Clinical governance in mental health services: A study of a quality system

Clinical governance is the most ambitious quality initiative in the history of the
National Health Service. It is a comprehensive system of steps and procedures to
ensure patients receive high quality care and, like most quality systems, it attempts to
do this by influencing the behaviour of staff members. This study evaluates the
implementation of clinical governance in 30 mental health trusts in England and
Wales. It is set broadly within the action research paradigm and uses a participative
research method to engage staff and help them learn from each other. Trusts were
evaluated against a set of standards and using open questions in two annual cycles of
self- and external peer-review. The first cycle focused on clinical governance
structures and strategy; the second focused on how managers enabled front-line staff -
a topic chosen in response to the findings of the first cycle. By the beginning of 2002,
5 years after clinical governance was introduced and when clinical governance was
probably at its peak, this study found that only half the key strategies and structures
were in place. Most managers view clinical governance as useful, but struggle to
implement it under pressure from the government and without sufficient resources. It
is of great concern that their clinical governance work is disconnected from the work
of front-line staff and hence probably has little impact on patient outcomes. There are 3
main themes from both cycles: there is a hierarchical rather than enabling management
style; there are poor resources, e.g. not enough skilled staff; and there are problems
with support for front-line staff, e.g. risk management training needs to be provided to
more staff. There was no statistically significant association between trust performance
in both cycles and whether there had been a recent merger. Organisational theory was
found weak and a tentative developmental model is offered. Clinical governance
standards may have declined since the study was conducted because it is no longer the focus of statutory regulator's programme of reviews and because there are new policy
priorities. Services need slow reforms with a staged pace and need enabling rather than
hierarchical management styles. They also need better resources and to develop
beyond a basic survival level to one where they are able to focus on growth and
investment before embarking on ambitious policy initiatives.

This thesis supplied via ROAR to UEL-registered users is protected by copyright and other intellectual property rights, and duplication of any part of the material is not permitted, except for your personal use for the purposes of non-commercial research and private study in electronic or print form. You must obtain permission from the copyright-holder for any other use. Electronic or print copies may not be offered, for sale or otherwise, to anyone. No quotation from the thesis may be published without proper acknowledgement.