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The NHS’s 50th anniversary sugar and adjust their insulin doses, achieving far bet- 2023 seek the continual improvement of an NHS full ter control than when the doctor was making the insu- of knowledge, taking the best as its norm, growing its lin adjustments.9 You learned from Dr David Sobel at capacity as a full and integrated system of shared effort, Kaiser Permanente in America, who trained chroni- wasting little, and respecting every patient as an cally ill adults to provide care and education to other individual. You continue to know that you started off chronically ill adults, achieving better health status out- right in 1948, and with some important midcourse 10 comes and lower cost for both teachers and students. corrections, you remain well on track. Maybe some day You built your programmes on evidence of the benefits healthcare leaders in the United States will catch up. 11 of patient self care in studies of asthma treatment, I am sure you will help them if they ask. hypertension treatment, and self diagnosis of urinary 12 tract infection. The author thanks Paul Plsek, John Oldham, Diane Plamping, Jo By the early 21st century, the NHS was becoming a Bufford, and Jan Filotowski for helpful comments. truly patient centered clinical care system. The empha- sis today is on helping people with acute and chronic illnesses to become experts in their own care whenever 1 Secretary of State for Health. The new NHS. London: Stationery Office, 1997. (Cm 3807.) they wish, able to participate fully in their own diagno- 2 Rogers E. Diffusion of innovations. 4th ed. New York: Free Press, 1995. sis, treatment, and monitoring. Shared decision 3 Batalden PB, Mohr JJ, Nelson EC, Plume SK, Baker GR, Wasson JH, et al. Continually improving the health and value of health care for a popula- making, incorporating every patient’s values and tion of patients: the panel management process. Qual Manage Health Care 13 circumstances, is now the norm. NHS patients today 1998;5:41-51. write in and read their own medical records, receive 4 Berwick DM, Nolan TW. Physicians as leaders in improving health care. Ann Intern Med 1998;128;289-92. much of their care in their own homes, and remain 5 Nolan T, Schall M. Reducing delays and waiting times throughout the health- fully connected with their loved ones and communities. care system. Boston: Institute for Healthcare Improvement, 1996. At first, your doctors resisted this trend—fearing, 6 Womack JP, Jones DT. Lean thinking; banish waste and create wealth in your corporation. New York: Simon & Schuster, 1996. perhaps, that it would relegate them to second fiddle, 7 Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects of demean their expertise, and perhaps subject patients physician-patient interactions on the outcomes of chronic disease. Med Care 1989;27:S110-27. to undue hazards. Instead, this reformulation of the 8 Devine EC. Effects of psychoeducational care for adult surgical patients: a respective roles of doctor and patient has helped metaanalysis of 191 studies. Patient Educ Counsel 1992;19:129-42. everyone—giving patients and their families the chance 9 Mulley A, Mendoza G, Rockefeller R, Staker L. Involving patients in medical decision making. Quality Connection 1996;5(1):5-7. to establish control over their own lives and giving 10 Sobel DS. Rethinking medicine improving health outcomes with doctors, nurses, and other healthcare professionals the cost-effective psychosocial interventions Psychosom Med 1995;57:234-44. chance to focus their time and energies on exactly 11 Lahdensuo A, Haahtela T, Herrala J, Kava T, Kiviranta K, Kuusisto P, et al. Randomised comparison of guided self management and traditional those technical, pastoral, and humanitarian tasks that treatment of asthma over one year. BMJ 1996;312;748-52. they are in the best position to pursue. 12 Nelson EC, Splaine ME, Batalden PB, Plume SK. Building measurement and data collection into medical practice. Ann Intern Med 1998;128:460-6. These principles endure. You are not by any means 13 Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL, eds. Through the finished. As in 1998, and as it will be in 2048, you in patient’s eyes. San Francisco: Jossey-Bass, 1993. Clinical governance and the drive for quality improvement in the new NHS in England Gabriel Scally, Liam J Donaldson A commitment to deliver high quality care should be at NHS Executive the heart of everyday clinical practice. In the past many (South and West), Summary points Westwood House, health professionals have watched as board agendas and Lime Kiln Close, management meetings have become dominated by Stoke Gifford, Clinical governance is to be the main vehicle for Bristol BS34 8SR financial issues and activity targets. The government’s continuously improving the quality of patient care Gabriel Scally, white paper on the NHS in England outlines a new style and developing the capacity of the NHS in regional director of 1 public health of NHS that will redress this imbalance. For the first England to maintain high standards (including time, all health organisations will have a statutory duty to dealing with poor professional performance) John Snow House, seek quality improvement through clinical governance. Durham University Science Park, In the future, well managed organisations will be those It requires an organisation-wide transformation; Durham DH1 3YG in which financial control, service performance, and clinical leadership and positive organisational Liam J Donaldson, clinical quality are fully integrated at every level. regional director, cultures are particularly important NHS Executive The new concept has echoes of corporate govern- (Northern and ance, an initiative originally aimed at redressing failed Local professional self regulation will be the key Yorkshire) standards in the business world through the Cadbury to dealing with the complex problems of poor Correspondence to: report2 and later extended to public services (including performance among clinicians Dr Scally [email protected] the NHS). The resonance of the two terms is New approaches are needed to enable the important, for if clinical governance is to be successful BMJ 1998;317:61–5 it must be underpinned by the same strengths as recognition and replication of good clinical corporate governance: it must be rigorous in its appli- practice to ensure that lessons are reliably learned cation, organisation-wide in its emphasis, accountable from failures in standards of care in its delivery, developmental in its thrust, and positive BMJ VOLUME 317 4 JULY 1998 www.bmj.com 61 RF (LC Aftermath) - BMJ 315-021-001 The NHS’s 50th anniversary in its connotations. The introduction of clinical governance, aimed as it is at improving the quality of e t t h m e i f a n clinical care at all levels of healthcare provision, is by h S "Average" far the most ambitious quality initiative that will ever S p s r e have been implemented in the NHS. e r a u d No of organisations l i g a f o o Origins of clinical governance d m o f r p r Although clinical governance can be viewed generally L e a r n a c t i c e as positive and developmental, it will also be seen as a way of addressing concerns about the quality of health care. Some changes in healthcare organisations have Potential problems Exemplars been prompted by failings of such seriousness that Low quality High quality they have resulted in major inquiries. Variations in Fig 1 Variation in the quality of health organisations standards of care between different services have been well documented. Under the previous government’s market driven system for the NHS, many felt that the standards of care—whether detected through com- quality of professional care had become subservient to plaints, audit, untoward incidents, or routine price and quantity in a competitive ethos. Moreover, surveillance—represent one end of the range. Organi- some serious clinical failures—for example, in breast sations that are exemplars represent the other end. At and cervical cancer screening programmes3—have present once good practice is recognised, the scope for been widely publicised and helped to make clinical more general applicability and methods to transfer it quality a public confidence issue. both locally and nationally are not well developed. The process of learning lessons from both exemplar and problem services has never before been tackled sys- What is clinical governance? tematically in the NHS. However, a major shift towards improved quality will occur only if health organisations Clinical governance is a system through which NHS in the middle range of performance are transformed— organisations are accountable for continuously improving the quality of their services and safeguarding that is, if the mean of the quality curve is shifted. This will high standards of care by creating an environment in necessitate a more widespread adoption of the which excellence in clinical care will flourish principles and methods of continuous quality improve- ment initially developed in the industrial sector and then later applied to health care.6 Generally these involve an Clinical quality has always engendered a multiplic- organisation-wide approach to quality improvement ity of approaches. Universally accepted definitions with emphasis on preventing adverse outcomes through have been difficult to achieve, and some have even con- simplifying and improving the process of care. sidered the term too subjective to be useful.4 The World Leadership and commitment from the top of the Health Organisation is helpful in exploring the idea of organisation, team work, consumer focus, and good data clinical governance.5 It divides quality into four aspects: are also important. x Professional performance (technical quality) In the NHS a key part of establishing a new x Resource use (efficiency) philosophy of quality improvement will be to decide x Risk management (the risk of injury or illness asso- how clinical audit fits in to an integrated approach.

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