Introduction
The National Health Service (NHS) in the UK has become synonymous with the country’s reputation and government apparatus. However, global fiscal constraints have placed the UK healthcare system in challenging position of scarcity of resources as well as ensuring the best quality of care to the public. Clinical governance was introduced to the NHS in the 1990s to address a series of concerns in quality and safety of healthcare, a response to conditions of increasing demand, consumer participation, cost pressures and litigations (Braithwaite & Travaglia, 2008).
Clinical governance can be defined as a “framework through which NHS organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care” (Wilson, 1998, p. 987).
It places a duty of responsibility on healthcare professionals and organizations to ensure satisfactory, responsive, and consistent level of care where individual staff cooperate with clinical teams and large systems of quality assurance to best upkeep clinical standards. This paper will examine how elements of clinical governance can play a critical role in maintaining public confidence in healthcare delivery and its quality in the socio-political context of the struggling NHS.
Social and Political Context
The NHS holds deeply interconnected role within the UK as an institution, often placing it in the midst of social, political and economic contexts and debates. A combination of the global fiscal recessions and UK austerity programmes since 2010, the NHS has shifted its focus. Local areas had to undergo radical reconfiguration of services through a mechanism known as Sustainability and Transformation Plans (STPs) in order to produce cost-effective measures.
Hudson (2017) notes this resulted in the cutting of many essential and previously free healthcare services throughout the UK. It became a catalyst for citizen involvement and opposition, publicly highlighting the numerous issues in the NHS and citizen accountability. Accountability is important because in its absence, those in power of decision-making, may act without regard for those whose lives were affected by the actions.
In the context of public accountability, the concept of public engagement has been brought forward as a key element in reforming the NHS to be more effective, accountable, and responsive to population needs. Public engagement goes beyond simple opinion polls but rather choosing committed and broad representation of the general public and providing them with essential information, determining ways to represent marginalised groups, eliciting values and expectations and receiving input regarding policy and decision-making.
Since the NHS is funded and used by the public, citizens can be perceived as key stakeholders. Greater engagement corresponds to principles of democracy that are socially valued. Furthermore, incorporating the public in decision-making regarding their treatment that will profoundly affect lives, will elicit greater support for policies and ensure that legislation meets the values and priorities of the community (Meetoo, 2013).
At the time of the 2017 election, 61 per cent of the UK population identified the NHS as the leading issue facing the country, above most everything else including critical issues such as crime, immigration, and education (Wellings & Robertson, 2019). Public satisfaction with the NHS is at its lowest level since the financial crisis of 2010, driven by public concern for long appointment and procedure wait time, staff shortages, and an overall lack of funding.
The crisis is more than just humanitarian, it is political, as politicians from all parties in the UK failed to provide funding for the NHS, with predictable but devastating consequences. Health facilities are unable to meet rising demands, resulting in inconceivable events such as four-hour wait times at emergency departments and treatment of patients on trolleys in corridors, which are the antithesis of quality and safety of patient care.
Ham (2017) argues the political context suggests that a number of successive governments that the UK has had in the last decade, largely failed to act upon reports of issues in the NHS, commonly choosing a superficial short-term solution of providing slightly more funds (temporarily and largely irrelevant for the needs of the system) instead of addressing complex long-term social and systemic issues.
The UK is a developed country which poses some common health needs for the population. Among these are chronic diseases, cancers, infection control, and mental health alongside traditional health services such as screenings, vaccinations, dentistry, geriatric care, gynaecological care, and emergency services.
The UK is also facing the challenges of increased demand due to a rapidly ageing population as well as a growing population as a result of immigration and natural population increase. As noted by Roberts (2018) for the BBC, the evolving healthcare needs in the UK require medical advancements, that are effective but increase costs considerably, costing an additional £10bn a year. At the same time, reforms in attempts to cut costs for the NHS has resulted in closure of local services in the context of centralisation and an increased reliance from both the population and the national system on privatised service providers.
Staffing in all NHS facilities remains low, with upward of 100,000 available positions, the majority of which are in general care where staff is commonly overworked and underpaid. These social and medical factors combined indicates that the NHS will require an additional 17,000 hospital beds by 2022 and significantly more staff and equipment to meet the health demands of the population (The Medic Portal, n.d.).
Education and Professional Development
The demands of high standards, staff engagement, and rigorous assessment brought by the clinical governance mechanisms makes continuing professional development a key component in the quality framework. Medical professionals with appropriate skill set and competencies working in multidisciplinary teams are vital to delivering high quality of care to assure patient safety. Patients trust medical professionals at their local NHS facility to provide necessary care in a manner that is safe and addresses patient health needs.
Nurses in particular are a large sector of the professional workforce whose roles must be optimized to deliver care (Jennings & Astin, 2017). According to Wall and Halligan (2006) clinical governance is meant to reflect this privileged relationship by unifying the framework that is necessary to assure a clinician’s duty of trust to patients. NHS organizations must be accountable for continually improve quality of services and safeguarding standards of care by creating an environment of clinical excellence.
In this context, professional development plays a tremendous role in assuring this duty of trust and ensuring that healthcare professionals are able to competently deliver the standards of care based on patient expectations, since the NHS in all its means is a publicly accountable service.
It is well-known that most modern NHS trusts are an example of partnerships between various stakeholders such as clinicians, managers, regional education, and training consortia. However, experts suggest including education as early as undergraduate in the process is critical to closing the gap between the existing and desired levels of quality in care. Educational aspects that clinical governance can address include enhancing the skills of existing staff via training and professional development and train a new group of staff with skillsets and competencies to meet the standards and challenges of modern medicine (Gibson & Ward, 2000).
Furthermore, Eppich et al. (2016) emphasize the importance of continuing professional development for all staff allows them to improve skills and knowledge and connects plans for quality improvement to training, education, and resourcing mechanisms. It is vital for competent professionals with proper skills training to deliver that care that will meet the quality agenda and requirements withing the clinical governance framework
Typically, professional education and training in healthcare is based on specific specializations or care for specific conditions. There are some elements of patient-based care, interdisciplinary care, and quality aspects, but only in recent years has there been a shift in education to encompass organizational behaviour, continuous quality improvement, and collaborative care (Wong et al., 2011).
Therefore, doctors and nurses would learn about care for a patient with a condition (i.e. diabetes) from separate professional viewpoints but the organizational aspects of care were lacking. It is key to take advantage of the education and professional development element of clinical governance to encourage healthcare professionals to understand the wider aspects of care.
Heard et al. (2001) suggests that this is necessary in order for quality improvement initiatives to succeed and have impacts since the NHS encourages interdisciplinary care decision-making based on the pooled expertise of those involved in the care process. Chief executives of health organizations alongside clinicians are responsible for aspects beyond administrative and financial but carry the burden of establishing quality clinical service.
It is imperative for practitioners to see quality improvement and to establish a culture where quality interdisciplinary care is prevalent (Heard et al, 2001). Notably, this will reflect on patient experiences and outcomes as well. Optimal patient outcomes are likely to be achieved in contexts of pooled expertise and collaboration where redundancies are excluded while the best treatment possible can be found. Such environments and cultures are established through professional education and development.
Poor performance in a healthcare system may be a result of multiple factors, but competency and skill are commonly a foundation. When implementing clinical governance, leaders need to understand the nature of the problem and then provide educational resources to deal with it and managerial resources to facilitate the said process.
Markwell (2009) emphasizes that accountability stems strongly from the professional education and competency background. There is individual accountability for the quality of their work, overseen by quality standards. The accountability of health professionals within the organizations of work is critical. Finally, there is accountability with others, for the organization’s performance and provision of local health services.
Throughout 20th century, clinicians exercised their skills with complete autonomy, but with the introduction of clinical governance and new standards and models, there is now an obligation for clinicians to meet explicit and higher professional standards (Markwell, 2009). These elements emphasize the need for practitioners to continuously strive to develop professionally in order to acquire or retain clinical skills, obtain best evidence-based practices, and participate in quality improvements or optimisation of care processes. These are essentially all form of explicit accountability which clinical governance encompasses.
Risk Management
Risk management is an important domain in the context of clinical governance. It is common sense that all health organizations and departments must focus on identifying risks, maintaining the lowest possible level of risk. However, it is a significant challenge to properly identify risks, especially if they occur rarely. There is a strong reliance on staff reporting of risks and it must be properly construed and encouraged (Starey, 2003).
As a result, Churchill (2008) suggests a risk and incident reporting system must be developed and maintained that will allow to analyse incidence and levels of risks. Incidence reporting has its own challenges as many risks may go unnoticed as individuals avoid voicing them due to fear of professional consequences or lack of awareness about the risks. Trigger list of reportable incidents and near misses must also be created to improve reporting levels, with significant events investigated by root cause analysis (Churchill, 2008).
Risk management does not consist of incident reporting by itself but encompasses multiple perspectives and sources to compose a local risk register. Meanwhile, Jain et al. (2018) offer a framework to risk management in any given industry which emphasize holistic and integrated systems that utilize resilience metrics for predictability. Most effective methods of controlling risk use a holistic approach, but failure to take systemically consider risk management may result in uncontrolled risks and adverse consequences
Effective clinical risk management is based on a culture of transparency and safety consciousness in health organizations. It is the organization’s system of governance, supported by risk management policy which captures the approach to risk and helps to reduce it, thus enhancing clinical quality outcomes.
The guidelines at Blackpool Teaching Hospitals NHS (2016) identify current and emerging risks impacts an organization’s ability to achieve quality of care objectives in a manner that is consistent with regulatory, legal, and patient expectations. Therefore, it can be directly argued that patient safety is directly tied to risk management, which is a matter of safety culture, integration of risk management activities, reporting, and open communication are among major guidelines for national patient safety. Hospitals should actively use risk management is vital to maintaining a safe environment while protecting patients, staff, and assets
Major risk factors and incidence in the NHS system include medication management, pain management, nutrition and hydration, behaviour management, and specialized nursing care (i.e. wound management or post-operation care). The introduction of reporting system is the cornerstone of effective safe practice in organizations.
However, risk management must go beyond reporting but how leadership responds to said risks. Chiozza & Plebani (2006) suggest that clinical teams must be able to change delivery of services based on process analysis and implementation of evidence-based practices, promoting clinical risk management processes.
This establishes an accountability system that provides tools for decreasing incidence rates but improving effectiveness of treatment. The primary question is whether clinical governance can be used to promote risk management as an element that must be consistently improved, not as a separate activity, but as an essential part of all other aspects and everyday practice of healthcare professionals
Aneta Wierzynska and colleagues (2020) attempt to address this question. In the context of public accountability and social perceptions, risk management is an important element of governance that is used in development of strategic priorities and policy objectives. The researchers also suggest that many risk management and anti-corruption strategies used in enterprise ca be recalibrated for healthcare by expanding traditional ownership and enabling specialists to mitigate risks.
This is driven by socio-economic trends and public attitudes toward health. Oxford University Hospitals NHS (2015) report states, when evaluating risks, organizations consider its likelihood and frequency of occurrence as well as its consequences. Some of the main domains of consequences that may occur due to risk include impacts on patient safety, quality complaints, and adverse publicity and reputation.
The NHS has begun to take into account the public perceptions of risk and its impact on patients and organizations. Incidents may lead to reduction in public confidence and elements of public expectations not being met). This approach is directly beneficial to establishing accountability within the context of quality of care and patient experience with the NHS.
Evidence-based Care and Clinical Effectiveness
The third and final aspect discussed in this paper is clinical effectiveness, which in the context of clinical governance can be defined as the application of best available knowledge to achieve the optimal outcomes for patients. It focuses on providing the best evidence-based care for the patient with the use of available clinical resources (Pearson, 2017). Practitioners are expected to work within established guidelines, protocols, and pathways for specific conditions and treatments to ensure that patient care is guided by best available evidence in the effectiveness of a particular treatment regimen.
Meanwhile local agreements between the NHS and secondary/community providers to streamline the patient experience and reduce costs. Clinicians are expected to be up to date on latest knowledge and practices in their field or specialization and consistently follow updated national NICE guidelines (The Walton Centre NHS). This suggests that clinical effectiveness is a broad term that describe a wide range of activities and mechanisms utilized to assess, support, and improve the effectiveness and quality of care.
Mechanisms of measuring clinical effectiveness can vary depending on needs, funding, and objective and can include clinical audits, clinical outcome measures, service evaluations, benchmarking data, and clinical indicators. Viner (2010) discusses the clinical audit is a method that is most efficient and commonplace in measuring clinical effectiveness.
The clinical audit cycle is a quality improvement process which establishes guidelines for addressing particular issues based on documented evidence and measuring effectiveness of the regulations once in effect, then modifying them as appropriate. It creates a cycle of appraisal and improvement, establishing an ongoing process of clinical improvement.
The Royal College of Physicians and Surgeons of Canada (2015) contributes to this emphasizing that clinical guidelines are systematically developed statements that assist practitioners and client decisions in a variety of circumstances. These differ from clinical protocols which are mandatory, but guidelines are recommendations. Guidelines have the benefits of assisting in application of evidence-based practice and providing a uniform standard of care.
They can also be used for education of health professionals and guide patients to make informed decisions, potentially improving communications, and managing expectations. Viner (2010) concludes the thought that guidelines in the context of clinical effectiveness contribute greatly to establishing awareness and communication in the healthcare sector that leads to better satisfaction and trust in the population.
It is evident that clinical effectiveness aspect of clinical governance can greatly improve both quality and satisfaction of patient care. Worcestershire Acute Hospitals NHS (2018) outline that the concept focuses not only on adherence to evidence and standards but implementing quality improvement tools. These consider the views of patients, clients, and service users along with staff. Evidence is collected from any incidents and risk analysis as well as outcomes from provided treatments and services.
This is supported by a study by Doyle et al. (2012) that emphasize the ability measure performance to determine if a clinician team or organization are achieving standards and set goals as well as areas of care that require further attention or research. For example, evidence suggest an inherent link between clinical safety and effectiveness outcomes with patient experience.
This information is collected and provided in open access for patients and communications such as press releases and public reports are utilised (Worcestershire Acute Hospitals NHS, 2018). Clinical effectiveness plans for facilities have shifted to becoming public and patient-centric focused on maintaining its promises regarding standards and quality as well as addressing issues of delays, cancellations, and lack of appropriate bed space.
Another element that can contribute to accountability is public involvement in the clinical effectiveness processes. The National Clinical Effectiveness Committee (2018) defines public involvement as any process that directly engages the public in decision-making and consideration of public input. Clinical effectiveness is the best element of clinical governance to incorporate public involvement as it focuses on quality improvements and addressing practical issues that important to the public interest.
Pickard et al (2002) support this approach by arguing public involvement is important in clinical effectiveness since allows to develop local priorities and implement improvements based on publicly identified needs rather than assumptions. With public participation in National Clinical Guideline and National Clinical Audit processes enhances their legitimacy from a public perspective and allows the population to participate in clinical guidance development
In the end, as eloquently described by Wilson (1998), in order for patients and families to trust the healthcare system and professionals, they must be aware that their treatment is clinically and cost-effective, modern, and meets evidence-based practice guidelines.
The emphasis should be placed on processes that are simple, safe, and effective. Government institutions can be set up to facilitate and promote adherence to clinical guidelines based on evidence-based practice as well as incorporating recommendations from clinical audits (which are integral to this element of clinical governance) and evaluation criteria.
Conclusion
The current social and political climate is challenging for the NHS, faced with significant public criticism for deteriorating quality and safety of patient care while remaining majorly underfunded and faced with austerity policies. Clinical governance was introduced to the NHS when it too faced significant crises, reforming the national system while introducing standards of quality and improvement.
This paper explored three elements of clinical governance: professional development, risk management and clinical effectiveness. Professional development increases skill and competencies in professionals, allowing to provide better quality care and be accountable for the treatment provided as well as organizational capacities.
Risk management directly addresses safety concerns, implementing a system of risk identification and shifting organizations to proactively act upon them, recognizing their accountability to the public safety and negative perceptions that incidents may cause. Finally, clinical effectiveness is a process of continuous improvement and implementing best evidence-based care. It is a quality assurance element which allows organizations to consistently improve and optimise processes by balancing proven care and available resources.
The NHS needs to adapt and act upon all three of these domains to remain an effective, flexible, and modern health system while supporting the growing demands of an increasing population with widely unavailable resources. Recognizing these elements and establishing responsibility are vital first steps in public accountability for the quality of provided care.
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