Personal views: The government’s initiative may be stillborn
Authors: Malcolm Frazer
Journal: BMJ (1998)

In one of the numerous documents I have received on the NHS white paper for England I read the following: “Clinical governance encompasses all the processes needed to achieve the highest quality clinical practice possible within available resources.” 

The last subordinate clause of that sentence is a killer and holds within it the reason this initiative may well be stillborn. In order to achieve the “highest quality of clinical practice” I need certain things. 

I need good quality information. l want this from a source I trust and respect. It should be easy to assimilate and have realistic goals. It also needs to address a commonly encountered clinical scenario. Local sources are best, preferably from someone occupying a similar post in a similar hospital to my own. I will look with the utmost cynicism on poorly written reports or recommendations handed down from ivory towers concerning diseases I hardly knew existed. Does anyone know whether this good quality information exists? In obstetrics and gynaecology it is quite hard to find data of sufficiently high quality to help improve my practice and I am quite certain that other specialties fare no better. This whole initiative seems to be based on the premise that we are all practising second rate medicine because we are too pig headed or arrogant to apply the information which lies all around us. 

I need audit feedback to close the cycle. Once my hypothetical practice is changed I would like to participate in understanding how this change has been for the best. I am, after all, a professional and interested in what I do. I need to be reassured that I am doing well and that the changes I went through were helpful to the only people that matter, my patients. I may not be all that interested in how much easier life is for anybody else. Does anyone know where the resources to help me do this will come from? 

I need some time. Now, this is the big one. I need time to reflect, consider, and then change my practice. So, looking around, I see that my clinical workload is too high. I do not have the hours to invest in such a cerebral approach to medicine. Does the NHS really expect me to evolve into the careful, thoughtful, constantly questioning clinician it envisages while I attend weekly three outpatient clinics, two theatre lists, one labour ward session, teach students and registrars once a week each, respond to inquiries, perform general administration, attend managerial committees, accrue my continuing medical education points for specialist accreditation, do my bit towards the developing research and development culture of the new NHS (which is not included in the clinical governance scenario), and try to fit in a bit of private practice (remember I am rewarded for this sinful activity by the NHS reducing my salary by 10%)? And don’t forget the on call commitment that I do for no extra charge. 


Perhaps you think I’m exaggerating. I suggest you read the documents and do the sums yourself. I haven’t included other aspects of the clinical governance package, such as developing my “clinical leadership skills” (whatever they are), risk management, sorting out my poorly functioning colleagues, organising health needs assessments of my local population, and finally participating in systems to ensure that lessons learnt are implemented. I think I’m being rather conservative. 


“The sad fact is it cannot be done within available resources”



But we are between a rock and a hard place. Who could possibly argue that the aims of clinical governance are not worth pursuing? If we object we run the risk of looking and sounding like the self serving dinosaurs some sections of the media accuse us of being. Most doctors would see these aims as laudable and worthy of our serious attention. But I wonder how seriously the government is taking the effective implementation of these measures? Be in no doubt that the effective implementation of clinical governance will require two sessions a week of my time. I would suggest that I lose one outpatient clinic and one theatre list. There are six consultants in the department. That is 12 sessions. That is another two consultant jobs to be created in our department alone—£100 000 a year. How many directorates are there in this hospital? What do we multiply that figure by? Ten? Probably. That’s £1 000 000 for Warrington. Multiply that nationally. What would you estimate? £200 000 000? And I haven’t taken into account the costs of improving information access in libraries, audit staff, and data collection systems to underpin these changes. 

But of course it’s all covered by that innocuous phrase at the beginning of this piece: “Within available resources.” The sad fact is that it cannot be done within available resources. I know it, you know it, and Frank Dobson knows it. 

I have no doubt that it will eventually be done, the way that audit has been done and the way that research and development is being done. Badly. And another opportunity to match vision with reality will have been lost. 

Still, no doubt before the next election, someone will come up with another idea to occupy us. It is hard not to come to the conclusion that the function of the NHS upper echelons is to find things for NHS staff to do under the guise of improvements.