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Clinical governance, the government's answer to high-profile scandals such as the Bristol babies' heart surgery case, does not go far enough, a study has warned.

A report by the King's Fund says the reforms focus on processes instead of results and are being introduced without the extra resources needed.

Report author Steve Dewar, King's Fund fellow in effective practice, says the Health Bill gives chief executives only 'a limited responsibility' for making arrangements to monitor and improve the quality of healthcare.

Senior managers will 'respond to the spirit' of the reforms, but the wording 'establishes responsibility for the process rather than the outcome of clinical governance'.

Mr Dewar says this means that chief executives will be able to argue they were not liable 'if the tragedy of future poor performance should occur in their trust'.

He told HSJ: 'I thought we were trying to get away from the spurious distinction between managers and clinicians.

'We are all working for the same organisation and we all need to take responsibility for outcomes.'

But NHS Confederation policy manager Tim Jones said it had campaigned against making chief executives liable for absolute quality. Senior managers had 'no control over clinical decision making, which was still the preserve of doctors', he said.

Nigel Offen, president of the British Association of Medical Managers, said that like doctors, chief executives should not be liable for poor outcomes 'if everything had been done correctly in terms of current practice'.

But Mr Offen backed the report's finding that senior managers will need more money and time to ensure good quality services.

Ministers have said repeatedly that there will be no extra funding for the reforms. The report says: 'Policy states that clinical governance should be cost-neutral. On the ground, everyone knows it will cost money.'

Mr Dewar said money was not the 'sole answer' to introducing clinical governance.

'We have to re-think the way staff work, the way people behave and the way we manage human resources.'

Managers and doctors were 'struggling' to reconcile 'top-down' guidance with building a 'bottom-up' service that responded to local staff and patient needs, he said.

The report warns that investment in staff time, education and developing standards would cause 'dilemmas' because that money would not be available for other services.

'At both local and national levels we will need transparent processes to identify and weigh up the real opportunity costs of quality.'

Clinical Governance Under Construction. King's Fund Bookshop. 0171-307 2591.£5.95.