Clinical governance is a concept that was introduced to the health service in the recent White Paper on quality, "A first class service" (PJ, July 11, 1998, p40). It is defined in the White Paper as "a framework 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."
These are fine words and no pharmacist will be able to take exception to them. But that is not to say that they will not face problems in working out exactly what clinical governance means to them and how they should behave professionally in the new environment that the introduction of the concept creates.
Fortunately, the Royal Pharmaceutical Society has come to their aid this week with the publication of a document on clinical governance. The Society sets out pharmacy's accountability, making a number of recommendations, and indicating support systems that the Society intends to develop (see p479). A key recommendation in the document is that in each health authority or health board area, a local community pharmacist should be nominated as the clinical governance lead for community pharmacy. In the hospital field, this function would be performed by trust chief pharmacists. Clinical governance will only be successful in raising standards if it has strong roots at the local level.
Reading between the lines of the White Paper and the Society's document it is quite clear that the Government, and in this it has the support of the Society, wants to raise the quality threshold by whatever means there are available. Preferably this should be through developing the capabilities of professionals, publication of clinical guidelines, self audit, and such like, but where standards fall below an acceptable level, rooting out bad practice through disciplinary and other mechanisms.
One of the dictionary definitions of "governance" is "direction". But we doubt whether the phrase “clinical direction” would have been acceptable in a service where much of the input comes from members of what are still liberal professions, which implies a certain amount of freedom of action. But the substitution of the word “direction” could in our view give a better indication of what the Government is about. Clinical practice, through official guidelines emanating from the National Institute for Clinical Excellence and national service frameworks, is bound to become more standardised and, while it will not be compulsory for individual practitioners faced with individual patients to follow particular guidelines, they will have to justify departure from ever increasing sets of norms. Professional freedoms are to be constrained. Increasingly, the type of service offered will be "directed" in the interests of patient care.