Whatever Happened to the 7 Pillars of Clinical Governance?


Picture by Rama distributed under a Creative Commons SA 2.0 License

Clinical governance is a process by which the quality of clinical practice can be assessed and improved. There are of course other definitions but the crux of clinical governance is that we look at a systematic process to improve what we do. Clinical governance sometimes gets confused with corporate governance but the two are distinct.

Many years ago, the seven pillars of clinical governance were espoused without question. From my perspective they have been an invaluable tool in supporting improvements in clinical practice. In some senses I would view clinical governance as the ‘engine of clinical practice’.

There is only one problem. The seven pillars of clinical practice have almost disappeared without a trace. As if they never existed. I looked online recently thinking it would be a straightforward matter to find the source material for the ‘7 pillars’. There were traces of the ‘7 pillars’ in online revision sites as well as tangential references in policy documents but the source material was not immediately forthcoming.

A clinical governance article by Scally and Donaldson has been quite influential but a cursory examination reveals no reference specifically to the ‘7 pillars’.

In the end, it was the internet equivalent of archaeology that came to the rescue. There are various archives which store parts of the internet in case it is lost or changes with the passage of time. Here is what I found.


I began to recollect events. There was an NHS Clinical Governance Support Team. Then it disbanded.


The documentation states that the functions will be taken over by the Strategic Health Authorities (SHA). Like the CGST, the SHA’s are now historical structures.

Looking through the archived documentation, it is clear that the seven pillars went through one more iteration before the closure of the CGST. They had now become an umbrella encompassing ten strands.


So there we have it. Policy became myth and myth became legend.

Although the story doesn’t quite end there…….

There is a much older reference to the seven pillars of clinical governance in a relatively obscure article by the remarkable Professor Avedis Donabedian. I hope I am not overstating the case when I refer to Donabedian as a ‘healthcare genius’ with a profound knowledge of healthcare systems and a philosopher-like approach to the fundamental healthcare questions. I would venture that there are very few people that would fully understand Donabedian’s considerable body of work that he developed on moving to America. To paraphrase…

Would the Real Clinical Governance Please Step Forward?

The article from 1993 is titled ‘Quality in Healthcare: Whose responsibility is it?’ in the journal ‘American College of Medical Quality’ and is freely accessible here.

Donabedian refers to two elements in healthcare – (1) healthcare science and technology and (2) The application of the healthcare science and technology.

From the interaction between these two elements, he identifies seven attributes.

(1) Efficacy

(2) Effectiveness

(3) Efficiency

(4) Optimality

(5) Acceptability

(6) Legitimacy

(7) Equity

While some of the terms may not be so obvious in their contextual meaning, Donabedian clarifies these terms with definitions. For instance:-

Acceptability: ‘Conformity to the wishes, desires and expectations of patients and responsible members of their families‘.

The quote above offers a firm foundation for the construct of patient and public involvement. Donabedian developed the concept of pillars in earlier works in the 80’s.

Clinical governance moves forwards in a more decentralised way in the UK. There are heavyweight organisations involved for instance in research that push forwards aspects of the clinical governance agenda.

However I am reminded of the Antikythera mechanism. This was a device found on the seafloor by the island of Antikythera by divers after 2000 years. The device has a possible link to Archimedes. The point is that when it was lost, so too was the knowledge associated with it. The Antikythera mechanism has features including a differential gear mechanism which were to be ‘rediscovered’ some 2000 years later.

The moral of the story is that great works with the potential to benefit society can be lost and forgotten about without a concerted effort to carry them forwards in some way.

I’m left puzzled by the various gaps in the narrative.

  • How did we get from Donabedian to the NHS 7 pillars of clinical governance?
  • How was the work of the CGST taken forwards?
  • Is there comparative evidence for national versus decentralised Clinical Governance systems?

Whatever the answers to these questions, there is one more quote from Donabedian about clinical governance and the wisdom he developed over a lifetime of work.

Systems awareness and systems design are important for health professionals, but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system’s success. Ultimately, the secret of quality is love

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Responses: If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk.

Disclaimer: The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

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