The clinical governance train is gathering momentum.

Everyone is at it. Our baseline assessments tell us we are heroically struggling to link systems for clinical audit with continuing professional development, education and training, serious untoward incidents and poor clinical performance. Some have even made the connection with health improvement programmes and additional resources needed to deliver better healthcare. We can all feel pleased that quality improvement is to be an equal partner of financial balance in the minds of our chief executives.

So far so good.

The clinical governance cavalcade needs to be aware of what is well known in public health circles as the 'prevention paradox'. This was first articulated by Rose, who showed that if most healthcare practitioners focus their efforts on the populations at highest risk of disease, the potential numbers benefiting are small.

1Much greater benefits to health can be achieved by targeting efforts at the whole population.

Translated into clinical governance parlance, it can also be argued that more health benefit can be achieved for a community by focusing on improving the performance of all practitioners a bit, rather than on the few whose performance is very poor. The evidence base from targeted population programmes suggests that this is correct.

The question we are at risk of failing to ask is: what is clinical governance for? Is it to ensure that small numbers of individuals are protected from the tiny proportion of potentially or actually dangerous practitioners, or is it to shift all practitioners' performance upwards in the interest of population benefit? It should surely be both, if we are seriously interested in equitable outcomes for all.

This will mean a shift from the language of blame, mistakes and disciplinary action towards that of learning and sharing better practice.Management and clinical effort also need to move, from individual patients towards the whole population.

The perfect vehicles for championing better population governance are the national service frameworks. They cover the health issues that should be priorities for all our communities.

So who are our local national service framework champions?

Clearly, public health practitioners, working across whole health economies, are natural advocates for this style of performance improvement.

However, public health commitment alone is not enough. We need clinical advocates for population governance if we want to spread high standards from the best to the average practitioners. This has been recognised by the Commission for Health Improvement, which has recruited public health as well as other expertise.

Medical and nursing directors and their clinical governance cavalcades are now actively engaged in protecting patients from the worst clinical performance, including murder, mayhem and near misses. This is a laudable goal.

But is the balance of corporate effort between the population and individual right? Take medical directors. Most have very little 'real' time in which to offer leadership, on top of heavy clinical commitments. It is important that every patient complaint and adverse incident gets a timely and proper response from the practitioners and organisations involved. But this intense activity is almost certainly at the expense of the wider clinical governance challenge of improving everybody's performance enough to benefit the whole population by providing better health and healthcare.

How can trusts redress this imbalance? First, they should create enough sessional space, especially for medical directors, to rise above the day-to-day 'incident' responses that cloud the important with the urgent.

In large, complex trusts medical directors will probably need to be full-time, with suitably qualified teams to support them.

Second, trusts should aim to recruit directors either with some population health skills, or with a promise to support further training in population health - either personally or within the clinical governance or senior management team. This will enable us to engender a climate in which trusts see the importance of measuring and improving outcomes in the 'ignored' populations of the unregistered, the 'did-not-attends' and those 'lost to follow-up' - as well as those who turn up in clinics and surgeries.

Finally, a tighter strategic rein needs to be kept on all elements of the clinical governance cycle, with audit, CPD and training resources more clearly focused on achieving relevant national service framework standards, rather than individually determined priorities. This will help doctors and other staff to focus their further development on what it is important for them to learn rather than the events and courses they enjoy attending.

Primary care trusts will be in a unique position. They will have both the responsibility and opportunity to improve the health of the whole population, rather than only those who are registered or in contact with services. Clinical governance will need to be practised across agencies. The advent of a quality improvement process in social services will help catalyse this joint work. PCTs will have access to public health practitioners, but will also need to help develop population skills within every general practice. In this way, all GPs will be able to become public health directors for their practice populations.

Once all this is in place, the clinical governance roadshow will become less jaw and more trousers.