Editorial

Citation

Gillies, A.C. and Harrop, N. (2015), "Editorial", Clinical Governance: An International Journal, Vol. 20 No. 2. https://doi.org/10.1108/CGIJ-06-2015-0018

Editorial

Article Type: Editorial From: Clinical Governance: An International Journal, Volume 20, Issue 2

Ideas in health policy tend to be cyclical. They come into fashion, and out of fashion, often as a knee-jerk reaction to the current problems of that moment. In a complex system, such changes simply tend to emphasise one dimension over another.

Clinical governance first came to primacy in the wake of the adverse events in the English NHS around the turn of the century, influenced by a number of factors including the Cadbury Report into corporate governance (Sir Cadbury, 1992). In the same system, commissioning seems to be achieving the same primacy.

It is worth noting, that the Care Quality Commission, with responsibility for the regulation of healthcare in the English system, have no jurisdiction over commissioning. Therefore, there is little linkage between the commissioning process and the governance process.

At the heart of any quality assurance process, including those in healthcare, is the idea of continuous improvement. Clinical audit, which arrived before clinical governance in the UK, was based around an audit cycle, and continues to provide an approach closely based on classical plan do check act ideas.

It is, however, worth noting that, even before the introduction of clinical governance, publications such as Gillies (1996) noted that the audit cycle was often incomplete. Lots of plan, some do, unless check, and almost no act.

Subsequent initiatives such as adverse incident reporting also depend upon a learning cycle.

Commissioning, like clinical audit, is envisaged as a cycle. Once a service has been commissioned, there is supposed to be measurement of outcomes to evaluate the quality of what has been commissioned, leading to reflection on whether the desired outcomes have been met.

Where those outcomes have not been met, there is then an opportunity to reflect on how the outcomes may be improved. The first stage should be to consider “what?” might be done differently to achieve better outcomes. Where this is not deemed adequate it may be necessary to ask the question “who?” and whether in fact a change of provider is necessary to achieve the desired improvement.

As with the audit cycle before it, the commissioning cycle is often delivered in an incomplete fashion. The evaluation and measurement of outcomes is often partial, and even when outcomes are measured there is by no means a comprehensive process to reflect on them and put in place actions to improve them. Too often, measurement is focused upon activity: “how many did we deliver?” and “was that more or less than we asked for?” rather than “what impact did we have?” and “was that more or less than was needed?”

As with many areas of healthcare, one of the key problems seem to be a lack of joined up thinking. Where the care quality commission acts as regulator, they can inspect only individual institutions, either hospitals or community services or general practices, or care homes.

Not only do they not have the power to inspect the commissioners, and examine the effectiveness of their commissioning and evaluation processes, they can only inspect one element of the provider chain in the patient journey at a time. Increasingly, the clinical and economic benefits of commissioning are seen in systemic solutions, with high levels of integration, not only between different healthcare providers but also with social care providers.

Many of the benefits, but also the potential problems, arise at the interface between different providers. Patients may receive excellent care in hospital but problems may start when they are ready to be discharged. There may simply not be adequate provision for them in the community, and if this is realised at this stage, they may be left in a hospital bed, which is neither the best solution for them or for the hospital, or indeed for the taxpayer who is left with a larger than necessary bill, for a less than ideal outcome. Alternatively, they may be discharged and the lack of support may lead to inadequate care and/or re-admission.

Communication at the interface is another common problem. The clinical record with its details of the patient’s prior care and needs is often transferred either slowly or incorrectly or in an incomplete fashion at the interface between providers.

There is an opportunity to re-envision the relationship between commissioning and governance. If clinical governance is re-envisioned as the check and act stages of a classic continuous improvement cycle, then it can truly become a mechanism for improving patient care in any system, where commissioning has primacy.

In such a system, the commissioning and governance cycles are combined. Governance becomes the process of checking that the outcomes and experience specified within the commissioning process are realised for patients. This would require an extension of governance activity to include the commissioning process, and to consider the whole patient journey and the impact of providers upon it, rather than simply inspecting specific providers. The care quality commission have already taken some steps in this direction, and are promising reports on the state of healthcare in specific localities.

A full implementation of this vision would make the clinical governance process patient centred instead of provider centred. It would apply governance to the critical interfaces between different providers, and it would facilitate innovations which required the transfer of resources from one provider to another in order to deliver clinical and economic benefits.

If we are serious about delivering truly patient-centred care, then we also need to think about truly patient-centred governance. By switching the focus of governance from institutions to the patient journey, we would go some way to achieve this. At the same time, by linking governance to commissioning we can evaluate the benefits across a health economy, looking at how different providers working together can provide more effective solutions than well-organised but segregated providers working in silos.

Alan Cameron Gillies and Nick Harrop

References

Gillies, A.C. (1996), “Improving patient care in the UK: clinical audit in the Oxford region”, International Journal for Quality Assurance in Health Care, Vol. 8 No. 2, pp. 141-152

Sir Cadbury, A. (1992), Report of the Committee on the Financial Aspects of Corporate Governance, Gee & Co. Ltd, Birmingham