Introduction

Clinical governance has been described as “by far the most high-profile vehicle for securing culture change in the new NHS.”1 However, the government's past preoccupation with delivery and top down performance management has undermined its developmental potential.2 To be effective, clinical governance should reach every level of a healthcare organisation. It requires structures and processes that integrate financial control, service performance, and clinical quality in ways that will engage clinicians and generate service improvements.3 We strongly endorse this view. Because clinicians are at the core of clinical work, they must be at the heart of clinical governance. Recognition of this fact by clinicians, managers, and policy makers is central to re-establishing “responsible autonomy” as a foundation principle in the performance and organisation of clinical work. We look at problems with the prevailing model of clinical governance and describe an alternative approach.

Improving quality from the top down or from the bottom up?

Clinical governance was conceived as being local in both its orientation and in its operation (fig 1). As a bottom-up mechanism, it was intended to inspire and enthuse and create a no-blame learning environment characterised by excellent leadership, highly valued staff, and active partnership between staff and patients.1

The reality in most trusts, however, is far removed from these high hopes. The clinical governance arrangements established meet the formal requirements of central bodies such as the Commission for Health Improvement (now the Healthcare Commission). They also reflect the government's past emphasis on inspection and performance management.5 6 Hence, in most trusts the operations of the stand alone “silos” (fig 2) are oriented to ensure that a trust's senior …