An interview with: Jeff Lucas and John Wright
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Clinical Governance: An International Journal (CGIJ) is one of the world's leading titles for clinicians and managers in primary, secondary and community care. It covers the rapidly expanding field of clinical governance and health care quality standards, including evidence-based practice and guidelines, good practice implementation, clinical performance indicators, audit, risk management, patient involvement and welfare, policy and strategy, and user involvement. The editorial advisory board includes the UK's Chief Medical Officer (and his predecessor) and the Head of the National Institute for Clinical Excellence along with representatives from Europe, North America and the Pacific region.
Dr John Wright is Director of Clinical Governance & Operations Medical Director at Bradford Hospitals NHS (National Health Service) Trust in the UK. He is the founder and Chair of NHS LINKS which promotes international health links with developing countries, Editor-in-Chief for the National Clinical Governance Support Team.
Professor Jeff Lucas became Deputy Vice Chancellor of the University of Bradford in 2004. Prior to that he was Pro-Vice Chancellor (Teaching and Learning) and Dean of the School of Health Studies. He is featured in this interview.
What "clinical governance" means
How would you describe CGIJ's editorial philosophy? How does the journal differ from its closest competitors?
Well, firstly there aren't a huge number of competitors out there, but the ones that are tend not to take a multi-professional perspective on clinical governance, some them are very medical. We encourage all professions that have a role to play in clinical governance to submit articles, and we probably get more from the nursing and allied health professions and from the pharmacists than some of our competitors. The other editorial philosophy that may be a little different about our journal is that it also takes quite seriously the education, training and continuing professional development dimension of clinical governance. That's an important aspect that is very often overlooked, and it concentrates on guidelines and compliance to codes. So we take a more rounded view, I think.
Given that "clinical governance" is a specifically British concept[1] how do you extend that into the international context, and in what way is the journal now international in its scope and remit?
Well although I agree it's been labelled a British concept, the antecedent if you like was a WHO directive that came out in 1983, which sowed the concepts of health improvement and continuous improvement in health care. It then got translated in the 1997 document "A first class service". It may not always be called quite the same thing in different countries – I've worked with it in Australia, in Scandinavia, and in America. Although the words "clinical governance" don't always loom large, the idea of health improvement and continuous improvement – there are translations of that in journals and in practice in both Australasia and in North America, and I've also seen some in Sweden and Norway. So I think once you unpack the words, you can find the intended meaning translated in slightly different ways in other countries. We do have a north American editor and regular North American contributions, but the words "health improvement" loom larger that "clinical governance".
The journal audience
You state in your published editorial objectives that your audience is primarily a professional one. Why is this particularly? Do you have an academic readership as well, do you think?
There isn't always clear blue water between the concept of a professional person and an academic; a lot of our readers are clinical academics in their own right. I would say the majority of our audience are practising health care professionals, and probably, from the kinds of addresses and titles that are attached to their subscriptions, I would guess that at least half of them have got academic posts; they are attached to a university and they have a teaching role. Certainly a very high percentage of them – almost all of them I think – would tick the "professional" box; probably 70 per cent of those are clinical academics. So I guess we're reaching out to a predominantly professional audience within teaching hospitals. But 30-40 per cent probably see themselves as professionals and don't have a lot of their time devoted either to academia or to teaching.
And within the specifically professional readership, how would you estimate the clinician/manager split – if that's not an artificial split – and does this fit with your publishing objectives?
That's an interesting question and it's a differentiation that I hadn't really thought about. Obviously quite a lot of clinicians are service managers. We do get some contributions from managers who are quite clearly not clinicians; they work on the audit side of the service, within the performance side of hospitals. We have invited some of those to write for the journal, and we also use them as reviewers, because we're in a situation where clinical performance / excellence / continuous improvement does have a set of metrics attached to it, and there are those that are employed to keep the scores. So they do feature in our readership and in our contribution, but I think when we set out, we probably didn't have the manager's view in mind – it was more a clinician's view – but we have moved over time to accommodate the managers' views as well.
You emphasize topicality as a feature of the journal. How far does it / can it fulfil the role of providing a current awareness service for its readership across the subject matter of clinical governance issues?
We have majored on some topical issues and we have set aside special editions for things which we think are in vogue, if you like, in terms of key strategies within the Department of Health. I would cite probably the contribution of primary care – clinical governance arrangements within primary care as one example, patient safety is another, and adverse incidents and errors, particularly drug errors – that was quite a topical issue recently, and we featured that quite strongly in one of our issues. Obviously we had a very big special on case studies that came from the National Support Team, so we invited case studies about lessons learned in the earlier days of establishing clinical governance support teams in hospitals. So we do have an eye to topicality; I think that's probably something that [co-editor John Wright] has got more of an eye on than I have, because he is a practising clinician as well as a researcher, and I'm not a clinician.
Commentators on health policy frequently note tensions in the relationships between managers and clinicians. Do you perceive a role for the journal in facilitating dialogue between the two groups?
I don't think we set out to be a forum or a platform where those tensions can be unpacked and discussed. I mean, we have had some interesting "Viewpoint" arguments, particularly about the nature of evidence, the issue of the difference between qualitative and quantitative measures of whether or not interventions are effective or not, and that's probably not to do so much with the differences between managers and clinicians, but between different breeds of clinicians, who embrace wider sources of evidence. I think it's been interesting to see that, as medical education has broadened, tomorrow's doctors are more likely to be rounded, and have more understanding of some of the more ethical, philosophical and sociological issues than yesterday's doctors did, and they tend to bring that debate to the table, so sometimes it's more of a tension between the younger and older practitioner than between managers and clinicians. As I said earlier, a lot of clinicians are managers, and most of the managers who are not clinicians are very much about being data stewards. I don't think we've really had much in the way of a brokerage of those tensions in the articles, but we have had the "nature of evidence" type of debate on a couple of occasions, and it's interesting that they have been very attractive articles in terms of the number of hits they've attracted from the readers.
Changes to contend with
Following the explosion of interest in clinical governance during the late 1990s, there now seems to be little coverage of it as a topic. What do you think this signifies?
That doesn't necessarily mean that there is less interest in the broader concepts of clinical governance. I do believe that you won't see so many articles with the words "clinical governance" in, because in the learning curve of understanding what it was all about, you headlined the words in the titles of almost everything you wrote, and even the books that came out about it had to clearly badged in that way. But now you can see articles regularly on risk management, patient experience and resource effectiveness, and these are all of the "seven pillars", as they say. Even the strategic and learning effectiveness features in some of the articles now, I would say that they all come from the same stable. You almost now don't have to say the name; the intended meaning is just there.
How do you see the changes that are currently taking place in the
UK NHS impacting on clinical governance? Are there parallels elsewhere in other countries?
Well, I guess I've seen some of this in my role as a non-exec on a strategic health authority and chairing an audit committee. I think one of the things that I truly believe in is – regardless of whether you are delivering health care in a foundation trust or in a private organisation – the basic concepts of continuous improvement and the metrics of good clinical governance should apply. I was very concerned, for example, that some of these private providers could absolve themselves of any responsibilities for training, which I think is being addressed at present, but it meant that they were going to be able to deliver in payment by results terms a service at less cost, therefore we wouldn't be seeing a measure of performance that could have the same value for money calculation attached. So in my own strategic health authority we insisted that contracts did tie them into being part of the "broader church" of education and training. The issue of substitution of roles: I'm a health regulator as well, and I've been concerned about whether we see the private providers getting round the use of regulated health professionals simply by changing titles and moving into assistant roles which are not so well regulated. That I think quite clearly put patients at risk and therefore it is a significant issue for clinical governance.
The debate we're having at HPC is that we've quite clearly got to address this issue and look quite seriously at scopes of practice for both assistant and advanced practitioners, and have a serious debate as to whether or not we should be moving to regulating assistant practitioners. If we do that, it has a massive consequence on the work of the regulator, but I would take some comfort from it that patients are better protected and that clinical governance is honoured..
I think there are parallels in other countries, as well. I'm no expert on these things, but there's a pilot on regulating assistant practitioners in Scotland. I have seen assistant roles regulated through employment in New Zealand and Australia, and I guess it's settled down and patient safety is no longer an issue, but in the early days it was very unclear what their scope of practice was.
The editorial process
How would you say that the journal itself is developing, and what are your plans for it over the next 18 months?
Well, I'm told by the Publisher that it's continuing to grow, its appeal is strong. I think it was perceived to be one of the strongest journals in the medical portfolio and has been for the last three years. We have thought about rationalising it with other more management-orientated journals within the Emerald stable; we haven't at present decided on a merger, but we have brought the two editorial teams closer together, so that we can differentiate the kinds of papers that are likely to go to clinical governance or to managing health care. So we've drawn up a bit of a template that gives the Publisher a bit more guidance as to how to direct the traffic, if you like. We're trying to see in the next year or so whether or not we tread on each other's toes. We'll review that, I think, in the next year or so and take a longer view as to whether a more comprehensively-titled journal might be the way forward – but I keep being advised that every time you change the title of a journal, you incur wrath from a huge number of people, particularly librarians.
What do the authors think, if they submit an article to one journal, and then get feedback saying we'd rather publish it in another journal? Are they bothered about that?
Well obviously I've had several occasions when I've refused an article because I think it would be better placed in a more specialist journal; nothing to do with Emerald. I've normally had a favourable response from the authors on that, they haven't felt slighted. Within the stable of Emerald, it's too early to say what the reaction might be for somebody wanting to publish in one of the more management-oriented journals and being offered a slot in Clinical Governance, so I think that's still to come, if it comes at all.
In terms of competition for space, we decided not to increase the number of issues, but we have increased the size of each issue, so we publish more in any one issue. If you've observed us over time, we are doing more in terms of more glossy insets, more "talking heads" type of things; these have proved very popular, so we'll continue with that. We'll probably source more Viewpoint articles with leading experts on named topics. We haven't done that in a very systematic way of late; we need to be more systematic about sourcing Viewpoints.
How do you work with your co-editor?
John and I know each other from way back, and we think we complement each another inasmuch as I've worked in the health service and been associated with the health service in academia for over 30 years, and have been extensively involved in modernizing education and training for all the health professions. I think over my time I've had some management responsibility for all the health professions, and I've managed a medical school expansion. So I bring that to the table, and I was a medical researcher in my own right, but now I've moved on to researching more pedagogic issues. John is a practising clinician and a very active researcher in his own right, a very bright young consultant, and is held in high regard. I think we have a complementary set of skills. One thing we don't do as well as we could is to target papers with a view to our particular skills, but I suspect that would put more work on John, by the nature of the articles themselves. I think I am probably at a greater disadvantage in knowing how to extend the reviewer base; he simply knows more people than I do, and I have to spend a lot of personal research time trying to find out who I need to join the reviewers' list because we don't have the right expertise to consider a particular article.
How do you use peer-review to maintain the quality of the journal? Your search for peer reviewers can be slightly ad hoc, can it?
I think that is a little bit of a weakness in the way that we work. I was always sensitive that there were rather too many reviewers from the local area than would have been ideal. When we receive an article and we start to see that it attracts a reasonable amount of interest in terms of hits then we do go back to those authors and ask if they'd be prepared to review in their own right, so we've extended recently our reviewer list that way, using our author base to complement our reviewer base. In the early days we tended not to delete people, but now we're been more ruthless, if you like, about getting rid of people who've provided inadequate reviews or who don't do them in a timely fashion.
- The term was popularized by a specific quality framework introduced into the UK NHS in 1997-9 with the publication of "A first class service: Quality in the new NHS" and related documents.
Publisher's note
Dr John Wright and Professor Jeff Lucas were interviewed in May 2007.
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