A major initiative to secure better quality care by the NHS and improve patients’ confidence in its services has made early progress and is already delivering benefits. However, according to a report by the National Audit Office, progress in implementing ‘clinical governance’ is patchy, varying between and within NHS trusts and between the components of the initiative.
According to today’s report to Parliament by head of the NAO Sir John Bourn, the structures and organisational arrangements to make clinical governance happen have been put in place in the corporate systems of most NHS trusts. And the initiative has had many beneficial effects. Clinical quality issues are now more mainstream and there is greater or more explicit accountability of both clinicians and managers for clinical performance. Reviews by the Commission for Health Improvement have focused attention on improvements needed in individual trusts. The professional culture has also moved towards more open and collaborative ways of working.
Most of the individual components of clinical governance – including clinical risk management, adverse incident reporting, better information for patients and use of information technology – are in place in most NHS trusts. The commitment to each component within individual trusts varies widely; and many trusts face other major barriers including a lack of resources, poor training attendance and a culture that is not conducive to reporting risks. Trusts need to build on achievements so far by, for example, making themselves more ‘patient-centred’ by demonstrating active working with patients, users, carers and the public. Clinical audit is not as well established as might be expected, with only a half of all trusts reporting its use in more than 80 per cent of their clinical directorates or departments. And many trusts are not achieving effective standards of risk management.
However, today’s report points out that the clinical governance strategy is changing the way trusts deal with quality of care. Up to now most of the changes have been to processes. There are now clear indications that there have been changes to the culture of trusts, in that boards have become more involved in clinical concerns; clinicians have begun to see those concerns as corporate rather than professional and personal; and attitudes of staff within trusts have become less defensive and more open. The components of clinical governance have been substantially developed and used more effectively and, as a result, some three quarters of trusts can identify specific improvements to patient care.
Apart from lack of resources and cultural difficulties, the other main barriers or problems trusts cited are conflicting priorities, particularly the concentration on short term waiting targets, organisational changes and mergers, the size, spread and heterogeneity of trusts and a lack of organisational direction and impetus for clinical governance. It is difficult to unpick the relative importance and merits of these barriers, but improving the rate of progress will require action on all of them.
Among the NAO’s recommendations are that the Department of Health should do the following:
- ensure that the Clinical Governance Support Team (part of the NHS Modernisation Agency) continues to develop and enhance its advice and support function, to satisfy the present unmet demand from trusts;
- explore with the Clinical Governance Support Team more effective ways of disseminating good practice, including examples identified by the Commission for Health Improvement; and
- evaluate the impact of the various patient empowerment initiatives and develop a set of good practice guidelines to help trusts make improvements in this area.
In addition, NHS trusts should act in the following areas:
- review the information requirements on quality issues required by their board and establish systems to ensure that such information is provided on a regular basis;
- consider developing with their clinical teams systems of internal reporting on quality on the lines being developed by the Clinical Governance Support Team; and
- benchmark key clinical governance initiatives with similar trusts and build on and share examples of good practice.