The November 25 issue of Chemist&Druggist reported that representatives of the Department of Health had told the Royal Pharmaceutical Society that clinical governance was a "less immediate topic"for the Society to consider. Having attended the National Institute for Clinical Excellence 2000 conference and done some further reading, I do not agree. Clinical governance is not a topic to be treated in isolation; the principles that the concept embodies enable a wide variety of quality services to be delivered.
A strong message emerging from the conference was that health professionals working in secondary care have already taken on board the full panoply of clinical governance activities. It is also apparent that practitioners in the primary health care sector have also started to encompass quality improvement principles into many aspects of clinical practice. Community pharmacists have always been aware that members of other health care professions consider that their clinical decisions have the potential to be affected by commercial pressures. "Pharmacy in the future — implementing the NHS plan"makes it quite clear that those who do not offer a quality service will suffer financially, and that those who adopt the underlying principles will benefit. The time is surely right to initiate a movement to negate the traditional image of community pharmacists as more interested in financial considerations than those of providing a quality service.
Firmly established
In order to ensure that the profession and, in particular, community pharmacy do not miss out on the overdue opportunities that are part of the NHS plan, we must be seen to be involved in all aspects of the NHS as soon as possible. Clinical governance is now firmly established as an integral part of the new NHS; it is designed to provide everyone with improved quality of care. We, as community pharmacists, must be able to demonstrate that we are at least planning the methodology by which our commitment to that philosophy is to be realised.
I have stated that we need to encompass clinical governance, and also that it should be treated as a matter of urgency, but there will no doubt be many dissenting voices. I do not, I hasten to add, expect dissenters to disagree with the underlying need for quality improvement, but with the priority with which it should be treated. It was apparent from the delegate list at the conference that pharmacy was poorly represented. Out of an attendance of about 2,500, there were perhaps 10 pharmacists. Although it is difficult to identify professional allegiance from job titles, it could be surmised that those who are "clinical governance leads"in secondary care do not have the future involvement of community pharmacists as a priority. The profile of (community) pharmacy at such events must be seen to be much higher if we are to be taken seriously as a major player in the NHS. Although there was a small stand for the Society, a much higher level of participation by the leading members of the profession — and that inevitably means the Council — must surely be appropriate.
The premise on which I base my argument arises from the definition of clinical governance from the DoH: "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."
The qualification of "NHS organisations"also comes from the DoH, which defines them as health authorities, primary care groups and trusts, general practitioners and community pharmacies.
At present there are no models for a framework that could be used to implement clinical governance by community pharmacy, although there is evidence that a suitable environment is evolving in secondary care. In my research I have found guidelines for pharmacists working in PCGs and a job description for clinical governance representatives on local pharmaceutical committees. The Society has published documents for England and Scotland entitled ""Achieving excellence in pharmacy through clinical governance", which acknowledge the importance of the four main elements of clinical governance, as defined in HSC 1999/065. These are:
• Clear lines of responsibility and accountability for the overall quality of clinical care
• Clear policies aimed at managing risks
• Procedures for all professional groups to identify and remedy poor performance
• A comprehensive programme of quality improvement activities.
What does not exist, or at least if it does I would very much like to see it, is any hint of a workable structure for the delivery of clinical governance in the very different and specific environment of community pharmacy. As a framework can only be decided upon when, in the true spirit of evidence-based learning, several models have been tested and fully evaluated, we have a long way to go. Clinical governance is all about continuous improvement of the quality of services. That means that it is essential not only to measure the range of activities that we do, but also to determine, by means yet to be established, if there has been an improvement in the quality of the services delivered. In other words, we not only have to measure what we do, but also whether or not we are doing it right — not an easy task. In order to demonstrate true clinical governance, audits are not sufficient; clear accountabilities, which allow for the very special responsibilities of the individual pharmacists and the pharmacy superintendent who is also a company director, have to be included in the framework.
Problems to overcome
There are, of course, many other problems to be overcome in the development of such a framework, not the least of which are the very different and inevitably separate commercial environments in which community pharmacy is practised. It may be suggested that a range of models need to be developed, as has already happened for other sectors of the NHS. While the approach may be a more "comfortable"option for some, it is not the way forward. One of the most noticeable messages at the conference, emerging from virtually every session, is that the successful implementation of the principles of clinical governance relies on teamwork. Put very simply, teamwork is vital to the development of the "blame free"culture that must be in place if quality improvement in any sphere of practice is to result. Community pharmacy has always been fragmented by the disparate needs of the multiples versus the independents and the bodies that represent them. While I am the first to agree that there is no easy solution to such a complex problem, I would like to suggest that community pharmacists try to reach a compromise in order to present a united front to the NHS. That means an amalgamation of the interests of several groups — the Council of the Society, the Pharmaceutical Services Negotiating Committee, the National Pharmaceutical Association and the Company Chemists Association, to name just a few — in order to drive forward a united approach to a concept that is fundamental to our long overdue recognition as part of the NHS. Once that principle has been agreed to and implemented by the parties involved, we can then begin to consider the underlying principles of clinical governance and develop a model to accommodate them into the present and, most importantly, the future practice of community pharmacy.