Competition and compromise in negotiating the new governance of medical performance: the clinical governance and revalidation policies in the UK

This article explores the development of two policies for the governance of medical performance in the UK: the Department of Health's (DH) clinical governance policy and the medical profession's revalidation policy. After discussing the institutional context in which each of these policies emerged, we examine how and why they were constructed. While the clinical governance policy was in large part a swift reaction to high-profile cases of medical misconduct in the late 1990s, revalidation was the profession's response to the politicisation of its self-regulatory apparatus. The profession took notably longer than the DH to piece together its policy as a result of internal disagreements about the role clinical standards should play in the evaluation of a doctor's fitness to practice. Following the Fifth Report of the Shipman Inquiry in late 2004, the government stepped in and eventually introduced legislation that modifies the profession's policy. With clinical governance, the state – via arms-length regulatory organisations – has entered the clinic in new ways, strengthening hierarchy-based forms of governance in the governance of medical performance. However, the success of hierarchical forms of governance is likely to be restricted by the lack of a clear system of sanctioning and the state's reliance on a lengthy chain of command in the National Health Service for the implementation of clinical standards.