CONTEXT OF PRACTICE: HS801
Clinical Governance in the UK
Introduction
Clinical governance is defined as the ‘framework through which National Health Service (NHS) organizations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish’ (Scally and Donaldson, 1998). There are three key attributes by which the definition embodies: recognizably high standards of care, transparent responsibility and accountability for those standards and a constant dynamic of improvement. In simpler sense, clinical governance affects the delivery of care, and through this virtue that clinical governance must be of highest priority and quality. Nonetheless, the structures, systems and processes that assure high quality care services are often the root of criticisms not only because of the process itself but also by which NHS takes accountability in clinical governance (Swage, 2004[ivl1] ). In this report, the concept of clinical governance through the seven pillars of clinical governance model will be analyzed and how seriously does the NHS take full responsibility in delivering clinical governance in the United Kingdom. Insights, perspectives and criticisms will be built upon the six elements of clinical governance and with emphasis on risk management particularly person-centered risk and system-centered risk.[s2]
The concept of clinical governance
Swage (2004) contends that like any other new idea, initial reactions are usually reactive and often defensive; clinical governance is no exception. Clinical governance, as the author argues, in essence is an opportunity for clinicians to take a lead role in the delivery of health care, to demonstrate how such action could be done effectively and to learn and share practice in a structured way. Clinical governance, as a relatively new conception, also emphasizes the opportunity for health care professionals to fulfill their obligations concerning continued development apart from implicitly addressing the issues of limited resources and poor access to further training and development.
In lieu with this, one of the necessary analyses of clinical governance is its fit with the NHS scheme. [s3]The NHS intends that clinical governance shall position itself with a closer integration with other NHS policies and will not operate in isolation or either function belligerently with other NHS initiatives. It is important to note is that clinical governance was established to redress imbalances within the NHS (The New NHS, 1997). [s4]
Watson (2004) claims that there is the possibility that clinical governance could lead to poorer patient care quality. This is because clinical governance is very target driven especially when it comes to throughput and adverse consequences, outing professional accountability may be in jeopardy. Clinical governance has a clear focus on health professionals’ responsibility to maintain safety of service users though rigid interpretation of professional rules of conduct. Such an idea could contribute to a conservative approach of patient-initiated activity which could be challenging and dangerous in nature (as cited in Watson, 2004, p. 43[s5]). Another criticism which sprung from the previous argument is how do the human rights of the patients or service users get into account within clinical governance. Also how does the cclinical governance framework encourage proactive and reactive expertise of practitioners is another topic of hot debate. Wagner (2004) noted that another criticism of clinical governance is its short-cutting aspects. The framework is designed to address health care initiatives faster thus reducing the effectiveness of practitioners. Since clinical governance persuades healthcare professionals to follow an evidence-based medicine practice, the experience and judgment of these professionals are inherently bypassed. Experience is a crucial part of professional development (Watson, 2004, p. 43)[s6]
Another criticism is how clinical governance is going to affect the performance of practitioners. Watson (2004) argues that clinical governance is “a clear manifestation of public and government frustration with the health services” (p. 39). Briefly, the author states that the reasons behind clinical governance is that within NHS, there was a plethora of quality initiatives but they dlivered no improvement while some do not achieve anything at all; as evidenced by the existence of medical scandals (Braithwaite and Travaglia, 2008). Clinical governance was seen to be a solution to this dilemma while also aiming to improve quality and patient care within the NHS. Not everyone is convinced, however, especially those proponents of ethical-based medicine. There are criticisms that clinical governance will leave doctors with less functioning as well as totally abolishing the roles of experts aside from being institution-centered. What the NHS did is to introduce the six elements which will put emphasis on evidence-based practice and patient-driven intervention. However, even these six elements are not exclusive of criticisms.
The six elements of clinical governance
Van Zwanenberg and Harrison (2000) maintain that ‘clinical governance remains a powerful and comprehensive mechanism in ensuring that high standards of clinical care are sustained throughout the NHS and that the quality of service is continuously improved’. This is carried out by committing to the six elements of clinical governance: education and training, clinical audit, clinical effectiveness, research and development, openness and risk management (Starey, 1999[s7]). The first element suggests that the whole medical community has no excuses whatsoever in tying up with the academic community, especially that different funding schemes are now available. In support of the continuing professional development, employers and relevant professional bodies are required to fund education of medical practitioners and other health professionals (Halligan and Donaldson, 2001). For instance, the NHS Trust takes full responsibility in the education of clinicians and clinicians have likewise the professional duty to remain updated. There is one problem though as Starey (1999) noted: education has been traditionally and is still individualistic in nature and that collective education has not been adequately addressed. Expectedly, such a condition has a downward effect whereby the health needs of the community as well as the requirements of the NHS could not be effectively responded to.
Clinical audit means the review of th clinical performance, the refinement of a clinical practice and the measurement of performance against standards – a cyclical process by which the quality of clinical care could be improved. Auditing is a traditional medical practice, and participation in the process is a requirement for all NHS Trust employees (Scally and Donaldson, 1998). Trained staff and committees of the NHS Trust facilitate clinical auditing and it is carried out in primary care through the Medical Audit Advisory Groups (MAAGs) because auditing at this level has only been encouraged and not mandated, depending on the availability of audit time (Braithwaite and Travaglia, 2008). Aside from this, even the NHS admits that the practice of clinical auditing varied from place to place depending on the importance given into it and also the funding, making it difficult to sustain the clinical audit activity unique to the clinical setting. Starey (1999)[s8] insinuated that since clinical audit does not involve the service users, the NHS and Health Authorities are encouraged to develop a framework to address such if it means to promote and sustain clinical effectiveness. Thereby, the integrated clinical governance requires that the clinical practitioners must conduct a formal audit programme where the formal steps will be closely adhered to (Halligan and Donaldson, 2001). In reality, however, not all practitioners adopt auditing specifically in the primary care where clinical audit is not underpinned by contractual agreements (Baker, 2001). How are clinical practitioners going to adopt a practice that is not even furthered by health care policy? How are practitioners going to adopt a clinical governance framework which is not firm in making clinical audit an effective contributor to quality care improvement schema?
A related element is clinical effectiveness which refers to the measure of how effective a particular intervention is. Two among the most important aspects of clinical effectiveness are appropriateness and value for money. Thereby, evidence is critical, and not only that, it is iportant is the process of making service users understand the processes that they are being subjected to the name of care (Scally and Donaldson, 1998). Clinical effectiveness reminiscent of the two concepts which are, from a personal standpoint, interrelated. These are personalization and triangle of care. The former refers to the increased ability of the people to have choice and control over the shape of support in all care settings while the latter refers to the collaboration between health professionals, service users and carers. In order for a clinical intervention or prevention to be effective, the health care policy must encourage ownership of decision-making in terms of healthcare. It is only through this context that the NHS could improve the responsiveness of the services as evidence of effectiveness aside from the integration with the National Service Frameworks, National Institute for Clinical Excellence (NICE) and the Commission for Health Improvement (CHI).
The implementation of research practices has also been critical in developing sound professional practices as a result of evidences. Research and development hence centers the effort to reduce time lag and associated morbidity as the emphasis is given not only on carrying out the research but also utilizing the information and implementing. Starey (1999)[s9] asserts that research and development are important in advancing operational practice into areas of agreed national priorities. Given the fact that all organizations shall provide high quality of care as a way to respond to the needs of the population it serves, therefore, when implementing research or just putting theories into praxis, transparency is a must and despite of public scrutiny. Through this way, NHS could possibly embed quality improvements into the health service at a structural level without ‘undermining the confidence of the public to NHS’ through the process (as cited in Halligan and Donaldson, 2001).
In making sense of the word ‘quality’, quality must be in existence for patients/service users, practitioners and organizations’ perspectives through effective risk management. For patients, specific ways to minimize risks are through regular, ongoing review of systems and practices, learning from complaints and complying with statutory regulations and medical ethical standards. There are also three ways by which the risks for clinicians could be diminished: by immunization, by ensuring a safe environment and by up killing and enhancing[s10] knowledge base (Scally and Donaldson, 1998). As Starey (1999)[s11] puts it, poor quality is a threat to an organization. Indeed, organizations should be also committed to quality improvement through ensuring high quality employment practices as well as a safer workplace and well-designed public involvement policies. From a personal standpoint, a better way to make this stance materialize is by means of managing and mitigating risks to the three groups, separately but also cooperatively. The approach must be proactive where a holistic identification of risks to the patients, to the professionals and to the organization including clinical, organizational and financial shall be a priority of the NHS Trust (Halligan and Donaldson, 2001). As such, the NH must be both operational and strategic in thinking and responding to risk management as coupled with quality assurance (Risk Management Strategy online; (Braithwaite and Travaglia, 2008).
While at risk management, clinical governance had always been criticize because of lack of person-centeredness base. James, Kendall and Worrall (2005, p. 322) states that the consideration of vulnerable people whose lives are virtually completely shaped and dependent upon formal human services presents a challenge to the technological and technocratic nature of modern formal human services. Clinical governance is not an exemption where the challenge is making human services more ‘humanised’ and less system-serving. As such, health policy shall focus on the need for person-centered values if it means to genuinely reflect an effective way to address person-centered notion of risk. Being person-centered as tied with the quality approaches, clinical governance should involve effective means of addressing lesser choices and access to primary health services, lesser social integration and lesser engagement in community-based activities.
If clinical governance is serious and committed in improving the life conditions of people in the UK, it should start with shifting from a system-oriented to people-centered governance. Clinical governance still embraces a ‘statutory duty of quality’ by which string organizational and systematic focus, supporting leadership development, structural and organizational change and incorporation of decision-making into a management and organizational framework characterizes clinical governance (James, Kendall and Worrall, 2005). Simply, although clinical governance thrives at servicing, it is more politically driven which puts greater weight on utilizing service user and professional balance. These are system-centered risks that must be mitigated especially that clinical governance is always equated with the concept of quality. Although clinical governance is basically a system aside from being a part of a wider government system, it would be necessary to strike a balance between being system-centered and person-centered to make services more humanized and with long-term benefits.
Conclusions
From the aforementioned above, it is clear that clinical governance is a crucial issue. Clinical governance concerns high quality care which is being delivered for the right patient at the right time and in a coordinated manner. Although clinical governance is a framework accepted in the healthcare community, there still prevail criticisms of the processes, systems, policies and implementation of clinical governance with emphasis on the NHS. Important for any organization committing to the framework is a clear understanding of the process of continuous improvement, quality assurance, clinical, applying and meeting standards, utilization of clinical indicators, encouraging clinical effectiveness, promotion of evidence-based practice, improving information sharing and effective knowledge management, supporting open disclosure, ensuring sound patient-healthcare professional relationship, credentialing medical practitioners and encouraging consumer healthcare decision-making. Realizing this, this report claims that clinical governance could be achieved through a range of strategies, making it an integrated framework as it is. In addition, if clinical governance would not be able to meet system-centeredness and person-centeredness at the middle, quality would not be achieved and that human services will only reached a very limited public.
Reference:
Baker, M 2001, The Bristol report: implication for clinical governance in primary care, The Journal of Clinical Governance, vol. 9, no. 3, pp. 109-111.
Braithwaite J and Travaglia, J F 2008, An overview of clinical governance policies, practices and initiatives, Australian Health Journal.
James, A J B, Kendall, T and Worrall, A 2005, Clinical Governance in Mental Health and Learning Disability Services: A Practical Guide, RCPsych Publications.
Halligan A and Donaldson L 2001, Implementing clinical governance: turning vision into reality. British Medical Journal, vol. 322, pp. 1413-1417.
Risk Management Strategy, retrieved on 8 December 2008, from www.salisbury.nhs.uk/media/trustreportsandreviews/riskmanagementstrategy.doc.
Scally G and Donaldson L J 1998, Clinical governance and the drive for quality improvement in the new NHS in England. British Medical Journal, vol. 317, pp. 61-65.
Secretary of State for Health 1997, The new NHS, Stationery Office, London.
Starey, N 1999, ‘What is clinical governance?’, Evidenced-based medicine, Hayward Medical Communications, retrieved on 9 December 2008, from http://www.evidence-based-medicine.co.uk/ebmfiles/WhatisClinGov.pdf.
Swage, T 2004, Clinical Governance in Health Care Practice, Elsevier Health Sciences.
Van Zwanenberg, T and Harrison, J 2000, Clinical Governance in Primary Care, Radcliff Press, Oxford.
Watson, R 2004, ‘Accountability and Clinical Governance’, in S Tilley and R Watson, Accountability in Nursing and Midwifery, Blackwell Publishing, pp. 38-46.
[ivl1]I think the reference should be here. If I am going to put it at the end, it will appear as if my introduction of the topic and the content of the report was taken from somewhere else.
[s2]another reference maybe to support this cynicism,!!!
[s3]The – don’t forget the definite article
[s4]For the reference put the New NHS not the Secretary of State
[s5]put in date please
[s6]put full reference
[s7]find a date please
[s8]date
[s9]date
[s10]does this mean improving??
[s11]date
Credit:ivythesis.typepad.com
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