Editorial

Editorial

Article Type: Editorial From: Clinical Governance: An International Journal, Volume 16, Issue 1

What is clinical governance? Greenfield, Nugus, Fairbrother, Milne and Debono show that, whatever its epistemological roots, clinical governance “is” something that exists because it is enacted within organisational settings. By applying an established model of clinical governance to an empirical study, they have learned about the model’s potential for refinement as well as providing the crucial insight, that managers, driving and “doing clinical governance to” the front line workforce, are losing sight of the motivation of front line caregivers, their values and the efforts they are making to drive improvement in the performance and quality of the services they deliver. Worse, the efforts to formalise and codify procedures and then verify conformance can compete against, rather than complement, positive motivation at the front line.

These authors argue that a successful model of clinical governance and its enactment needs to contain two key factors. First, it must expose the adequacy or otherwise of the organisational structures and the resource environment that create a material, rather than a moral climate for healthcare quality and safety. Second, the model must capture what is actually being accomplished, in terms of new relationships, activities and outcomes as opposed to statements of policy and intent.

Amongst the values of clinical governance, equity is also especially apparent in this edition of our journal. Three papers relate more or less to the topic of inequality.

Ratcliffe, Dabin and Barker remind us that the distinction between mental and physical health provision is a false dichotomy. For patients classified into the category of formal psychosis, their physical healthcare requirements can be overshadowed by their psychiatric label, even when the medication associated with their diagnosis has distinct effects on metabolic risk factors for major physical disease. Special efforts are needed to ensure that this disadvantaged group of patients can participate equally in general practice-based health maintenance programmes. The authors have produced an audit instrument that they believe can be used more widely by commissioners and providers of primary care.

A mentally disordered patient may be brought to the emergency department of a hospital, as a “place of safety” within the meaning of the United Kingdom Mental Health Act (1983), if their behaviour in a public place is thought by a police constable to place them in need of care or control. Some people brought to hospital under this statute need both to be provided equally, safely and simultaneously rather than sequentially.

Mentally disordered behaviour can cause havoc in the emergency department. The alternative place of safety is a police cell but the emphasis there is on control rather than the care of physical illness that might be the cause or consequence of inebriation, drug use, organic delirium or formal psychiatric illness.

Sadiq, Moghal and Mahadun provide a snapshot of the activity of a facility to segregate disruptive people safely in a clinical-custodial environment, avoiding inconvenience to other patients and to the doctors and nurses responsible for their care.

It is fitting for this international journal that concerns from the affluent, industrialised world should be complemented by a paper that addresses health inequality in rural India. The paper by Narang applies an established instrument to provide a user-based assessment of services in community health centres. The challenge they have addressed is to adapt the instrument they have chosen to the cultural setting in which it has been applied.

Meeting this challenge goes beyond translating the instrument from one language to another. Narang has taken steps to understand the way their respondents think about things and comprehend their circumstances – in terms of concrete, monetary value exchanges rather than abstract concepts of quality. Their paper exposes differences in the appreciation of services, between genders and between different educational and income groups. The low expectations of the least privileged, as well as positive government action to enhance women’s services, contribute to their satisfaction.

The North American perspective we present takes us to the values (the “axiology”) of clinical governance, and to the way these values can be applied in practice (a “methodology” for clinical governance).

One dimension of the “methodology” aspect of clinical governance promotes the dissemination of policy through the structure of the formal organisation. However necessary, this dimension is insufficient. Policy has to be assimilated and put into practice at the front line of healthcare. The implementation of clinical governance is not a goal in its own right. It is a key task for managers and planners, to help the front line develop and pursue its own ethos, based on the key values that give clinical governance its reason for being.

Smith and Mireles elaborate on their first paper, published in this journal (Vol. 15, No. 3), demonstrating the key role of a “super-ordinate goal”, in this case, the safety and well-being of patients, in building ethos and firing the direction and spread of local, collaborative effort.

The midwife for change is a core community with a membership carefully selected for knowledge, experience, insight, expertise and influence within the host community for change. The approach to change is exploratory and critical instead of prescriptive and programmatic. It carefully balances idealism and pragmatism by focusing on the feasibility and practicability of means as well as the value of goals.

In the Australian perspective, Travaglia, Debono, Spigelman and Braithwaite present an exploration of the key concepts enshrined within the label of clinical governance. They clearly show that the “nature of being” of clinical governance (its ontology) is that of an evolving discipline, rather than something that authors can compete to define authoritatively. As the concept has been explored in successive samples of the literature, they show that it has become more complex, its depth of penetration has increased and the discussion has become more concrete as the concept has become embedded in distinct locations and situations.

As regards the “nature of knowing” within clinical governance (its epistemology), these authors point to an explosion of literature with clinical governance as its centre since 1998, when the concept became institutionalised within the UK NHS. This has been followed by an apparent implosion because “clinical governance” has been superseded by its sub-topics as a principal focus of books and journal articles.

It is not surprising that, as the concept has evolved, its focus has diffused. Its origins in the regulation of clinical practice are complemented by roots in management science and the theories of motivation, organisational behaviour and psychology. These “soft” components of an emerging clinical governance discipline need to be appreciated alongside the “hard” components of controls assurance, business continuity planning and crisis recovery. Even the fundamental concepts of quality and safety contain extensive sub-categories, where “hard” and “soft” components collide, as in control of infection, rational antibiotic use, safe prescribing and avoidance of surgical mishap.

In this issue, we have seen important papers on theory placed alongside instances of practice. In future editions of Clinical Governance: An International Journal, we hope to continue publishing papers that not only describe practice but also contribute to the enrichment of methodology, where practice has informed theory and theory has been refined through application in the real world.

Nick Harrop, Alan Gillies