A NICE way to run the NHS

The National Health Service is introducing clinical governance as part of its drive to improve patient care. Julia Hinde reports on what this change will mean for academics

This week, some 16 months after they were first proposed in a white paper, the first steps towards establishing a new system of NHS clinical governance have been taken, with the launch of the National Institute for Clinical Excellence. The institute is to be headed by Sir Michael Rawlins, professor of clinical pharmacology at Newcastle University.

The new system should affect every doctor (including medical academics), medical student, nurse and nursing student, and all those responsible for some part of patient care in the NHS. It will also have implications for the undergraduate medical curriculum in universities and for research, everyday medical practice, teaching, and, some say, should present new money-making opportunities for universities keen to get in on continuing education.

* What is clinical governance and how will the changes affect universities?

According to the King's Fund, an independent health policy charity, clinical governance is part of a new approach by government for assuring quality health care in the NHS. It is a framework intended to ensure that all NHS organisations have in place proper processes for monitoring and improving clinical quality.

What is new is that for the first time it makes chief executives of NHS trusts legally responsible for clinical quality. Until now hospital and trust boards have been responsible for balancing the books, but responsibility for patient care has been with individual clinicians. High-profile cases, such as the current public inquiry into heart operations on babies at the Bristol Royal Infirmary, have raised questions about clinical responsibility. How could such apparent poor performance have continued for so long? Why did no one notice or blow the whistle?

The new system will shift responsibility for clinical quality to the trust. Individual doctors will be expected to undertake clinical audit, monitoring their own performance against others, while it will be up to trust boards to monitor regularly and improve this performance.

The new system is not just about preventing future high-profile cases such as Bristol, but also about ensuring that quality generally is improved, with doctors following best practice.

According to an NHS circular issued last month, the new system will be "underpinned by modernised professional self-regulation and extended lifelong learning". With all this formalised self-appraisal - and possible future five-yearly reappraisals for doctors by the General Medical Council - it is likely that retraining and extra education will become increasingly important.

But much of what constitutes clinical governance is still being formulated, and some of it, such as the responsibilities of the trusts, is dependent on the health bill currently making its way through Parliament.

Who will provide the lifelong learning and help doctors and nurses keep up to date with NICE guidelines is as yet unclear, but universities should certainly be among the lead contenders.

"There is a huge agenda for teachers," explained a spokesman for the King's Fund. "If clinical governance is going to work they will have to make sure every doctor, and every health professional, is kept up to date with the latest developments. It remains to be seen who will be doing the teaching, but if I was a health manager, I would want to be making links with local universities for continuing education."

He added: "Clinical governance marks a major change in what it is going to be like to be a doctor. You will be far more under the microscope, far more under pressure to be accountable and to perform better. But there will also be systems in place to help you do that."

* How will clinical governance affect medical academics?

Almost without exception, clinical medical academics who teach and research in universities have honorary NHS contracts. Many spend up to half their working time in the NHS, either in hospitals or in the community. It is seen as crucial that those teaching the profession have current experience of working in the NHS. So medical academics will be expected to go along with clinical governance.

On top of research assessment exercise and teaching quality assessment paperwork, as well as General Medical Council course accreditation, medical academics will now have to undertake clinical audit of their own work. This is already done in many hospitals, but it is not consistent nationally.

Their clinical audits will be judged alongside other doctors who may spend all their time in practice. If found not to be up to scratch, or simply not at the forefront of practice, they may be offered training and help to improve. It is as yet unclear what happens to a university contract if a trust decides a doctor on an honorary NHS contract is not clinically up to speed and takes away his NHS work.

Like other doctors, medical academics will also be expected to follow the clinical guidelines produced by NICE.

Medical academics will also be affected by clinical governance in their role as teachers of the next generation of doctors. Graham Buckley, secretary of the Association for the Study of Medical Education, and Jill Morrison, senior lecturer in the department of general practice at the University of Glasgow, wrote in a recent edition of Medical Education:

"Clinical governance as a whole needs to be introduced as a strong and coherent concept from the beginning of medical education. In this way, it can become a continuous theme throughout the lifelong process of learning in medicine and an accepted part of its culture."

Already some medical schools teach audit skills and encourage their students to take control of their learning. All that might be needed, suggests one clinical academic, is a "change in language", so what is currently being taught is taught in the language of clinical governance.

John Bligh, professor of medical education at the University of Liverpool, explained: "We are trying to organise our education for medical students so they are better prepared for the market place they are moving into. Clinical governance will alter the way doctors work, with more team working and the need to keep up to date. We need our students to be aware of that."

Clinical academics might also be involved in delivering top-up training to fellow doctors and other health-care professionals.

They are also likely to be involved in institutions such as NICE, and the still-to-be-established Commission for Health Improvement. Academics, often leaders in their particular medical field, have in the past consistently taken leading roles in such organisations.

* What is NICE?

Established on April 1, NICE is one of the first structures set up to support clinical governance.

Its job will be to provide health professionals with guidance on clinical management. Though it will be only guidance, doctors will be expected to follow the institute's advice, which should include up-to-date information on which drugs to use and which procedures are most effective. If doctors do not follow the advice, they may be called to account.

The institute will undertake appraisals of new and established health techniques - including new drugs and procedures - taking account of clinical and cost effectiveness. They will issue their advice to all doctors who will be expected to keep abreast of the guidelines. NICE will also produce clinical guidelines on the management of particular conditions, as well as advice on methods for clinical audit.

Though NICE will not undertake its own research, it will collaborate with the NHS research and development programme.

"Clinical academics will have to knuckle down to this the same as every other doctor," said Professor Rawlins, who will continue his work at Newcastle, alongside heading NICE. "Academics can do a lot more than they have in the past to promote clinical audit. It has not been something that academics have totally taken to heart. Clinical audit does not count in the research assessment exercise, to which their focus has been very understandably diverted. But now I hope they will do clinical audit themselves and teach it to their students.

"I think there should be a few chairs of clinical audit in the country. There should be research into the best ways of doing it."

* And CHI?

The yet-to-be-established Commission for Health Improvement is the NHS's answer to the Quality Assurance Agency or Ofsted. It will be a new national inspectorate making regular visits to hospitals and trusts to check each organisation has a system in place for ensuring quality. Provision for CHI is included in the health bill. Its head is yet to be named.