• Clinical governance

In these days where corporate governance seems a watchword for dubious practice within multinational companies, such terms often are bandied around without much thought given to their meaning. A similar word, clinical governance, is used within medicine particularly by administrators and funding bodies who set their own agendas within health care.

In 1998, the National Health Service (NHS) introduced into the United Kingdom namely, the concept of clinical governance. This was used to denote the systematic coordination and promotion of activities that contribute to continuous improvement of quality of care.¹

The broad elements that make up the panoply of clinical governance include the processes of clinical audit, risk management, professional development and patient participation. As such, clinical governance requires better communication systems, organisational change and a paradigm shift on the part of clinicians toward more open and impartial evaluation of clinical care and its outcomes.² It is worth observing, albeit sadly for the traditionalists, that this laudable aim is consumer driven rather than medically determined.

Although there is currently little published evidence that clinical governance makes any measurable difference,³ at the heart of the concept is the desire to evaluate the quality of medical practice against agreed standards and to remedy any gaps identified in routine practice.

Professional specialist groups, such as those that exist within sports medicine in various countries regard themselves as the legitimate arbiters of standards of athlete medical care. In doing so, these bodies present expert-endorsed best practice guidelines and position statements as evidence of their standing within this field.

But to what extent is routine care matching the predetermined standards? Unfortunately evaluation, at least at a national level, is fragmented in mainstream medicine and non-existent in sports medicine. Where this evaluation does occur, it is largely performed by academics, health care organisations or by civil servants, all of whom have their own agendas in these matters. We, as sports physicians, lack standardised national and international benchmarks of quality of care in virtually all areas, which in turn impairs any ability to coordinate improvements in patient care.

In the UK, the Clinical Evaluation and Effectiveness Unit of the Royal College of Physicians, in collaboration with a number of other bodies, is mounting the Myocardial Infarction National Audit Project, which is a collaborative audit of the care of patients with myocardial infarctions involving nearly all of the hospitals in England.⁴

The difficulties of replicating such a concept in sports medicine may seem insurmountable; however, we have several areas that would lend themselves to such analysis. These areas may also provide the model by which other aspects of sports medicine may tackle the clinical governance issue and at an international level.

In 2001, the International Ice Hockey Federation in conjunction with the International Olympic Committee and FIFA ran a meeting in Vienna on the topic of concussion. The outcomes of this meeting, previously published in the Journal, were an international expert consensus set of guidelines.⁵ In November 2004, the second such conference will be run in Prague and will develop the guidelines much further (see www.iihf.com for conference details). These meetings provide the basis of the first step in any such governance process, namely the establishment of agreed universal benchmarks of clinical care. Once this is done, then the second step will be reviewing the practice of individuals, teams and national governing bodies in this regard. Once that is complete then the issue of redressing any gaps in clinical performance can be undertaken.

Where do we proceed from there? For organisations that fare well in such analysis there is little more than the warm inner glow of satisfaction of a job well done. By contrast, organisations that perform poorly on such analysis may be encouraged to improve by a combination of external funding pressures or ultimately by disgruntled athletes who sue the organisation because their regulations are not reflective of clinical best practice and fail to meet accepted benchmark criteria.

Medical insurance bodies also have a strong role to play by refusing to provide insurance to sports doctors whose management is not in line with agreed best practice standards. If the team doctors then are unable to attend athletes, then the organisations they work for will need to change in order to accommodate this development.

A practical example of such disparity can be found by examining some of the codes of football played in England. One code is in the process of developing clear guidelines for the management of concussion involving individualised cognitive assessment and medical education (as per the Vienna guidelines) whereas the other larger code still largely recommends a mandatory exclusion policy. From a clinical governance standpoint, the second organisation would have problems in justifying their procedures against national or international best practice. In part, some of these difficulties come about because we often work in an international environment that often requires extensive negotiation on rule changes. Nevertheless this can also be seen as an opportunity whereby improvement can by driven by a committed international organisation who see the obvious benefits that best practice has to offer.

As with much in medicine in this era we should consider change before the lawyers force us to!