Study objectives: (1) To evaluate the development of clinical governance within public health departments. (2) To assess two models for examining clinical governance in public health departments.
Design: Semi-structured interviews carried out during the annual visits of the regional director of public health to the health authority public health departments.
Setting: West Midland Region, England.
Participants: Directors of public health plus other members of public health departments.
Main results: These visits demonstrated that there is already a substantial amount of clinical governance activity taking place in the region's public health departments. There was also a need to reclassify many routinely occurring activities and include them under the clinical governance heading.
Conclusions: The two models both proved useful for examining clinical governance in public health departments, however combining them into a matrix provided the best results. This matrix will still be useful after the reorganisation of the NHS and could be used to assess any public health department in the world. The West Midland public health departments find the visits valuable as they provide a source of external peer review of their activities. The public health departments have ownership of the process.
The Faculty of Public Health Medicine in the UK (FPHM) has described clinical governance as "a framework for improving quality and safeguarding high standards by creating an environment in which excellence will flourish". (1) Since the introduction of clinical governance in the UK through the white paper The New NHS Modern Dependable (2) there have been many papers describing initiatives in the clinical setting, but few reported from the setting of public health departments. (3) However, there have been several publications on components of clinical governance such as audit and quality control and their application to public health departments. (4-9)
Although clinical governance is generally thought of as the province of clinical service providers, it is also essential in public health departments as they are responsible for the population's health. Any failure in performance at public health department level could have much wider consequences than the failure of an individual practitioner. There is therefore a need in public health departments for systems that bridge the gap between individual and corporate governance. Clinical governance is the ideal framework by which to improve the quality of performance of public health departments.
The NHS regional offices (RO) have (until 1 April 2002) been responsible for ensuring that all clinical governance guidance is implemented in a coherent manner across the regions, and for assessing progress against individual organisation's objective. (10) The regional director of public health (RDPH) based at the RO is specifically responsible for the development of the public health function at local level. (11) The RDPH for the West Midlands Region (WM) has carried out annual visits to health authorities (HAs) in the region since 1994, in order to develop performance within a framework agreed with the directors of public health (DsPH). (The DsPH lead public health departments based in the health authorities, which are responsible for public health in a population of about 400 000). Each year the visit has focused on a different aspect of the departments' performance, including communicable disease control; departmental management; information technology; and research and publications. In 1999 the visit foc used on clinical governance within the public health departments, this was in parallel with an audit of clinical governance within the hospital trusts of the WM, carried out by the public health directorship.
Two models were chosen for the audit of clinical governance in the WM region, one was the FPHM's model described in Governance of the Public Health Function (1) and the other was a model developed at the NHS WM Regional Office (by R K Griffiths and C Grainger). This model known as "SPOCK" consisted of five main themes: Structure, Process, Outcome, Culture, and Knowledge, which could be further subdivided into topics directly related to clinical governance. The model described by the FPHM (1) consisted of four levels at which to consider aspects of clinical governance. The four levels are: (a) the individual public health practitioner, (b) departments of public health and other similar groups of public health professionals, (c) health authorities, health boards, and similar organisations and (d) partner organisations, which are referred to in this text as individual, department, organisation, and partners respectively.
The RDPH visited the public health departments of the HAs of the WM region. In preparation for the visits, the departments were provided with copies of the FPHM papers on Governance of the Public Health Function and Revalidation in Public Health Medicine and they were asked to provide the following documentation:
* A completed questionnaire about continuing professional development (CPD) in the department. (CPD is a requirement for revalidation of medical practitioners with the General Medical Council.)