a local level, a view held by Jarrold (2005)

Fig. 1.1 The drivers of clinical governance.

politics with a small p makes the world go round. Getting things done, seeking support, building alliances, compromising – that’s all politics, and inescapable and natural. (p. 35)

The challenge for healthcare professionals is translating policy into practice and keeping up-to-date with changes in healthcare policy.

Changes in health policy

In brief, the NHS was established in 1948 following the passing of the National Health Services Act 1946 which committed the government at the time to financially funding the health service ‘which rested on the principles of collectivism, comprehensiveness, equality and universality’ (Allsop 1986, p. 12. The politicians at the time thought that by addressing the healthcare needs of the public, this would subsequently reduce the amount of money required to maintain the NHS. The assumption being that disease could be controlled. However, this was not the case. The NHS activity spiralled, resulting in uncontrollable year-on-year expenditures to meet the rise in public demand for healthcare. In an attempt to manage this trend, the government introduced the principles of general management into the NHS (Griffiths Report 1983). The philosophy of general management was concerned with developing efficiency and effectiveness of services. The rationale behind this report was to provide services that addressed healthcare needs (effectiveness) within optimal resource allocation (efficiency). It recommended

that general managers should be appointed at all levels in the NHS to provide leadership, introduce a continual search for change and cost improvement, motivate staff and develop a more dynamic management approach. (Ham 1986, p. 33)

Key organisational processes identified as missing in the report.

Absence of this general management support means that there is no driving force seeking and accepting direct and personal responsibility for developing management plans, securing their implementation and monitoring actual achievement. It means that the process of devolution of responsibility, includi...