Editorial

Citation

Gillies, A. and Harrop, N. (2012), "Editorial", Clinical Governance: An International Journal, Vol. 17 No. 1. https://doi.org/10.1108/cgij.2012.24817aaa.001

Editorial

Article Type: Editorial From: Clinical Governance: An International Journal, Volume 17, Issue 1

Globally, health care is facing difficult times. Politicians and commentators will trot out the classic arguments about the unsustainable cost of health care due to factors such as the aging population, new and expensive treatments, people living with chronic conditions, growing obesity problems not just in the developed nations, but in the emerging economies as wealth and aspirations grow.

Whilst not denying the reality of these issues, the reality is that these issues come to the fore because we cannot afford our health care systems as currently configured. Affordability is not just about cost, it is also about income. With GDP almost static across the Western world since the financial crisis of 2008, it is the affordability of health care that is at issue as much as the cost.

In every problem situation, there is an opportunity. Change in health care does not happen when things are going well. The status quo tends to go unchallenged, and inefficiencies and poor outcomes can be masked by throwing money at the problem. Only when money cannot be thrown at the problem is there a need to make more fundamental change.

Change does not necessarily lead to improvements. Where improvements in one area can be achieved, within the complex adaptive systems that are our health care systems, it may be at the expense of another. Thus, better outcomes may be achieved at higher cost, or savings may be achieved by sacrificing outcomes or by simply moving costs to another part of the system.

This issue of Clinical Governance: An International Journal reflects the challenges faced in today’s health care system, and the role of clinical governance to both facilitate and evaluate effective change. The articles use system re-design, new technology and education as well as the traditional audit cycle to demonstrate how clinical governance can contribute to effective change.

Old and Rogers’ article on restructuring services to reduce waiting times and prevent complications is an example of a completed audit cycle. The re-audit phase is carried through to ensure that change has led to improvement, rather than simple change for its own sake. In 1994, Chisholm and Gillies published an audit of published audits (Chisholm and Giles, 1994), which demonstrated that even amongst published audits (approximately 20 percent of the whole in the region examined) only one-third included a re-audit to demonstrate improvements following change. The editors hope that studies such as the one described by Old and Rogers show that we have developed our thinking, design and audit practice.

However, Garg, Singhal and Neelam’s online survey of psychiatry trainees suggests a rather less rosy picture. A total of 2,267 audits were carried out by 504 respondents. Of the respondents, 42 percent completed at least one audit-cycle (which does mean 58 percent didn’t!). Nearly half of the audits were presented locally and 37 percent were submitted to the local audit departments. Recommendations from two-thirds of all the audits went unnoticed because of inadequate dissemination and implementation. This suggests that whilst the audits may fulfil a useful role in the development of the trainees, they are not having an impact on the services evaluated. Whilst there may be some legitimate reasons for this, it appears as a classic case of practice which needs to be reflected upon, at the very least. Are we getting trainees to do the audit, because it’s a dirty job and someone’s got to do it, and they are the most junior? Are we ignoring their findings when we don’t like them because we can because they were only done by the trainees? Or, is it simply a case of a disjointed system and a lack of joined up thinking?

O’Brien, Pengelly and Lambert’s study also demonstrates the importance of re-audit within the audit cycle, but with evidence of a more successful intervention. It is a strong example of how informatics can facilitate better clinical practice, provided it is implemented properly. The failure to provide new doctors with appropriate access to electronic information was a barrier to effective care. Faced with such a barrier, the doctors resorted to inappropriate measures to gain access to the information they needed. It highlights the need for technological solutions to consider the human aspects of a socio-technical information systems view as well as the technology itself if unintended consequences are to follow.

Naughton, Callanan, Guerandel and Malone’s study from Ireland develops the theme of privacy and appropriate behaviours in respect of personal information. The management of personal information is governed throughout the EU by a common data protection directive enshrined in national laws. The study highlights how the strong cultural tradition of respecting patient confidentiality rooted in the Hippocratic Oath is struggling to keep up with modern technological developments, and how there is a need for education for both skills and attitudes towards the use of new information technologies. In spite of the threats arising from malign use of new technology, people remain the biggest threat to the privacy of personal information through ignorance, carelessness and a failure to perceive the consequences of their actions (or inactions).

Pferzinger, Thöni, Huber and Pferzinger’s contribution from Austria highlights the importance of gaining professional confidence in clinical guidelines by basing the guidelines on the best possible evidence. The article highlights prior research demonstrating the slow uptake of such guidelines. The adoption of guidelines can be stereotyped as either cookbook medicine or stubborn recalcitrant professionals resisting a perceived threat to their autonomy. The role of clinical governance should not be to simply record slavish adherence to protocols, but to improve and evaluate the appropriate use of guidelines, which means balancing the population-based evidence base against the needs of the individual patient.

Scott, Ross and Prytherch’s paper considers the important issue of continuity of care and specifically the hand over process. One of the characteristics of the changes in health care systems in response to the current pressures is the increased role of multi-agency care. The need for effective handovers has never been greater, and it is a myth that the solution to this issue lies solely in technology. This comprehensive review is highly recommended reading for all clinicians working as part of a team (i.e. all clinicians).

These articles are intended to highlight issues that go beyond their immediate context and give cause for reflection. Here are ten suggested questions for personal reflection, prompted by this issue’s articles:

1. 1.

   Can I show that the last significant change in practice or service delivery led to improvement rather than just change?

2. 2.

   How many audits carried out in my service looked at the impact of change and not just measured current practice?

3. 3.

   How do the outcomes of audits feedback into practice or service delivery in your organisation?

4. 4.

   How many audit studies take account of multi-professional perspectives?

5. 5.

   Who carries out the audits in your organisation and department and why?

6. 6.

   How has information technology changed the way you work for the better, and for the worse?

7. 7.

   How has information technology increased the risk to your patients’ confidentiality?

8. 8.

   How has information technology changed the way that you ensure your patients’ confidentiality?

9. 9.

   What are the barriers to your greater use of clinical guidelines, and can anything be done to reduce these barriers?

10. 10.

    How do you communicate to colleagues involved in the care of your patients, and is it effective?

Alan Gillies, Nick Harrop