Intended for healthcare professionals

Sacred Cows

Clinical governance

BMJ 1998; 317 doi: (Published 19 December 1998) Cite this as: BMJ 1998;317:1725
  1. Neville W Goodman (, consultant anaesthetist
  1. Department of Anaesthesia, Southmead Hospital, Bristol BS10 5NB

    Every so often, and seemingly increasingly often, a new “Big Idea” reaches the NHS. The BMJ issue that celebrated the NHS's 50th anniversary contained an essay by Gabriel Scally and Liam Donaldson about the latest: clinical governance.1 This Big Idea is different: unlike previous ones it has no intuitive meaning. Ironically, the word governance in the sense intended (“The manner in which something is governed or regulated; method of management, system of regulations”) is marked as obsolete in the Oxford English Dictionary,2 which gives a quote from 1660: “To enquire of the Foundation, Erection, and Governance of Hospitals.”

    The editor, in his editor's choice of that issue, remarked, perhaps pointedly, that Scally and Donaldson “try to spell out the meaning” of clinical governance. I have read “Clinical governance and the drive for quality improvement in the new NHS in England” carefully, word by word, and some parts several times. I have tried to understand why they needed over four pages to impart the commonsense message that we must all strive after quality in practising medicine; I have retained little beyond that it is our statutory duty now to provide quality in our medical care. The essay is all thought and no action, an epitome of hope over expectation, a high sounding clarion call of wonderful things just over the horizon. Most depressing of all, the authors seem to recognise the real difficulties but ignore just how obdurate these difficulties are. The result is an essay full of the “what” but short on the “how.”

    “Rigorous” rhetoric

    The rhetoric starts with the title—the drive for quality in the new NHS. The NHS is not new; it is 50 years old. It could even be argued that the Labour government—by turning away from “dominat[ion] by financial issues and activity targets”—is trying …

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