Clinical governance is on stream, overseen by the commission for health improvement (CHIMP), a new government inspectorate with responsibility for a rolling programme of visits to NHS organisations, with the aim of ensuring implementation of quality control processes and procedures.
CHIMP will ensure that the quality frameworks developed under the guidance of Professor Rawlins at the National Institute for Clinical Excellence (NICE)1 form the basis for delivering quality care.
Clinical governance has been defined as 'a system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish'.2 Hailed as no more than yet another Big Idea by some,3 others4 welcome the possibility of continuing self-regulation against the spectre of an altogether more draconian centralist option.
Professional self-regulation to date has largely fallen to the GMC. Inquiries into medical disasters frequently highlight issues relating to the quality of routine care offered to the public. It is perhaps not surprising that reform of the GMC, now under the chairmanship of Sir Donald Irvine, is proposed and accepted in principle, but ironic that the first doctor to be suspended under new GMC regulations governing performance rather than misconduct was a GP registrar judged to have 'seriously deficient' medical knowledge and skills.5
So what are the implications for general practice? The GMC has already decided that 'specialists and general practitioners must be able to demonstrate, on a regular basis, that they are keeping up to date and remain fit to practise in their chosen field', and that a link should be established between this and continued registration.6 The RCGP recently supported the revalidation of GPs, and decided that continuing membership of the RCGP would be increasingly linked to an explicit demonstration of satisfactory standards of care for patients.7
To the average GP striving hard to deliver quality care against a continually changing primary care backdrop, perhaps clinical governance offers the potential for a true change in culture permeating every level of the NHS. The government agenda for quality improvement (getting research into practice, measuring performance against standards, ongoing education for all healthcare professionals and managing/learning from complaints)8 may be the rudder steering quality, but the lack of a clearly defined modus operandi for implementing clinical governance may be a problem. Systems will need to develop which are sensitive to local needs, but this requires time, training and support for those directly involved in leading the local clinical governance agenda.
PCGs must respond to the clinical governance initiative. Each must appoint a lead individual to ensure/oversee quality of care for the primary care population served; that person might not be a doctor. The new definition of quality involves the ideal of 'doing the right things, for the right people, at the right time, and doing them right first time'.9
The task is huge, and involves changing cultures as well as policing professionals, moving from naming and shaming to identifying good or poor performers, informing and disseminating good practice, and improving standards through the implementation of evidence-based practice.
General practice will surely rise to the challenge. Carrots are needed all round – resource allocation, skill acquisition, supportive policies, increased opportunities for personal professional development – and are more likely to be effective than 'a stick hardened in the fire'.
- See also News in this issue.
- Br Med J 1999; 317: 1476.
- Scally G, Donaldson LJ. Br Med J 1998; 317: 1-65.
- Goodman NW. Br Med J 1998; 317: 1725-7.
- Campbell JL, Proctor SR. Br Med J 1999; 318: in press.
- Kirwin S. Br Med J 1999; 318:10.
- GMC endorses revalidation proposals. GMC Press Release 10 February 1999, London
- Br J Gen Pract 1999; 49: 84-5.
- DoH. A First Class Service. London, 1998.
- Donaldson LJ. Q Health Care 1998; 7 (Suppl): S37-44.