Accountability and responsibility: clinical governance beyond the institution

Abstract

The principal focus of clinical governance is intended to be at the level of the statutory organisation such as a Health Authority, Primary Care Trust or NHS Trust. This paper suggests that there are at least three levels (micro, macro and meta) at which clinical governance must operate if the original vision of flourishing excellence is to be fulfilled. These do not, regrettably, fit comfortably into the current organisational arrangements for the NHS in England and some cut across any traditional understanding of accountability relationships. With clinical governance at a relatively early stage of its development in many hospitals, and little better than vestigial in most Primary Care and Ambulance Trusts, it may be premature to take on such complex and challenging issues. However, the types of scenario described are typical of those that might create the next major system failure if they remain beyond the scope of clinical governance.