Popular phrases find their way into healthcare jargon, and having negotiated domestic political manipulations they are then exported abroad. Clinical governance (CG) is an example. CG was first launched at the end of the previous millennium in the UK by the socialist government, after conservatives had been in power for almost 20 years. Cited also in a WHO Report [1]) at the start of the new millennium as an innovative conceptual approach to managing and improving the quality of health care, CG was then adopted into the political jargon of other European countries. In Italy, a National Draft Bill [2]) focused on CG is still pending in parliament after almost a decade of discussion in its passage through a succession of politically diverse governments. To explore the diffusion of the CG concept in Europe, we first conducted a literature search.

1 Clinical Governance in the European Literature

Studies focusing on CG in European countries were identified in the PubMed international database.Footnote 1

The majority of articles selected came from the UK (94%), a few from Italy (5%) and one each from France, Greece and Ireland. Most were published in journals of speciality medicine and surgery (30%), nursing (28%) and health policy (20%) (Fig. 1). More than four-fifths of the UK articles were published in the ten years following the introduction of CG in the British NHS, while all the Italian studies but one were published later (Fig. 2).

Fig. 1
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UK and Italian articles including Clinical Governance in the title by type of journal

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Fig. 2
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UK and Italian articles including Clinical Governance in the title

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2 Clinical Governance in the English NHS

Following the election victory of the new Labour government, the CG concept was introduced into the National Health Service (NHS). The white paper ‘The new NHS: modern, dependable’ [3] set out how the new government intended to counteract the managerial and competitive environment pursued by the conservatives during the previous decades. They replaced the rhetoric of the ‘internal market’ identified in the white paper ‘Working for Patients’ [4] with a politically opposite system based on partnership and performance management. The Labour paper focused on quality of clinical care, emphasizing the importance of introducing standards and guidelines, audit procedures and evidence-based service frameworks for disease groups, in order to monitor and enhance clinical quality. The paper gave the following definition of CG.

A new initiative… to assure and improve clinical standards at a local level throughout the NHS. This includes action to ensure that risks are avoided, adverse events are rapidly detected, openly investigated, and lessons learnt, good practices rapidly disseminated, and systems are in place to ensure continuous improvements in clinical care.

In a later consultation document [5] national health policy was more targeted on quality improvement and the term CG implied a more precise meaning.

A framework through which NHS organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.

Thus, CG became an ‘umbrella concept’ involving activities including clinical audit, risk management, continuing professional development; all aimed at improving the quality of healthcare services through a local framework for planning and organizing [6].

CG soon experienced its political ‘sunset’ in England—coinciding with the return of a conservative government in 2010. CG was replaced by the even wider concept of ‘quality governance’ putting clinicians and managers together with a similar aim of delivering high-quality services [7].

3 Clinical Governance in the Italian NHS

In Italy, a national draft bill on CG is still under discussion in the parliament [2]. CG is emphatically defined as ‘a system which fulfills the needs of patients and health workers through the integration of clinical and managerial activities, guaranteeing the continuous improvement of quality in respect of the principles of equity, appropriateness and universality’.

The legislative measures referring to CG so far approved in Italy are summarized in Table 1. CG was very soon cited in the Regional Health Plan 1999–2001 of a central region (Emilia Romagna) [8]. Some years later the same region and its neighbour (Tuscany)—both historically led by ‘left wing’ governments—issued two autonomous laws [9, 10] specifically referring to CG. It was later mentioned in the National Health Plan 2006–2008 [11] as a tool for improving quality in health care, and identifying clinical risk management and patient safety as priorities to pursue. In the same period a report by the Ministry of Health [12] defined CG and its components—basically translated from the English documents quoted above [3, 5]—and concluded by mentioning the two regional laws as positive examples of CG implementation. In the following five years, various legislative measures [13–16] cited CG for different reasons, e.g. the involvement of patient experience in improving healthcare services and the introduction of an information system for monitoring medical errors.

Table 1 Legislative measures referring to Clinical Governance (CG) so far approved in Italy
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4 Policy Implications

Our literature search showed that Italy was the only European country that widely referred to CG in its domestic jargon. Arguably translated in Italian ‘governo clinico’ (literally ‘clinical government’) at the real beginning [17], the ‘importers’ did not consider the two major differences between the two health services.

First, the Italian NHS is a three-tiered (central–regional–local) and highly decentralised public service. The twenty Italian regions (governed by elected politicians) autonomously manage and control the services delivered by their hospital trusts and local health authorities [18]. This implies that a national policy is not necessarily applied by all regions homogeneously. Specifically, regions can autonomously launch local policies without national endorsement. Thus, in contrast to the UK, Italian CG legislation has resulted in piecemeal and mixed provisions since its introduction, depending upon whether it originated in central or regional tiers.

Second, the Italian NHS has historically suffered at least two major clinical weaknesses in delivering primary and secondary care.

  • All Italian general practitioners previously worked single-handed and are still somewhat isolated within the healthcare system, unlike the majority of their British colleagues [18]. Although several regions (like Emilia Romagna and Tuscany) have encouraged group practices since the late 1990s, at present, patients are still registered with one doctor. This is a major hurdle to working in groups.

  • Medical consultants previously played the dominant role in hospitals, since graduation in nursing was introduced only in late nineties—2–3 years’ programs during high school age were previously enough to become a nurse in Italy. Thus, the adjective ‘clinical’ is still synonymous with ‘medical’ in the Italian common language. In contrast, nurses traditionally counterbalance medical power in the UK: it is no coincidence that around one-third of the English articles on CG were published in nursing journals. The Royal College of Nursing claimed that CG ‘… is a framework which helps all clinicians—including nurses—to continually safeguard and improve standards of care’ [19].

In summary, this controversial example of a political import restricted to Italy may not have wider implications. Yet, the major object of CG—improved quality of healthcare—is an unarguable duty of health managers and professionals: effective systems for monitoring and auditing clinical performance must be introduced and quality must be pursued on a daily basis. However, simply adopting foreign politically sensitive practices without understanding their (ir)relevance to local settings causes confusion. This eventually wastes the human and financial resources that might be better invested elsewhere. Health experts who advise politicians should oppose this ‘copy and paste’ practice rather than simply adopting it. It is a potential lesson which we would like to share with an international readership.