Intended for healthcare professionals

Letters Regulation

Clinical governance can become oppressive

BMJ 2007; 334 doi: (Published 15 March 2007) Cite this as: BMJ 2007;334:549
  1. D B Double, consultant psychiatrist (dbdouble{at}
  1. Norfolk and Waveney Mental Health Partnership NHS Trust, Norwich NR6 5BE

    Bruce mentions the climate of fear and the culture of defensive practice created by increasing regulation of doctors.1 The government white paper on which his editorial is based recognises that there has been managerial over-reaction in NHS trusts.2 It also concedes that more should be done to ensure clinical governance structures can facilitate fair and effective action locally.

    Clinical governance must be implemented in a facilitative and non-oppressive way. James Reason recently noted that the belief that medical errors are necessarily due to incompetence, carelessness, or recklessness for which naming, blaming, and shaming are appropriate responses is perhaps the greatest obstacle to improving patient safety.3 Other authors think that NHS organisations can be idiosyncratic, self serving, and autocractic, so they react to problems in arbitrary and sometimes capricious ways.4 These authors also suggest that “such organisations are not necessarily easy to identify, because they may contain persuasive individuals who are practised at statements of intent (where words such as ‘collaboration' and ‘partnership' are heavily used with ideological correctness), but where these qualities are not evidenced or observed.”

    Independence may not be sufficient to limit the potentially oppressive nature of governance when things go wrong. For example, homicide inquiries in mental health services often become destructive.5 Maybe the term “clinical governance” has become so tainted with this failure to improve clinical care that it needs to be replaced. The government needs to support a credible and effective quality improvement system that meets the needs of patients and health professionals.


    • Competing interests: None declared.


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