Will clinical governance make a difference?

Another meeting on clinical governance and yet again it is surgeons who are cast as the main villains by purchasers, managers, and even fellow clinicians. Since surgery is the only discipline where it is easy to measure outcome all discussion on this topic seems to revert to surgery. I ought to be used to the charge of being an élitist megalomaniac. After all I am a neurosurgeon, and everyone knows that the only difference between God and a neurosurgeon is that God does not want to be a neurosurgeon. However, I do not think that I fit this caricature. What is it that really motivates me and my colleagues?

For me, surgery has always been a vocation. I have been able to accept the responsibility of operating only by setting myself the highest standards. Of course, resources are limited, but I used to be proud to be part of a system that allowed for ideals other than personal financial gain. To be a successful surgeon you have to learn to cope when things go wrong. It is not my successes that I remember, it is my failures, which provide the motivation to get it right next time. The system may have been imperfect but I felt supported by the naive view that when things did go wrong I would be protected by a collective responsibility. The key was simply to do my personal best.

It would have been nice to audit my practice in detail so as to define best practice, especially as my workload was steadily increasing with each successive efficiency target. However, attempts to do so using the hospital information systems were doomed to failure; these had been set up to service the requirements for purchasing, not to provide clinically relevant information. So I resorted to data collection by reviewing notes on selected topics—audit of a sort, but by no means comprehensive. Operating on more patients meant an increase in the absolute number of complications even if there was no increase in complication rate.

But the main psychological blow of the past few years came with the patient's charter. The majority of patients, as well as clinicians had regarded NHS health care as a privilege. By and large they accepted the limitations of the service as long as their carers actually cared. Overnight health care became a right. With rights come expectations and intolerance.

Then came the Wisheart affair at Bristol. Surgeons were now wholly and personally responsible for outcome in their patients, irrespective of everything else including the limitations of the service, political pressures, underfunding, even the ruling of the General Medical Council. I immediately referred to the professional guidelines regarding safe neurosurgical practice, finding that my workload was twice that recommended. I therefore set about halving my workload, an initiative supported by the trust but only on a temporary basis.

From that moment things have improved. I seem to have time for patients again and I have time to organise my own audit. I know what my mortality rate is, but more importantly I know why the patients died and whether their deaths reflected inadequacies in their care or the severity of their presenting condition. I can therefore respond to the simplistic notion that excellence in surgery is inversely proportional to mortality rate. I can now tell patients exactly what my complication rates are for a procedure. In time I will accrue outcome data as well. In short, my practice is under control again. The question is, will it last?

The UK government's document, A First Class Service, defines clinical governance as a “framework through which NHS organisations are accountable for the quality of clinical care.” There is, after all, to be a corporate responsibility for health care involving clinicians, managers, purchasers and politicians. In theory, therefore, the trust will now have no alternative but to find the resources for safe practice. The responsibility of the purchasers and their political masters will be either to provide those resources or to prioritise access to care. They will have to take responsibility for rationing, which so far they have studiously avoided doing.

My wife is encouraged by recent events. Statutory requirements regarding the working week will make the 80 plus hours a week I have been working illegal. If I can halve my workload on a permanent basis she hopes that I will be less depressed, regain my enthusiasm for the job, and have more time for the children. I too hope that once again it will become my privilege to care for people. With a sustainable reduced workload I will be in a position to embrace the principles of clinical governance wholeheartedly. Forgive my scepticism, but I remain to be convinced that trusts, purchasers, and politicians will do the same. The stereotype of the ogre surgeon provides too convenient a scapegoat.