Although the concepts of good governance described above are increasingly acknowledged and are progressively being applied to the health care sector, there are many barriers to the implementation of effective governance systems, including:
• unique professional cultures and subcultures which impact on clinician engagement;
• traditional methods of employing or engaging medical practitioners;
• debilitating workforce shortages;
• a paucity of evidence-based clinical governance tools; and
• in some jurisdictions, a lack of a clearly identifiable governing entity for each health care organisation, with a resulting merging of regulatory, governance and operational responsibilities.
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We explore some of these barriers in more detail below.
Engagement of medical practitioners in clinical governance Although a degree of independence is considered essential to the effectiveness of governance systems, good governance also depends on structures and processes which are embedded in the day-to-day operations of the organisation. The most effective governance occurs when there are:
• a common organisational vision and strategy which are subscribed to by all stakeholders;
• well-designed systems for delivering services and monitoring, responding to and demonstrating accountability for their safety and quality; and
• an organisational culture of continuous improvement and an unwavering commitment to service safety and compliance with evidence-based standards.
An effective governance system cannot be imposed unilaterally. The governing entity can lead the organisational culture and invest in organisational systems, but those systems will not operate effectively without the engagement of the key professionals who work within them. The issue of engagement of medical practitioners is a particu-larly serious one, because they have ‘plenary legal authority’ and very little happens in health care without their endorsement (Reinertsen et al. 2007).
For such engagement to occur, medical practitioners need to recognise the need for and legitimacy of governance systems. There are, however, well-documented differences in management and pro-fes sional subcultures in the health care sector which have made the task of engaging medical practitioners, and therefore governing health care organisations, exceedingly complex. These subcultures are deeply entrenched and to some extent are perpetuated by the system of post-graduation pre-vocational learning for medical practitioners in Australia, which continues to be based primarily on an apprenticeship model.
Tension between medical professional aspirations for clinical auton-omy and the recognised need for individuals and organisations to comply with clinical systems and account for their clinical performance have been well documented over many decades and continue to pose a major clinical governance challenge in the twenty-first century.
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109 Sir George Newman, thefirst chief medical officer at the Ministry of Health, saidto the British Medical Association in 1920:
The state has seen in the profession a bodyinsistent on the privacy and individuality of its work, the sanctityof its traditions and the freedoms of its engagements. The professionhas seen in the state an organisation apparently devoted to theinfringement of these traditions and incapable of putting anythingworthy in their place. It has feared the imposition of some castiron system, which might in practice make the practitioner ofmedicine servile, dependent and fettered. (Kendall and Lissauer 2003: 4) It was only in the mid-1980s that individual general managers replaced consensus management teams dominated by doctors in the UK National Health Service. The British Medical Association responded to that proposed reform in the following terms:
It could be interpreted from the [Griffiths] report that a somewhat autocratic ‘executive’ manager would be appointed with significant delegated powers, who would—in the interests of ‘good management’—
be able to make major decisions against the advice of the profession . . . it should be clearly understood that the profession would neither accept nor cooperate with any such arrangement—particularly where the interests of patients are concerned. (Harrison 1999: 7)
Donald Irvine, former president of the UK General Medical Council, has described the culture of medicine in the United Kingdom in the following terms:
The profession remained ‘wedded’ to a 19th-century professional culture, when society was changing profoundly. In the 20th century, the profession was vigorously progressive in developing medical science and technology, while remaining deeply conservative on matters of attitude and human relationships about which patients care greatly. Attitudes to paternalism, communication and patient consent exemplified this.
(Irvine 2004: 272)
Irvine concludes that unqualified professional autonomy has become demonstrably inappropriate and is incompatible with evidence-based practice. He describes ‘inappropriate autonomy, manifest as divisive tribalism aggravated by the fragmentation caused by specialisation,
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[which] has resulted in a profession less and less able to act creatively as a coherent entity.’ (Irvine 2004: 272).
Research on New Zealand health care students suggests that, even before commencing their training, medical students believe that clinical work should be the responsibility of individuals in contrast to nursing students who have a collective view and believe that work should be systematised. Pharmacy students are at a mid-point on this continuum (Horsburgh et al. 2006).
This very strong professional culture of personal accountability—in particular an entrenched belief that service quality is determined mainly by individual competence and performance—together with well-documented cynicism of the motivation, competence and/or per-formance of non-clinical managers has impeded the full engagement of the medical profession in clinical governance. Recent major health system inquiries in Victoria and New South Wales have confirmed a significant division between public health service managers and clinicians, including a significant lack of trust by clinicians in managers (see Garling 2008; Victorian Government Department of Human Services 2005).
Internationally, there have been calls for a rewriting of the ‘implicit compact between the government, the medical profession and the public’ and re-establishing ‘responsible autonomy’ as the primary organising principle for clinical work (Ham and Alberti 2002; Degeling et al. 2003). At issue here is the ethos of arranging for judgments to be made. The traditional medical ethos is that the best arrangement is for each senior clinician to make their own judgments, and be respons-ible for them to their patients. The ethos we are proposing is that, in a health care organisation, there must be a layering of arrangements for making clinical judgments. There should be joint decision-making over protocols, agreements over standard approaches for common clinical activities, peer review of clinical performance, and an alignment of the clinical activities and other activities in which the organisation is engaged, with clinicians and other senior staff understanding and taking account of the judgments that each makes.
In several jurisdictions, horizontal clinical networks are being implemented as a strategy to improve clinician engagement (Dunbar 2008), although they generally are still developmental and their effectiveness has not been evaluated in the Australian context. Clarity of roles, responsibilities and authorities is critical for the effective functioning of clinical networks. Consistent with this observation,
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111 a recent review of clinical engagement in clinical management structures in New South Wales (unpublished, referred to in the Garling report 2008) recommended clearer definition of the role of hospital and hospital network general managers in the clinical stream environment.
At a whole-of-system level, we consider that relationships between the professional colleges and health bureaucracies need to be strengthened significantly. Most of the professional colleges work primarily through their fellowship bases, and we observe that many colleges feel dis-empowered by an inability to influence operational decision-making in individual hospitals and health services, as well as at a system-wide level.
Professional colleges are in a unique position to advise health services on issues of clinical standards, credentialling, scope of clinical practice, competence and performance, all of which are critical elements of an effective clinical governance system. The establishment of sound systems for developing, receiving and valuing such advice will foster good decision-making and support good clinical governance.
It is clear that relationships between the medical profession and the health care system need significant further development to sustain the improvements in clinical governance that have been achieved in recent years. More research is required into the structures and processes that facilitate meaningful clinical engagement while ensuring continuing clarity of authority and responsibility for core health service operational and governance functions.
The influence of workforce shortages
Internationally, there are serious shortages of health care professionals (Productivity Commission 2005). In Australia, there is both a shortage and a maldistribution of doctors, and in recent years suggestions that medical practitioners in some specialties may be leaving the public sector and concentrating only on private sector work. Many public sector governing entities and managers fear that if they require medical practitioners to engage in onerous clinical governance activities, they may not be able to retain an adequate workforce. This situation is exacerbated by the overall shortage of medical practitioners, the relatively more attractive remuneration opportunities in the private sector for procedural specialists, the perceived greater value accorded by private hospitals to medical practitioners, less complex private sector working environments and the developing opportunities to engage
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in teaching and research in the private sector (Morey et al. 2007). In rural areas, where medical workforce shortages are most acute, the consequences of losing a medical practitioner because of a failure to resolve mutual concerns about clinical governance are potentially very serious for health care organisations.
These factors combine to increase apprehension by governing entities that, if they require participation in clinical governance systems that incorporate requirements that medical practitioners perceive to be unduly onerous, those clinicians may simply seek a less burdensome working environment elsewhere, leaving the organisation without coverage in critical clinical areas. Workforce shortages are believed to have been a significant contributing factor to the clinical governance deficits that occurred at the Bundaberg Base Hospital (Davies 2005).
Nevertheless, governing entities, particularly of public sector organisations, may be required to balance the potential consequences of a total loss of a service against the potential consequences of a poorly governed service with inadequate accountability arrangements.
Clinically informed guidance that addresses whether no service is better than an unsafe service would help governing entities to make rational decisions in such circumstances.
The structure of hospital medical staff and implications for good governance
Australia has a mixed public/private health care system which has served the nation well, but which creates challenges associated with governing a specialist medical workforce with a relatively high proportion of part-time participants in both the public and private sectors. Many medical specialists in Australia work part time in both the public and private sectors. In Victoria, industrial conditions have favoured part-time employment of specialist medical practitioners in public hospitals over full-time employment, although a recent review suggests that there has been an increase in the number of specialists working only in one or other sector (Morey et al. 2007). That review noted that, as expectations regarding clinical governance increase, hospitals are identifying the need to engage more full-time staff.
Some private hospitals appoint large numbers of medical practitioners with an expectation that many of those practitioners will engage with the hospital on an infrequent basis. The focus has been on developing a large medical staff with the potential to attract large numbers of patients to the hospital, even if the frequency with which individual
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113 specialists admit patients is low. Reducing the size of the medical staff to a core group of specialists who admit patients regularly may be a preferable arrangement from an operational and clinical governance perspective, but its practicality is limited because of its potential impact on the hospital’s occupancy, and therefore its commercial viability. In the private sector, engagement of full-time specialist staff remains the exception, and in both the public and private sectors, a predominantly part-time staffing structure is more usual. In some circumstances, the extent of individual professionals’ regular contact with the organisation may be quite limited.
It is extremely difficult to engage individuals in team-based processes of clinical care and organisational governance processes if they are not exposed to them regularly. We have seen some of the most inspiring quality and clinical governance systems operating in health service settings where there is continuity of senior staff working well together across disciplines within a common vision and mission, highlighting the value of teamwork (Braithwaite and Travaglia 2005). The typical structure of the medical workforce in large hospitals, however, means that clinical engagement processes need to be designed specifically to influence and accommodate relatively more individuals than would be the case with a predominantly full-time workforce.
We believe that all health care organisations should review their medical staff structure to ensure its compatibility with organisational governance aspirations. This is a critical strategic issue which can be influenced by a planned and systematic appraisal of the optimal structure, the current structure and the steps necessary to close any identified gaps.
THE STRUCTURE OF THE PUBLIC SECTOR AND ITS