Intended for healthcare professionals

Education And Debate

Clinical governance: fine words or action?

BMJ 1998; 316 doi: (Published 24 January 1998) Cite this as: BMJ 1998;316:297
  1. Nick Black, professor of health services researcha
  1. a London School of Hygiene and Tropical Medicine, London WC1E 7HT

    The current purchaser efficiency index has resulted in perverse incentives and a distortion of clinical priorities.1 In the name of increased efficiency, cost saving measures have been rewarded while few attempts have been made to assess the quality of care provided. When attempts have been made, variation has often been shown in the quality of care delivered and the outcomes achieved by different providers.

    In a significant and welcome change from the previous administration, the new government recognises these problems and proposes several measures to deal with them—at every level of the NHS. At the centre, a National Institute of Clinical Excellence will promote clinical and cost effective care by producing research based guidelines. National service frameworks will also set out the patterns and levels of service which should be provided for major care areas and disease groups, along the lines of the current reorganisation of cancer services. This fits with recent calls for a national clearing house to support the commissioning of specialist services.2 Meanwhile locally the new purchaser organisations, the primary care groups, will be expected to include explicit quality standards in their service agreements with provider trusts.

    For the first time in the NHS monitoring and ensuring quality of care will be a statutory responsibility, with trust chief executives personally accountable. This extension of corporate governance from financial to clinical matters is one of the most fundamental and radical of the government's proposals.


    The extension of corporate governance from financial to clinical matters is among the most radical of the white paper's proposals


    To support, and more importantly, oversee the quality of clinical governance and of clinical care, a Commission for Health Improvement is proposed. This statutory body, “at arm's length from government,” will publish information on the comparative performance of trusts in relation to all three dimensions of quality: effectiveness (health outcomes), equity (access to their services), and humanity (patients' and carers' views). In many ways it can be seen as a natural extension of the current work of the Audit Commission.

    While the proposal to improve “clinical governance” in the NHS should be universally welcomed by clinicians, managers, politicians, and the public, the mechanisms for monitoring and managing clinical performance will almost certainly prove more controversial. The white paper correctly notes that in the past “performance was driven by what could readily be measured.” To avoid this in future the government must recognise the inadequacies of routine administrative data, such as Hospital Episode Statistics, for measuring most aspects of quality. Information which purports to compare the performance of trusts (such as the clinical outcome indicators due to be published for the first time in England later this year) is likely to harm the already damaged reputation of interhospital comparisons.

    Instead, there should be much greater reliance on national specialised clinical databases, such as that in intensive care, which can potentially achieve much higher levels of detail, completeness, and accuracy.3 These features are essential if differences between trusts in case mix are to be adequately adjusted for.

    If the key role of specialist databases is accepted, then it follows that the Commission for Health Improvement should not involve itself directly in large data gathering exercises but act as an umbrella organisation, harnessing help and input from the specialist groups. The commission would need to monitor the quality of the databases. This would mean that initially it monitored only some areas of health care, but this is preferable to a potentially misleading comprehensive audit.

    Whichever organisational model is adopted, there is no escaping the fact that information of the quality required for clinical governance will prove much more expensive than that required for financial governance. Unless each level of the NHS is prepared to accept that and provide adequate funds for clinical data collection and analysis, the good intentions contained in the white paper will not be realised. Making trust chief executives personally responsible for the clinical performance of their services might prove to be just the incentive needed.


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