On assuming office in 1997 the Labour Government inherited a complex set of challenges. On the one hand the 1990s had brought with it a loss of pub-lic confidence in the health service, poorly performing healthcare practitioners and seemingly unjustifiable variations in practice between regions. On the other hand this was accompanied by a history of previous substantial invest-ment in research and developinvest-ment, audit, clinical effectiveness, risk manage-ment, and continuing professional developmanage-ment, and, no matter how generous Government spending, a finite budget to support any change (Table 6.1). For decades there appears to have been a constant swing between policies that promote central as opposed to devolved decision making in the NHS. This reflects the tensions inherent in the organisation. On the one hand its depend-ence on public funds centralises accountability, on the other the perceived inadequacy of those funds inevitably persuades ministers that it would be best to devolve responsibility for how they are spent (Klein, 2001).
Given this context, how was the Labour Government to respond? A com-plex task lay ahead, but what Labour did promise was that in its efforts to address these shortfalls there would be no return to the old centralised
The Labour Government’s challenge 67
Table 6.1 Driving policy: the Labour Government’s challenge.
Key policy drivers Loss of public confidence in the NHS
Poorly performing healthcare practitioners
Variations in practice
Previous substantial investment in quality improvement initiatives
Finite budget
Illustrated by:
1996 50% of those interviewed declared themselves to be dissatisfied with the NHS (Mulligan, 1998)
A rising number of complaints going to litigation (Department of Health, 1996)
The number of cases that received high profile media coverage. For example:
the Allitt enquiry
a bone tumour service in Birmingham that misdiagnosed cancer, which in some cases led to unnecessary, drastic and disfiguring surgery
errors in population screening programmes for women’s cancers at Kent & Canterbury Hospital
high death rates from paediatric heart surgery at Bristol (Donaldson & Gray, 1998; Brocklehurst & Walshe, 1999)
Claims of ‘postcode prescribing’
In 1997 the Department of Heath reported variations in treatment patterns between regions (and even within regions). For example:
the number of hip replacements in people aged over 65 varies from 10 to 51 per 10 000 of the population the proportion of women aged 25–64 screened for cervical cancer varies from 67% to 93% in different areas of the country (Department of Health, 1997) First Department of Health Research and Development Strategy (Department of Health, 1991)
The Culyer Report (Department of Health, 1994a) made proposals to strengthen the quality of research and development and to protect its funding.
Evolution of NHS framework for risk management (NHSE 1996a)
NHSE(1996b) Promoting Clinical Effectiveness: a framework for action in and through the NHS.
Policy initiatives such as The Health of the Nation (Department of Health, 1992).
Claims of under funding and the continued drive for efficiency. In 1996 the NHS was declared the people’s top priority for extra spending (Mulligan, 1998)
68 Accountability and Clinical Governance: a Policy Perspective
command and control system. Furthermore, there was a pledge to save and modernise the NHS with a central commitment to ‘what works’ rather than any particular political ideology (Klein, 2001).
Practising within an era of increasing accountability
Before examining Labour’s response to the challenges of improving clinical care it is helpful to look at the related key development of corporate governance.
Corporate governance
Originally established to protect shareholders’ investments and company assets from fraud and malpractice, the principles of corporate governance were intro-duced into the NHS in 1994 as part of the Conservative Government’s attempt to demonstrate their commitment to improving public services (Department of Health, 1994a). Interestingly, during the same period a number of finan-cial irregularities had already started to come to light in the NHS (Smith, 1998). In the NHS, corporate governance is about having efficient and effective systems in place to show that those services provided are value for money and moreover, that public money is not wasted. The key principles underpinning corporate governance are:
• Accountability – everything done by those who work in the NHS must be able to stand the test of parliamentary scrutiny, public judgements on propriety and professional codes of conduct.
• Probity – an absolute standard of honesty in dealing with NHS assets:
integrity should be the hallmark of all personal conduct in decisions affecting patients, staff and suppliers, and in the use of information acquired in the course of NHS duties.
• Openness – there should be sufficient transparency about NHS activities to promote confidence between the NHS authority or trust and its staff, patients and the public. (Department of Health, 1994a, p. 2) In short, corporate governance is about ensuring that public assets are not put at risk or public money wasted in the delivery of healthcare and in so doing it demands accountability, honesty and transparency in all activities.
These principles would later be adopted by the Labour Government and re-emerge in policy documents intended to tackle the perceived decline in the reputation of the NHS and for standards of clinical care.
Towards a modern and dependable NHS: the Labour Government’s response
Reflecting upon the challenges the NHS presented to the Labour Gov-ernment when they came into power in 1997, review and modernisation of
The Labour Government’s challenge 69 the healthcare system was almost inevitable. The drivers for change were strong and there was a political imperative to act. The ‘new’ way forward to a ‘modern’ NHS was revealed in the 1997 policy document: The New NHS:
Modern, Dependable (Department of Health, 1997). Six key principles were identified:
• renewing the NHS as a genuinely national service
• making the delivery of healthcare against national standards a local responsibility
• getting the NHS to work in partnership
• driving efficiency
• focusing on quality
• rebuilding public confidence
The message was clear, the efficiency and effectiveness of the UK NHS and the clinical care it delivered needed to be increased, even if this meant (despite earlier reassurances to the contrary) reversing the previous drift towards decentralisation to an NHS much more strongly influenced by cent-ral Government.
Enter clinical governance
First introduced in 1998 clinical governance was described as:
a framework through which NHS organisations are accountable for con-tinuously improving the quality of their services and safeguarding high stand-ards of care by creating an environment in which excellence in clinical care will flourish. (Department of Health, 1998, p. 33) Clinical governance built upon its predecessor corporate governance and became an integral part of the NHS following the NHS Act of 1999.
As a result the last few years appear to have been dedicated to fathoming out what clinical governance is and how it can be made to work. Arguably, rather less attention has been given to whether it is a worthwhile endeav-our. Clinical governance is associated with improving quality and as such, it is difficult to argue with; indeed to do so would appear morally unjust.
Generally speaking most clinical staff have accepted the concept, if only as a result of the belief that problems with the NHS, that are currently largely (and one assumes incorrectly) attributed to failing healthcare professionals, will be exposed. That said, as a method to assure and improve quality, based upon accountability, it is not without its critics (Goodman, 1998; Loughlin, 2000). What does seem certain, however, is that the quality of clinical care has taken, and is set to remain, centre stage at least for the foreseeable future.
So what does clinical governance mean for individuals, practitioners and local organisations such as NHS trusts? From a very pragmatic standpoint many of the elements of clinical governance are ‘nothing new’. Clinical governance is intended to promote the delivery of safe, effective, patient centred healthcare and encompasses many pre-existing systems and processes
70 Accountability and Clinical Governance: a Policy Perspective
for monitoring and improving practice and services. Examples of such systems and processes include: clinical audit, risk management, education, training, continuing personal and professional development, and staffing and staff management.
However, greater emphasis is now placed upon involvement of patients and service users and the integration of existing quality initiatives to form a coherent whole. Gone are the days when departments such as risk man-agement, audit and training could operate in relative isolation (if in fact they ever did so successfully). Integration and working together are seen as the keys to high quality healthcare. It is also recognised that co-operation rather than the competition of previous years (and reinforced through the internal market) must be promoted, if individuals and organisations are to share best practice and learn from each other’s mistakes. This leads to the crux of the change: what clinical governance appears to represent, moreover require, is a whole cultural shift from a situation where when things went wrong the question asked was ‘who was to blame?’ to one where the major challenge is to find out ‘what went wrong?’
The requirement for a ‘no blame’ culture and more integrated working arrangements are not the only major changes associated with clinical gov-ernance (Figure 6.1). For the first time since the inception of the NHS in 1948, accountability for the quality of clinical care rests firmly at organisational level; final legal responsibility being placed with the chief executives of NHS trusts (Department of Health, 1998).