Clinical governance -making it happen
Edited by Myriam Lugon and Jonathan Secker-Walker Royal Society of Medicine London 222pp£17.50
A well-timed book such as this will allay the gathering panic about clinical governance by helping all those concerned to take a long, hard look at what needs to be done. Success will depend as much on the ability to convert existing systems, procedures and committees as on creating new elements of an over-extended bureaucracy.
There can be no doubt that the NHS needs to do better. As the editors point out, it is vital to restore patients' trust in the aftermath of Bristol, Kent and less publicised failures.
Clinical governance requires systems which are open and understandable. That's easier said than done, as two excellent chapters by the editors and by David Hands make clear. It is suggested that the organisational infrastructure should differentiate between clinical policy and clinical monitoring. This is worth exploring further. Such a separation clarifies function and spreads the workload, but it may also create conflict and, more seriously, remove the policy-setters from the consequences of their own policies. The danger of a book like this is that it becomes too prescriptive and didactic, with the overuse of words and phrases such as 'should' and 'need to ensure'. Jenny Simpson's chapter on the role of the medical director falls into this category. Perhaps it is because there is as yet little research into how medical directors do their job.
Given the responsibility now entrusted to the chief executive, it would have been useful to examine how they plan to become more closely involved, particularly as to date they have been seen by some researchers as relatively ineffectual in bringing about changes in clinical governance.
Particularly useful is Anne-Louise Ferguson's exploration of the legal power of protocols and guidelines. It appears that they cannot be used as a substitute for expert advice.
On the other hand, an absence of protocols could be said to be a sign of negligence. The Pre-Action Protocol for the Resolution of Clinical Disputes, published in 1998, helps managers and clinicians through the dilemma of how to deal promptly with an incident without exposing their trust to unnecessary liability.
For me, the most powerful chapter is Ewan Ferlie's examination of the implementation of evidence-based medicine. Supported by research, he points out the rational linear models of implementation are 'seriously misleading' as the process is 'far more interactive, negotiated and uncertain'. A prerequisite of successful implementaion is the ability to translate the science of EBM for practitionerts in the field whose knowledge is 'craft- based, tacit and experiential'.
Medical science needs converting to social science to be effective. This is not an excuse for doing nothing. The obligations of clinicians, managers and boards are clear, and this book will do much to help them all to honour them.
Andrew Wall is a visiting fellow at Birmingham University's health services management centre.