<See my other posts and sorry if I repeat myself----the managers see it as
a way to control doctors, not necessarily "bad" doctors.   Improving
standards is part of being professional.  The biggest drawbacks I
experienced to improving standards in practice were 
1. The limitations (financial and organisational) of the system in which I
worked.
2. The unreasonable demands on my time and energy.
3. The amount of socio-economic deprivation and chronic illness in my area,
 yet totally ignored by deprivation payments etc.>


<<<<Where could clinical governance possibly have helped me with that
lot?>>

It might at least tell you what was expected of you - something that most
of 
us I suspect don't know inn clinical terms at least>>

But surely being a professional is not about doing stuff because the
hierarchy says you must? Isn't being a professional about providing a
service, working to a high standard, keeping up to date, self-regulation
etc.
I see the way people work in employee mode and quite often the system does
not motivate them much, sometimes seriously demotivates them, as I find in
talking to employed staff in the local trust. 
I just cannot see clinical governance doing much in the situation I was in.
For example, I had a lot of work from people who were pretty disabled with
various types of chronic pain; they were genuine, not looking for compo or
any of that and there is plenty of literature on the condition.  I saw them
because I could not close my mind to their suffering while some of my
colleagues could close off very easily and hence those patients did not
come to them.  I suspect clinical governance, if done right, would want a
EBM approach to the problem and would hassle my colleagues to do more.  It
is very unlikely that that would have reduced my workload much because I
would, at best, have been able to move on from mostly firefighting to
spending more time on attempts to improve their quality of life---that BTW
would have taken more resources from community care and secondary care than
the trusts or health board could have afforded. EBM would dictate that
these patients receive treatment which had a reasonable chance of making
significant and lasting improvements in their lives but the local health
board did not want to hear of anything involving either a new service or
sending patients for expensive residential therapy out of N Ireland. The
sums are very easy to do and the "expensive" treatment if given to a dozen
patients would have *reduced* health and social services costs over two
years for that group of patients even if not all of them improved.  
CG goes on about "quality of care" and routine application of
evidence-based practice to everyday practice----yet when I tried using the
evidence to get treatment with a chance of improving my patients (as
opposed to what they were getting which had no chance at all of improving
them and in fact carried the risk of making them worse) I found that those
up top could not be bothered to even read the papers I sent on,  look up
the references, talk to experts in the pain field and the bean counters
could not do the sums because some of the costs and potential savings were
coming from someone else's budget. 
I fear that CG in this area will be used ( if they get it going) to cap
costs, to hassle doctors and generate acres of reports. For the last four
years or so the board here has been nagging GPs for audit reports.  I
eventually got so fed up with them that I wrote to tell them that I had
been doing audit for years, that I was doing proper audit designed to help
me improve my services, that I was using my audits to improve but I could
not for the life of me see why I should bother sending them copies of
everything just so they could report on up the line that they were getting
X audits in from GPs each year.  I refrained from saying that board members
had shown quite clearly that they really weren't interested in evidence to
guide their decisions.  Like many petty bureaucrats they just wanted to
make it look good
It may be that my experiences have been mostly bad and others have had
better but talking to other GPs across N Ireland makes me conclude that
things were as bad in other health board areas.
CG does not the power or the facilities built in to cut across
bureaucracies,  penetrate empires or bypass the agendas of power-brokers in
the NHS.  It is set to become an industry, like EBM,  like FH.  There is
little or no evidence that what is proposed under the banner of CG will be
any good at all.   
1.  Trust Chief exec responsibility, reports etc----what happens when
difficult customers of doctors start writing to the CE telling him that
certain services are unstable or unsafe because staff levels are way down
or necessary equipment is not available? And that other services will have
to be cut to generate resources to improve the first lot?  Will we see
intermediate layers of management trying to protect the chief?  A bit like
Ronald Reagan's cabinet and Irangate---"We need to keep the President out
of the loop on this one, boys." 
2. Evidence-based practice will put costs up massively.  No more GPs
looking after little old ladies with CCF alone---EBM says full assessment
inc an ECHO and modern  treatment inc adequate dose of ACEI .  No more
messing about nurse advice for high cholesterols----statins if don't
improve on diet and we all know how many IHD sufferers get cholesterol down
on diet!
Where will funding for all this come from?  
And one of these days Pfizer will get the bright idea of sending out packs
with info on assessing psychological distress in impotent men (GHQ or SF 36
or HAD or BDI or whatever) to all GPs and bingo!  The number of men will
very significant levels of distress (done in a proper statistically valid
etc EBM-type way) will be significant I bet and there goes NHS Viagra
spending through the roof. 

I could actually dissect CG line by line but what's the point in wasting
bandwidth?  It may well have honourable aims but when the costs start to
rocket it will go the same way as the Patients' Charter went in a health
board not to far away from me----simple statement that charter standards
would not be met due to shortage of money and that was that.
Declan
. 


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