Clinical governance in a changing NHS
International Journal of Integrated Care, 1 June 2006 - ISSN 1568-4156
Book review
Clinical governance in a changing NHS
Edited by Myriam Lugon and Jonathan Secker-Walker
London: The Royal Society of Medicine Press Ltd, 2006, pp 218,
ISBN 1 85315 665 5
Wim Schellekens, MD, MPH

Scally and Donaldson originally propounded clinical governance in 1998.[1] The UK Government's White Paper (A First Class Service) defined clinical governance as:

a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish (page 116).

For the last 8 years quality improvement in the NHS has been very much a top-down led effort. The UK Government has invested hugely in developing new methods and tools and in building capacity for improving timeliness, effectiveness, safety, efficiency and patient-centeredness of care.

This book (the third in a series of books related to Clinical Governance) is a reflection of what has been developed during these years: a myriad of approaches, models, instruments to support professionals and local leaders to improve care.

In 13 chapters, 18 writers describe the state of the art of what has been called ‘clinical governance’. I agree with the editors in their preface that all these efforts have brought many improvements for patients but also some unwanted side effects caused by the way the results are measured, audited and published, and the financial and managerial consequences.

The book suggests that while overall progress has been made in all aspects of clinical governance the implementation across the NHS is still patchy. In particular, the book concludes that there is a need for a much more integrated application of the various quality systems and—even more important—they should transcend the traditional organisational boundaries, following the patients' journey: integrated care.

Topics covered in this easy-to-read book are the role of the medical director, patient safety, care pathways, infection control, (clinical) information systems, the role of nurses and midwifes, transparency about performance, chronic diseases, out-of-hours care and training of doctors. Personally I liked very much the chapter of James Reason about the psychology of patient safety: a must-read for every professional and clinical leader. Moreover, this book offers a comprehensive overview of the state of the art of care pathways: nothing really new, but very important and still much underestimated.

The same is true concerning the chapter on infection control: not a hobby for microbiologists, but a central issue for every professional and clinical leader to prevent unnecessary harm and suffering, and to earn a lot of wasteful spend money, just by doing what evidence tells us to do: it urges the need for infection control to be embedded within the corporate governance of organisations.

The chapter on the role of the medical director is a good example of the many responsibilities regarding clinical governance: almost a mission impossible. I do not like so much the emphasis on the should-do and must-do. Too much of this is still opinion-based instead of evidence-based.

Emphasis in this book is on the quality improvement efforts within the hospitals. The strategies, tools, experiences and results successfully explained in this book should be applied also to the integrated care pathways together with primary and tertiary care. It is a pity that the editors did forget this important aspect for the patient.

This brings me to the conclusion: I recommend this book to every professional and clinical leader. It gives a fast and easy to read overview of important topics to improve patient care. Learn from it, but more important: practice it: professionals, clinical and managerial leaders together, in a collaborative way. I hope the next book in this series will cover the integration of all these topics, approaches and methods in a comprehensive quality-management system, as part of normal leadership and management. And secondly we need a strategy for national and local spread of the learned lessons and best practices.

I look forward to read the fourth book in this series related to Clinical Governance to learn how these strategies and instruments apply to the integrated care: for patients primary, secondary and tertiary care should be a continuum: in this field there still is a lot to improve.


Scally G, Donaldson LJ. Looking forward: Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998; 317: 61–5.