Trickcyclists.co.uk - Exam advice for MRCPsych candidates

Introduction

In 1997, the Government published a White Paper entitled The New NHS: Modern, Dependable, and within this document they introduced the concept of 'clinical governance'
clinical governance is a tool for ensuring high clinical standards are met, and that processes are in place to ensure continuous improvement in clinical practice within trusts
although the term is fairly loosely defined, it is backed up by a new statutory duty for quality within the NHS
Chief Executives are now responsible and accountable for assuring the quality of services provided by the trust, along with their responsibility for the proper use of resources
does this help us to understand what exactly clinical governance is? Probably not, but as a concept we can see how it would fit in with everyday clinical practice.
Some examples may help us to discover what it really is.

Perhaps the most publicised case where there has been a failure of clinical governance is that of the Bristol heart surgeons — the General Medical Council's inquiry into the cases of 53 babies treated by Bristol Royal Infirmary found that the problem seemed to have been a failure of quality assurance systems within the Trust.
Such assurances are vital to restore public faith in the NHS, and also to renegotiate medicine's contract with patients.

Clinical Governance can be seen as the area of convergence between managerial priorities of delivering the best possible service to the public and the best possible price, and the clinical priorities of managing patient healthcare to the maximum benefit of the patient.
Incorporated into the principles of clinical governance are a number of different tasks, which all have as their common theme improving the quality of the care provided within the NHS. These tasks including:
quality improvement programmes
clinical audit processes
introduction of evidence-based practice
dissemination of clinical guidelines and practice standards
clinical risk management programmes
monitoring of adverse events and complaints
systematic professional development programmes
monitoring of poor clinical performance
We will look at each of these in turn, examining how they will impact on psychiatric practice

it is expected that there will be a rolling programme of work intended to increased the quality of care provided
there should be the establishment of clinical governance committees, which would probably be led by a named senior clinician, and comprise of a broad range of specialties and professions within a given trust
responsibilities of the committee include:
quality data
clinical practice indicators
clinical audit
clinical guidelines

audit is the process whereby current practice is examined against a set of quality standards, current practice is then improved, and re-audited to ensure that the standards have been met
most clinicians will have had some experience with audit, whether it is simply looking at clinic attendance rates and improving upon these, or more complex analyses of current methods of working
the key to audit is that it should be a continuous practice, and if done properly results in the continuing improvement in the quality of care

Evidence-based medicine is 'the conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients' (Sackett et al. 1996)
the clinician these days should be able to define the clinical question to be answered (e.g. how long should I continue antidepressants for?), search for the evidence (e.g. Medline, journals, etc.), appraise it, and apply it
it has been estimated that evidence exists to support just over 50% of psychiatric interventions

governmental creation of the National Institute for Clinical Excellence (NICE) and the Commission for Health Improvement (CHI) should go some way towards supporting and overseeing the quality of clinical governance, and clinical services
the danger is of course that medicine becomes too 'prescriptive' and individual experience is lost in the craze for guidelines that must be followed to the letter

the monitoring of complaints, to some extent, seems to be approaching ground level, with individual doctors taking some responsibility for both monitoring adverse events within their own sphere of practice, and also dealing with any complaints

the continuing professional development of doctors in the NHS is a vital step towards ensuring that best possible care is being delivered to the public

the failure of this aspect of clinical governance was probably the key factor in the Bristol heart surgeons case
without a structure in place for the reporting of poor clinical performance, with adequate protection for all parties involved, it would seem impossible that best practice can be met
of course, linking early detection of performance problems with ongoing professional development should aid the general increase in standards in the NHS

we may not know it, but all of the above practices are essential to the delivery of good mental health care
without incorporating evidence-based medicine into our practice, we run the risk of being left behind, or our own practice being out of date
without committees disseminating the best established practices, we can leave ourselves open to criticisms of ignoring current best opinions, or being a 'lone cannon'
auditing our practices is the only way to identify problems and rectify them. It also allows us to provide evidence for our own particular methods or practices
monitoring of poor clinical performance speaks for itself, but we must be confident that there are structures to allow us to raise issues about performance within a constructive environment