There is a contemporary move in the National Health Service (NHS) to adopt commercial-style governance for provider trusts. Clinical governance has been developing toward ‘integrated healthcare governance’, and there is now an intense focus on corporate responsibility for healthcare activity, especially in NHS foundation trusts.

Any form of governance requires systems to manage risk and to provide information on performance, which are surely essential tools for all senior healthcare staff. However, governance initiatives may fail if they are overly bureaucratic, and this may be a particular risk in the complex world of mental health. Good governance is therefore of great importance to psychiatry.

Successful governance depends on innovation and integration at a strategic level. This should begin with the culture of the senior staff and directors, and a simple reporting system, such as the balanced scorecard. These must embody a clear vision of future success, based on ‘what really matters’ for patients.

Governance may sound a very dry concept, of limited relevance to psychiatrists. However, in order that large healthcare organisations deliver good services for patients, there must be good governance arrangements of some form. For organisations which are not well run, real innovation in governance is essential for effective clinical practice to develop and flourish. Understanding good governance is therefore crucial to all clinicians, including psychiatrists.

Corporate and clinical governance

Corporate governance is about how commercial companies are run, and the integrity of relationships between company boards, staff, shareholders, customers and society. In practice governance often focuses on the control of company finances, and on board responsibility for corporate risks.

Governance has been developing in the NHS for some years, around finance audit and systems of controls assurance (Emslie, 2004). NHS foundation trusts are now set to have a code of governance (Monitor, 2005) which relates closely to the UK Combined Code on Corporate Governance (Financial Reporting Council, 2003). The Combined Code begins with a clear statement:

  ‘Every company should be headed by an effective Board, which is collectively responsible for the success of the company’.

In recognition of the potential for improved governance in the NHS, clinical governance was introduced for local NHS trusts, a new concept ‘built on the principles of corporate governance’ (Department of Health, 1997). Scally & Donaldson (1998) gave one of the shorter definitions of clinical governance:

  ‘A framework through which NHS organisations are accountable for continually 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 some consensus that clinical governance has not been clear or effective in achieving excellence. Many have suggested different ways of working (see Degeling et al, 2004). Healthcare Commission reports on NHS services have found failings in clinical governance, especially in mental health (Oyebode et al, 2004). Clinical governance has resulted in a loss of clinical autonomy and influence for psychiatrists, at least in Australia (Callaly et al, 2005). This is consistent with a long-standing perception by senior NHS mental health professionals of a culture of mistrust and unrealistic management plans and directives (see Norman & Peck, 1999).

The fall-out from high-profile incident inquiries has also had a major impact on NHS psychiatrists and the services they work in (Salter, 2003). The NHS response is national risk management initiatives such as the National Confidential Inquiries, and newer bodies such as the National Patient Safety Agency and the NHS Security Management Service. How can a local NHS trust and its staff deliver good governance and clinical excellence in this climate?

Integrated healthcare governance

Integrated healthcare governance is not easy to define concisely, but the Department of Health (2006) has recently tried:

  ‘Systems, processes and behaviours by which trusts lead, direct and control their functions in order to achieve organisational objectives, safety and quality of service and in which they relate to patients and carers, the wider community and partner organisations’.

Integrated healthcare governance has origins in US corporate and not-for-profit healthcare (Sugarman, 2005). A programme of integration promises to make healthcare services simpler to run, more effective for patients and more dynamic to work in. True integration of governance must create a non-bureaucratic culture of shared knowledge, teamwork and high achievement. Integration should bring together line management, clinical governance and risk management in finding solutions (Sugarman & Midgley, 2005).

Integrated governance has been particularly pursued by NHS trusts to meet regulatory requirements (Healthcare Commission, 2005; Department of Health, 2006). Many will recognise the strategic vision in integrated governance, but have doubts that complex governance initiatives in the NHS can lead to positive change.

Conclusions

Mental healthcare providers, increasingly independent of central control, will be able to prioritise use of scarce human and financial resources. Cultural change in mental health services will require further deconstruction of traditional structures and thinking. Innovations in teamwork will be necessary for better use of resources and better patient outcomes. Clinicians should be at the forefront of this change.

New forms of governance must empower mental health service users, clinicians and managers to find innovative routes to recovery. The only successful strategy will be to create a culture of trust where diverse people truly work together on what really matters for patients.

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Philip Sugarman, CEO and Medical Director

St Andrew’s Healthcare, St Andrew’s Hospital, Billing Road, Northampton NN1 5DG, email: .(JavaScript must be enabled to view this email address)