clinical governance

Hospital consultants, immune from management strictures since the NHS began, will find that clinical governance transforms their relationship with chief executives, says Roy Tyndall

The debate about power, responsibility and accountability between chief executives and consultants has been raging ever since the changes in the structure and organisation of the NHS first carried out in response to the Griffiths reforms in the mid-1980s. The new doctrine of clinical governance will effect a fundamental change in the relationship between them.

Although the basic tenet of general management was local accountability and decision making through designated accountable officers, the reality is that unit general managers - and since 1991, chief executives and their boards - have remained constrained in their relationships with consultants.

The freedoms provided - and assumed without challenge by managers or politicians since the NHS began - have allowed consultants to seem immune from the management processes (control and accountability) associated with other employer-employee relationships.

This unique and privileged position would not be allowed to develop in any other business or industry. It is, indeed, normal for professionals and specialists to be subordinate to, and restricted by, chief executives and their boards, the principle being that the corporate whole is far more important than the individual parts.

The arrival of clinical governance will herald a change in the relationship between chief executives and consultants of a type never experienced before and, alarmingly, not yet appreciated by most chief executives and clinicians. This overt approach to clinical governance is either an impressive and profound political stratagem or a miscalculated high-risk strategy which may expose the health service to public censure on an unimaginable scale, and which was previously avoidable because of the protection provided by covert clinical freedoms.

How will clinical governance impact on existing relationships between chief executives and consultants? Progressive chief executives will already be giving serious thought to how their structures will be reconfigured to facilitate change.

In particular, it is difficult to believe that part-time medical directors will have the time and resources to deliver the minimum requirements of clinical governance in addition to their already crowded agenda.

Chief executives will now have real authority over consultants. But at the same time they will assume a far more demanding and challenging role, requiring an outlook and attributes that current management styles are unlikely to include. All chief executives must engage in honest introspection and assess whether they have the courage, conviction and skills to respond to the challenge to improve beyond recognition the quality of care and service delivered to NHS patients. Such improvements must be the raison d'etre of clinical governance. But the power shift from consultants to chief executives must not be lost.

Clinical governance is now the absolute responsibility of the chief executive as the accountable officer. Using performance management and an evidence-based framework, chief executives and the board must ensure that everything possible is done by the organisation as a whole and its constituent parts so that patients receive the treatment and outcomes they are reasonably entitled to expect.

Chief executives can no longer claim, in mitigation, that their authority is limited by the 'doctrine of clinical freedom'. Indeed, the chief executive will be required to ensure that information and intelligence about clinical activity and outcomes is thoroughly analysed and that early warning systems are introduced to protect patients.

Trust boards will demand regular reports providing reassurance that all reasonable checks and balances are in place and identifying any potential problems and appropriate remedial action.

Chief executives will be required to confront consultants about perceived flaws in clinical procedures and standards. Consultants will be instructed to end the practice of deferring clinics to juniors, while chief executives will have to make decisions about whether consultants should be allowed to continue to undertake certain procedures, and even, in extreme cases, whether they should continue in employment.

Such decisions will be exacting, not only because of the personal injury involved, but also because of the 'dependence on probability rather than proof'.

The emergence of clinical governance will present chief executives with the authority and influence they have claimed is necessary if they are to manage the NHS more effectively.

The defence of total clinical freedom, including self-regulation, which has been a shield against objective performance management, conveniently available to both chief executives and consultants, will largely disappear.