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Michael Deighan1, Fiona Aitken2

Author Affiliations: 

1Director, RCPE Quality Governance Collaborative, Royal College of Physicians of Edinburgh, Edinburgh, UK; 2External Relations & Quality Governance Associate, Royal College of Physicians of Edinburgh, Edinburgh, UK

Correspondence to: 

Fiona Aitken, Royal College of Physicians of Edinburgh, 11 Queen Street, Edinburgh EH2 1JQ, UK


Journal Issue: 
Volume 51: Issue 2: 2021
Cite paper as: 
J R Coll Physicians Edinb 2021; 51: 123–4




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Honesty in governance is an essential virtue, which should not be pretentious or misused. Employee and patient fates should rest on the Board’s inherent responsibilities to uphold honest values and decisions, and not solely focus on their accountability. The understanding of governance and its implementation is essential for physicians/professionals working in healthcare. The term governance, however, can often be abused, where individuals and/or groups bend the meaning to their desired agendas; occasionally to the extent of using the term as an excuse for inappropriate behaviour during major clinical and corporate decision-making. This misconstruction can occur when emphasising the apparent need to maintain the values, policies and codes of conduct of an organisation at the expense of good practice. This, in effect, protects a lack of transparency in decision-making1 to the exclusion of the clinical and economic reality.

The use of the term governance without a distinct definition and rationale is contentious and could be misleading. It should, therefore, always be clearly explained. We raise this argument as a proposition to promote more honest approaches to using the term. Organisation’s moral guiding principles, and these principles should take precedence when taking and making decisions for the benefits of others. As Sir William Wells, previous Chair of the NHS Appointments Commission has said ‘Governance is an attitude – it is the right way of doing things’.2

Governance at its core is the sum of its parts – leadership, decision-making, goal setting, audit and review, scrutiny, values and principles, organisational culture, diversity, environment and direction.

Understanding that governance at its most basic can be defined as ‘The way in which an organisation is managed at the highest level. And the systems for doing this3 and not a method to obfuscate for a weak policy. This error can come by placing a proposition before the word governance.

The concept of Good Governance, though widely used, means little unless the user specifies what ‘good’ represents and what it should reflect in practice. The NHS Scotland ‘Blueprint for Good Governance’ is an example of the effort that needs to go into defining exactly what is meant by ‘good’.4 Governance is the means to ensure strong, ethical and evidence-based decision-making and actions. It should not be used as an excuse for risky decision-making, or false legitimacy with little or no underpinning clinical or economic evidence.5

A further positive example relates to the early focus of Clinical Governance.6 The definition of clinical governance was designed to ensure that clinical and safety issues were at the forefront of decision-making in healthcare, while also making clinical issues the primary focus on Health Board agendas. Equally, clinical governance became prominent within UK NHS Government Policy.

The use of the term Integrated Governance is a natural progression from clinical governance. It is a term with the means to encapsulate all forms of governance within one overall Board framework. However, integrated governance does not occur easily, as all the forms of governance being combined must be valued equally in order to achieve desired outcomes.7

Global Governance is a term growing in popularity. Not unlike good governance, it can hold different meanings and should be defined upon use. At its base is a belief that governance is not the sole responsibility of one group and should always incorporate the involved actors, the source of rules and the scope of rule applicability in the entire governance process.8

A strong live example of an organisation and/or joint bodies determining their own definition of governance can be seen in the unique Royal College of Physicians of Edinburgh (RCPE)/World Health Organization (WHO) Joint Working Definition of Excellence in Quality Governance (Box 1).

Box 1 RCPE/WHO Joint Working Definition of Excellence in Quality Governance

“The means by which all institutions and organisations involved in the design and delivery of healthcare translate health policy into clinical practice and management in order to improve the quality and efficiency of healthcare.

The ability to ask the right questions and to implement the right mechanisms to ensure the organisation discharges its duties in line with its purpose and with focus on good clinical practice.”11

Right Question – Right Answer – Right Time – Right Outcome


When developing this definition, consideration had to be given to ensuring it was applicable for both the RPCE and WHO, as well as the associated member states.

Allowing sensible governance practice to become the norm is difficult without multi-professional support. In this context, professional is defined as the ability to create the correct support role for the organisation at Board level.

Namely adding value by appointing a Governance Secretariat appropriate to the organisation’s needs. In the case of health, one which has a valued understanding of clinical issues, patient safety and delivery of care requirements.

The disappointing factor is when a governance post is created, for example – ‘Director of Integrated Governance’. This can be misunderstood as an organisation fulfilling its governance responsibilities to deal with a perceived governance failing, if it does not ensure governance is central to all Board protocols. By making such appointments, are organisations surrendering their corporate responsibilities? – Yes, they are!

To fulfil future development and create lasting improvement of governance standards we would welcome both national and international collaborations. We look towards new ‘working definitions’ of governance as a means to continually review and analyse future scoping of clinical, scientific and corporate questioning of performance at Board level.

The definitions and methodologies for improving practice in governance should not have rigid parameters but be adaptable and foster ongoing critical and systematic evaluation of future clinical and corporate need.

It is the responsibility of the organisation or the collaboration to establish their own Board. The Board should handle necessary decisions and have skilled individuals with the ability to question and challenge when necessary. Thus guaranteeing there will not be a Chair/Board that breeds acquiescence bias. ‘Two qualities emerge from all my board experience; you need independence of mind and spirit and intellectual rigour. Also, readiness to be unpopular. Too many boards lack backbone.9 – Lord Chandos.

There is a need for professional agreed succession-planning approaches supported by the WHO, the Royal Colleges, and national and international scientific associations in order to create membership of Boards in the future.

By reviewing the etiquette of the ways in which Board members challenge their peers on specific decisions, we are asking for complete honesty of focus. Thus safeguarding complete transparency as the new code of conduct.

Governance is not a game of perfect.10 Dr Harry Brünjes. Using the correct terms when referring to governance issues and decisions becomes the Board/user’s remit. Therefore, the ability to translate their usage throughout discussions becomes their responsibility.


1 Ben Chu Economics Editor. Financial crisis 2008: How Lehman Brothers helped cause ‘the worst financial crisis in history’. Independent. 12 September 2018. (accessed 24/11/20).

2 Sir William Wells, in conversation, 2020.

3 Paterson A. Learning from serious failings in care: main report 2015. Academy of Medical Royal Colleges and Faculties in Scotland. (accessed 15/01/20).

4 “Governance” Cambridge Advanced Learner’s Dictionary & Thesaurus, Cambridge University Press, GOVERNANCE | meaning in the Cambridge English Dictionary. (accessed 24/11/20).

5 NHS Scotland. (2019) A Blueprint for Good Governance. Retrieved from: A Blueprint for Good Governance. (accessed 20/01/21).

6 Deighan M, Gray P, Aitken F et al. Quality Governance - What Happens as the Dust Settles, 2020, pp. 6–10. (accessed 24/11/20).

7 Bell D, Deighan M, Gillen P et al. Quality Governance – A Call to Arms. J R Coll Physicians Edinb 2018; 48:195–7

8 Halligan, A, Donaldson L. Implementing clinical governance: turning vision into reality. BMJ 2001; 322: 1413

9 Tusa, J. On Board: The Insider’s Guide to Surviving Life in the Boardroom. London: Bloomsbury Business; 2020. p, 214.

10 Dr Harrry Brunjes, Chair of the English National Opera (ENO), in conversation, 2020.

11 RCPE, WHO. (2019). RCPE QGC and the World Health Organization joint working definition of Excellence in Quality Governance. (accessed 10/04/21).

Financial and Competing Interests: 
MD is the Director of the Royal College of Physicians of Edinburgh (RCPE) Quality Governance Collaborative and RCPE Fellow. FA is an employee of RCPE.