Intended for healthcare professionals

Rapid response to:


Regulation of doctors

BMJ 2007; 334 doi: (Published 01 March 2007) Cite this as: BMJ 2007;334:436

Rapid Response:

Clinical governance can become oppressive

David A. Bruce mentions the climate of fear and the culture of defensive practice created by the increasing regulation of doctors.1 The government white paper, Trust, assurance and safety – the regulation of health professionalsin the 21st century, on which his editorial is based, recognises that there has been managerial over-reaction in NHS Trusts.2 It also concedes that more needs to be done to ensure clinical governance structures can facilitate fair and effective action at local level.

Clinical governance must be implemented in a facilitative and non-oppressive way. In the recent book Clinical Governance in a Changing NHS, James Reason notes that the belief that medical errors are necessarily manifestations of incompetence, carelessness or recklessness for which naming, blaming and shaming are appropriate responses is perhaps the single greatest obstacle to improving patient safety.3 In addition, Hittinger & Fielding observe that NHS organisations can become idiosyncratic, self-serving and autocractic which means that they react to problems in arbitrary and sometimes capricious ways.4 Furthermore, these authors go on to 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 inquires in mental health services too 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 both patients and health professionals.


  1. Bruce DA. Regulation of doctors. BMJ. 2007; 334: 436-7 (March 3) [Full text]
  2. Secretary of State for Health. Trust, assurance and safety—the regulation of health professionals in the 21st century. London: Stationery Office, 2007.
  3. Reason J. Resisting cultural change. In: M Lugon & J Secker-Walker (eds) Clinical Governance in a Changing NHS. London: Royal Society of Medicine Press, 2006
  4. Hittinger R & Fielding LP. Organizational culture: Cultural indicators as a tool for performance improvement. In: M Lugon & J Secker-Walker (eds) Clinical Governance in a Changing NHS. London: Royal Society of Medicine Press, 2006
  5. King M & 59 other signatories. Community psychiatry inquiries must be fair, open and transparent. The Times, 4 December 2006 [Full text]

Competing interests:
None declared

Competing interests: No competing interests

05 March 2007
D B Double
Consultant Psychiatrist
Norfolk & Waveney Mental Health Partnership NHS Trust, Peddars Centre, Norwich NR6 5BE