1004-CD1.1: Participative Medical Governance in the Delivery of Health-Effective Medical Services


This paper puts forward a model of participative medical governance. It builds upon two other models being developed by the Tuke Institute: i) a model of biopsychosocial medical services framed by a personalised assessment of illness, which is used to bench-mark individual medical outcomes that focus above all on health-effectiveness—i.e., helping the ill to get well and stay well long-term; and (ii) a model of measurement that relies on scientifically validated methods to determine if and how a medical service is being health-effective, thereby ensuring a valid evidence-base for medical governance.

Medical governance is required to ensure that a medical service remains health-effective and delivers services first and foremost to the public rather than to its providers. This model of participative medical governance specifies a robust system by which the public can ensure that information on health-effectiveness is used to ensure quality of service and it relies on the public’s participation at all gradations of service, from the patient and the family caring for the patient all the way out to national policy, in a horizontal framework. Importantly, this model provides the means by which to identify at an early stage the points where intervention is necessary with poorly performing clinicians and administrators, so as to protect the public’s health and prevent malpractice.

The model provides tight feedback on the quality of service, which is likely to increase clinicians’ morale when their performance is assessed as good and provide early motivation for all clinicians and administrators to address anything less. It promotes mutual knowledge-transfer between service-providers and service-users and ensures high transparency and accountability, preventing scapegoating while engendering a culture of professionalism and personal responsibility. Together, these aspects promote the repair of trust in and goodwill towards medical service-providers, which have been so badly damaged through the present medical culture that has lead to excessive litigation and the need, in Britain, for government Inquiries over the recent years.

Many solutions to the problems of medical effectiveness fail to demonstrate that they—or the model they support—are fit for their intended purpose. For example, while such initiatives as the multi-billion-pound “Connecting for Health” programme are essential, they can not be health-effective (and therefore cost-effective) without building in a framework of health-effectiveness-measurement and of participative medical governance. This paper shows why. Many of the problems analysed here are typical of nationalised medical service-systems and the British National Health Service (NHS) is used as an exemplary problem to solve. The analysis is framed specifically in relation to the findings of the British Government’s Bristol Inquiry, a high-water mark of problems in the NHS, the final report of which made a series of recommendations intended to be solutions to those problems. However, the report did not specify how its proposals would deliver solutions to long-standing organisational and cultural obstacles; this paper fills that gap and proposes a system that has the scientific benefits of being evidentiary, coherent, practicable, and testable.

While the model provides a solution to the problem of medically and financially ineffective nationalised medical services, it is not aimed at solving the problems of the British National Health Service (NHS) per se: it is equally a model for American systems, for example, where there has been inadequate emphasis on medicine as a pro-social service rather than a pro-market opportunity. While elements of the model can be applied in commercial medicine, a partial implementation severely constrains the model’s health-effectiveness: only a nationalised system is able to address comprehensively the illness-related needs of a given individual in the interests of that individual and the public as a whole. Additionally, the model discussed is equally and directly applicable to social medicine—that is, not just to ‘health-care’ but to ‘social care’ as well—and provides a common framework for solving common problems.

Date: 01.04.2010

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