Clinical governance, together with a number of national bodies to support and monitor it, was established in the NHS in 1997.¹ Seven years on, it seems a good time to reflect on how effective this national quality assurance/improvement strategy has been, particularly in the light of subtle changes in the UK government’s attitude to quality. The recent publication of a new standards framework,² the replacement of the Commission for Health Improvement (CHI) with the Healthcare Commission from April 2004, and insistence that trusts will have greater local autonomy² all suggest a change in the wind—although the direction of the change is not quite clear.

In the initial guidance on the duty of NHS trusts to implement clinical governance,^3,4 the government set out the mandatory components of clinical governance (variously …