Muhammad Hanif Shiwani  ( Department of Surgery, Barnsley District General Hospital, Wakefield,United Kingdom. )

The word "governance" has been in vogue among the medical academia focusing on the ultimate management issues. The important debate is on the "good clinical governance" which has the ultimate focus on patient in terms of assurance for their physical and mental well being. This issue is not complex when we understand the true spirit behind it and that lies with the continued professional development (CPD). Updating with the fast advancing knowledge on clinical issues will reflect in the better patient care, participation in training initiatives, being and becoming aware of clinical guidelines, developing anti discriminatory practice and becoming well versed with cultural issues. It will help to deal with complaints and sensitive matters in a cooperative manner to be a good communicator and a good listener, accept and provide clinical supervision and manage the clinical auditing on a regular basis. It can go a long way in setting ground for good clinical governance which is all about changing the way people work, demonstrating leadership, team work and communication, thus causing the health system to sail smoothly with efficient and beneficial results in terms of general health care. The gist is in the simple process of clinical decision making and the process by which these decisions are implemented.

In United Kingdom the term "Clinical Governance" has been defined as a system through which National Health Service 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. 1

In Pakistan, amidst the scenario of very low health budget, massive population, poor health care system, mushrooming of poor quality medical schools and fragile training structure, can one imagine of getting the benefits of good clinical governance? Even after half a century's independent life, governments have failed to provide basic healthy living conditions to the masses and should be accountable for the serious mortalities due to lack of safe drinking water and epidemics of water borne diseases. Basic health units have become ghost houses. At least 600,000 illegal medical practitioners are 'treating' millions across the country for a variety of ailments. In the given circumstances the concept of clinical governance seems far seeing.

However, governance does not mean government. The onus of good governance is not on the government. The key players of clinical governance are the doctors and the independent social and non governmental organisations. Clinical governance is the responsibility of managers and clinicians working at all levels within a health care delivery system. Therefore it is vital to have access to clearly written, reliable information on clinical governance and be equipped to deliver these complex and challenging roles.

The development of clinical governance is designed to consolidate, codify, and universalise often fragmented and far from clear policies and approaches, to create organisations in which the final accountability for clinical governance rests with the chief executive of the health organisation, with regular reports to board meetings (equally as important as monthly financial reports) and daily responsibility rests with a senior clinician.

Currently there are clinicians providing non-standardarized clinical care justifying on the basis of economic and cultural shortfalls. There is no accountability and no mechanism in place to control unprofessional practices which is well reported in Pakistan. 2,3

In Pakistan there is a need to create a single excellence-in-practice organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health as created in many developed countries. 4 The concept of clinical governance does not exist but it could be introduced as "a system through which doctors could be 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".

There is no clear guidance to doctors about the standards of professional conduct expected of them. Professional self regulation is very important to achieve good governance in clinical practice. Doctors should be accountable for their professional practice and must always be prepared to justify their actions and decisions. Failures in providing "good medical practice" as described by General Medical Council of UK 5 can be detected through the process of complaints, audit, reporting of untoward incidents and routine surveillance. Doctors cannot be blamed solely. The "process" of standardization and accountability merely exists in many sectors, therefore, a culture has developed where there are no goals to achieve and strive for an ideal health care. Hence there is an increasing need to set standards for many well established medical therapies.

One suggestion would be to develop National Advise Bureau of Clinical Excellence. This should be an independent autonomous body of well qualified and experienced health care professionals from a wide group of representative from medical colleges and universities, professional associations and societies, relevant governmental and NGOs, PMDC, PMA and medical academics. They should develop guidelines for standard, continuous professional development and appraisal and assessment of doctors should be introduced. Evidence based clinical practice should be adopted. Mechanism should be in place to obtain data of clinical performance and quality of data should be assessed by the independent sector. Failing doctors and poorly performing institutes should be kept under scrutiny.

Clinical outcome indicators can provide insights into quality of care and highlight variations in outcome worthy of further investigation. Therefore, one would expect health care staff, senior clinicians who are in charge of individual units, medical superintendents, provincial health secretaries, ministers and directors of health to know how their figures compare with the rest of the country, to understand what their results mean and be able to demonstrate what follow-up action is being taken. 6

There is need to create an open, transparent and no blame culture. If we have to raise the standard of health care in our country then we have to adopt the culture of good clinical governance.

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

2 Najmi MH, Hafiz RA, Khan I, Fazli FR. Prescribing practices: an overview of three teaching hospitals in Pakistan. J Pak Med Assoc 1998;48:73-7.

3 Hussain SF, Zahid S, Khan JA, Haqqee R. Asthma management by general practitioners in Pakistan. Int J Tuberc Lung Dis 2004;8:414-7.

4 National Institute of Clinical Excellence. United Kingdom. http://www.nice.org.uk. accessed 1995.

5 Good Medical Practice, General Medical Council. United Kingdom. http://www.gmc-uk.org. accessed 1995.

6 Health Department, clinical outcome indicators, Clinical Outcomes Working Group, July 1999.