Mention the words Clinical Governance to a group of doctors and I guarantee that it will only succeed in generating apathy. Most will regard it as on a par with appraisal, revalidation and emptying your bowels – something necessary to do on a regular basis, but not to spend too much time on if possible.
The very word ‘governance‘ has a ring of boredom about it and conjures up a picture of men in grey suits, dull meetings, masses of turgid reports and many hours wasted when we could be doing something more useful. Putting the word ‘clinical’ in front of it seems to give it a spurious respectability but the reality is that most doctors think it should be left to the managers and a few geeky clinicians to sort out.
And indeed they do! If you go to the data banks of any trust today you will soon find reams of policies and procedures, governance committees, lines of accountability and individuals with important sounding titles like ‘Governance Lead’ and ‘Head of Patient Safety’. Hours will be spent collecting and collating all sorts of data such as drug errors, trips and falls, hospital acquired infections, clinical adverse events etc. Much of this data collection is a statutory NHS requirement and trust boards are required to review it on a regular basis.
So why is it that many doctors do not appear to take CG more seriously? I think the answer is that although the processes may look good on paper many doctors have little confidence that the system will actually result in organisational change. To give a straightforward example they may discover that the ward staffing levels are unsafe. But when they raise it as a ‘Clinical Adverse Event’ reported through the rather cumbersome DATIX system (which many use) nothing seems to happen and no one takes any notice. We can all think of multiple similar examples throughout the NHS.
The consequence of this is clinical disengagement which was one of the main conclusions of the Francis Report into the Mid Staffs debacle.
Interestingly the recent Kennedy Report highlighted something similar. For the uninitiated, this report is a review of the response of Heart of England NHS Foundation Trust to concerns about Mr Ian Paterson’s surgical practice. Report author Prof Sir Ian Kennedy - who also famously chaired the inquiry into the Bristol heart surgery scandal in the 90s - makes a series of recommendations.
When doctors raised clinical concerns based on robust audit data they were ignored for years. When finally the trust management took action they went down the HR route (personal conduct) rather than the clinical route. Consequently immediately everything to do with the matter was cloaked in confidentiality so that the doctors involved had no idea what, if anything, was happening.
However I believe that Clinical Governance is something that is of fundamental importance and that all doctors should be actively committed to the process. If it doesn’t work then it behooves us to find ways to make work. Ignoring the issue or leaving it to others is simply not an option.
In a recent thoughtful blog Anton Joseph highlighted that there is little confidence that appraisal and revalidation will identify poorly performing doctors. From my own experience I know this to be true. But my contention is that if clinical governance is deeply embedded in the culture of a hospital and that all clinical and managerial staff are committed to it then there is a good chance that bad clinical practice or a poorly performing doctor will be exposed before too much damage is done. Robust data collection from multiple sources will allow a vigilant governance team to triangulate information and highlight concerns.
Here I must declare an interest. I have recently started working (in my own time) as an adviser to the Clinical Governance unit of Capsticks, a large legal firm specialising in health and social care. Working in conjunction with a highly experienced group of associates (medical, managerial and nursing in both primary and secondary care) the unit provides a variety of NHS organisations with assessment, support and training for both corporate and clinical governance issues.
The aim is not just to wag a finger at the clients telling them what they are doing wrong (which they probably already know), but to actively work with them to find solutions. The NHS tends to wait until disaster strikes before acting, but surely it is far better, and ultimately cheaper, to be far more proactive with regard to governance. Fire prevention seems a better way rather than belatedly calling the fire engine once the house is ablaze.
For me, the work I have done so far has been both challenging and highly educative. All good clinical staff have a passion to see things done better, and the quality and governance agendas should go hand in hand together. I can sense a bit of missionary zeal rising in my soul.
The NHS world has changed since Francis and Kennedy. We need to change with it.