Throughout the world, societies are striving to determine how best to organise their health systems and deliver services. Increasingly, there is recognition that the development and evaluation of new therapies and diagnostic tools is only part of the answer to better health care(1). Clinical governance first began to appear in the NHS vocabulary after Labour came to power in the 1977 and was one of the foundation stones of the NHS planning blueprint. The NHS plan was published in 2000 and the policy has underpinned the governments raft of reforms ever since (2).
The department of health’s clinical governance support team defines clinical governance as: “A framework through which NHS 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 can flourish” (3). When major reforms of health care and social services were introduced in the 1990 in the NHS and Community care act the government put quality on the agenda for the first time.
The reforms were based on two white papers: Working for patients (department of health 1989a), with its focus on the NHS, and Caring for people (Department of health 1989b), which addressed care in the community. These aspects collectively contribute to the idea of clinical governance (4). The standards of clinical governance were set nationally by the National Institute of Clinical Excellence (NICE), which were agreed by wide consultation and use of research into effectiveness and cost effectiveness of clinical practices.
National Service Frameworks (NSF) also set standards. A key element of good clinical governance is work to deliver the standards set by NSFs and the NICE(5). Principles of clinical governance extend to all NHS services; including community pharmacists who have an important contribution to make to the development of a coherent strategy for assuring and improving service provision across the local health community. Most community pharmacies have undertaken a significant level of clinical governance activity.
This includes the use of standard operating procedures; such as recording, reporting and learning from adverse incidents; participation in continuing professional development and clinical audit; and assessing patient satisfaction(6). The development of clinical governance of community pharmacy services is supported and encouraged by Primary Care Organizations (PCOs)(6). Clinical governance can be broken down into a series of smaller processes, which when brought together, can help assess the quality of services provided to patients in the NHS.
There are key components of clinical governance which have implications on practicing pharmacists and pharmacy services. These components are: Patient and public involvement, clinical audit, risk management, clinical effectiveness, staff management, education, training, continuity professional and personal development (CPD), accountability and research and development (7). One of the core concepts of clinical governance is that the patient or client should be the centre of their healthcare experience (8).
Patient and public involvement is an important implementation in clinical governance as it allows patients/clients knowledge and expertise about their health and well-being, which can be used in partnership with experts’ professional knowledge to provide effective quality care. Structures and processes are needed to facilitate professionals and patients to work together in order to achieve positive outcome to a patient (8).
This has shown to have impacts on pharmacists in England and Wales as they are encouraged to undertake annual patient satisfaction surveys which are then reviewed and changes are then considered which could improve service provision. Other services such as complaints system should be in place. Pharmacies co-operate with local Patient & Public Involvement Forum visits and give consideration to any report of such visits and identify and take appropriate action. Co-operation with PCO and other appropriate external bodies on monitoring and auditing of pharmacy services, by authorised persons are also undertaken (6).
Other services provided by pharmacies are there act on the Disability Discrimination Act 1995 duty to make reasonable adjustments to the physical features of premises(6). The principles for best practice in clinical audit document defines audit as: ‘A quality improvement process that seeks to improve patient care and outcome through systematic review against explicit criteria and implementation of change (9). In one form or another, audit has been part of good clinical practice for generations. Pharmacists and their staff should participate in two clinical audits.
One practice based audit and, one PCO determined multidisciplinary each year. Both audits must have a clear outcome, which will assist with developing patient care(10). Risk and staff management (including root cause analysis), are also important aspects to consider in the pharmacy setting as it is necessary to have in place standard operating procedure, recording systems for interventions and reporting system for errors and near misses. Suitable waste disposal systems for any clinical and confidential waste should also be in place.
Pharmacists must ensure that their work practices are safe and effective, and superintendents and chief hospital pharmacists must ensure that procedures are designed to minimise risk. The Chief Medical Officer’s report ‘An organisation with a memory’ identified the need for action in a number of areas to improve patient safety in the NHS. It set a target to reduce the frequency of serious medication errors by 40% by 2005(11). Pharmacists should be aware of current evidence (clinical based evidence from guidelines) and apply this to their practice including monitoring patients care.
This is the basis of clinical effectiveness. This has an important impact on pharmacy systems as they are used to ensure appropriate self-care advice is given to patients, e. g. use of protocols/standard algorithms, SoPs. Managing and dispensing of repeatable NHS prescriptions for medicines or appliances, in partnership with the patient and prescriber and the medicines use review service, in particular, pharmacies will contribute to improving the clinical effectiveness of prescribing(12).
Pharmacists have to ensure that all of their team (including any locums) receives appropriate induction and training, for example confidentiality procedures, health and safety issues and security. This is part of resource management and improves quality of prescribing. Each pharmacist has a professional obligation to maintain a record of CPD, which is a cyclical process of reflection, planning, action and evaluation. CPD allows pharmacists to be kept up to date with knowledge (reduce litigation) and allows determination of poor professional performance at an early stage which ensures wellbeing of patients and the public(13).
Generally there is research which supports CPD to be an effective technique; however, there are cumbersome to administer and fail to address adequately the health needs of the community and the requirements’ of the NHS(14). It is for this reason that a new training strategy is being launched by the RSPGB scheme(14). Implementation of clinical governance can be difficult however when looking closely at the different aspects of clinical governance it shows the importance on practicing pharmacists and pharmacy services.
The proposed indicators and examples of good clinical governance practice have been developed to help individual pharmacist prescribers ensure that their practice is safe and of a high standard which is important within all aspects of prescribing and medicines management. It is also important that pharmacists as health care professionals practice within the law, to a high professional standard, to ensure that they strive to continuously improve the quality of care that they offer to patients.