Legitimacy Chasing its Own Tail: Theorizing Clinical Governance through a Critique of Instrumental Reason

Clinical governance was introduced in The New NHS: Modern, Dependable in 1997. Through changing structures and systems around the management of risk, knowledge and performance, the policy essentially seeks to mould the working culture of the NHS, yet there is inconclusive evidence as to its success, with many studies suggesting its impact has been highly limited. While modifying the system and structures within which practitioners operate is straightforward, cultures of shared norms and values cannot be so easily, or indeed successfully, shaped. Applying Habermasian social theory as an analytical framework, clinical governance is seen as responding to a constructed legitimacy crisis following NHS dysfunctions such as Bristol Royal Infirmary. Paradoxically, this misnomer has led to a policy that undermines its own legitimation among the professionals it seeks to control through its separation of purposive-rational interests from norms and values. Thus, a reliance on sanctions rather than norms to orient the actions of individuals working within the NHS elicits superficial rather than substantive compliance, undermining the effectiveness of auditing/accountability mechanisms. Whereas intra-organizational trust is more efficient in managing transactions, clinical governance, as it functions currently, represents a form of control which is not only more expensive, but ultimately ineffective and self-defeating.