Dr Richard Baker, Director of the CGRDU, Dept of General Practice & Primary Health Care, University of Leicester

Clinical governance can be a difficult concept to grasp. Perusal of the various White Papers and Health Service Circulars suggests that clinical governance comprises a wide range of activities. These include professional development, audit, evidence-based practice, team-building and risk management, among others.

The constituents of clinical governance appear to go on forever, and the prospect of being involved in all of them is more than enough to generate anxiety in the average clinician.

And then there is the added issue of accountability. Clinical governance includes systems to account for our performance, and if we are not performing adequately we will be encouraged to take part in programmes to help us improve

However, we do not have to respond to clinical governance with a combination of confusion and panic. In truth, clinical governance is a very simple idea.

At its core is the belief that quality is as important as quantity and cost, and in order to improve quality we must do anything and everything required.

In order to show how the pieces of the clinical governance jigsaw fit together, our team eveloped a practical model.1 This has three principal components:

  • The primary care group (PCG) must decide what it is trying to achieve – quality and the objectives of quality improvement must be defined and agreed.
  • The PCG needs to identify the causes of poor performance, and have access to a wide range of methods to bring about improvements.
  • The group needs to develop systems of accounting for performance to the health professionals in the group, local patients, and the health service. A PCG that has the first two components of clinical governance well in place will find the requirements of accountability easy to fulfil.

By applying this model, most PCGs and primary healthcare teams will be able to implement systems of clinical governance over the next few years. They will need time, some resources, and effective leadership from the PCG board. And some groups will need external support to help them with particular problems. However, we should expect clinical governance to deliver clear improvements in care in the next 5-10 years.

The simple idea of clinical governance has two important implications that we should not overlook.

  • In order to achieve quality, the individuals providing care on the front line must receive all the help and support they need. If quality is to be assured, it is no longer acceptable for health service staff to work under intolerable stress, to feel they must carry on even when they are ill themselves, or to expect little or no help as they seek to develop their careers. The most successful PCGs in the future will be those that pay attention to, and meet the needs of, their member health professionals.
  • With quality of care as the imperative, boundaries between health professionals and managers must break down. A PCG cannot have a set of general objectives with an aspiration for quality bolted on. Quality comes first, and therefore all the organisational systems and policy options must be chosen with a full understanding of their impact on quality of care.

In 5 years time, in many PCGs, the distinction between the general management of the group and clinical governance will have dissolved.

  1. Baker R, Lakhani M, Fraser R, Cheater F. A model for clinical governance in primary care groups. Br Med J 1999; 318: 779-83.


Guidelines in Practice, June 1999, Volume 2
© 1999 MGP Ltd
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