As stated in the Foreword to this worthy book, many of the qualities of clinical governance are difficult to assess and, although attitudes towards it are positive, its implementation requires much skill and commitment. The challenge for the editors of this book was to assemble a volume that engages, informs and is above all else practical and usable. The approach taken is appropriate and straightforward. The book is constructed from four parts. The first describes the concepts of quality in the National Health Service (NHS) since its inception and since the introduction in 1997 of clinical governance. The second part lays out the operational structures required to move the enterprise forward. This meaty section highlights a number of underlying tensions. Why does clinical quality struggle to gain a foothold on the agenda of so many NHS trust boards? How will the original concept of clinical governance as a tool to ensure continuous improvement of services survive the shift from the Commission for Health Improvement (CHI) to the Healthcare Commission, with its emphasis on the inspection and monitoring of key performance indicators, few of which are clinical outcomes? Sandford's prediction that ‘over time, the relationship between good clinical governance, patient outcome and public health may become clearer’ (p.73; my italics) is probably insufficient to sustain the engagement of clinicians and clinical teams.

The third section discusses eight ‘key elements’ from the involvement of service users through risk management, appraisal and clinical audit to inter-agency working. Each chapter stands independently as a basic primer often with some excellent yet simple advice on ‘making things work’, for example on risk management and clinical audit. There are many hidden gems, for example, Mary Lindsey's tabular ‘good and bad organisational practice in relation to policies and procedures’ (p. 167).

The fourth and final part attempts to locate the ordinary clinician and clinical team in the overall picture. Many of the chapter authors regard the clinical team as the central engine of clinical governance. After all, at its most basic, clinical governance must be about those involved with services being able to describe what they do, how they know it works and how improvements will take place. Far from easy, particularly if Briscoe's appraisal of the state and future of clinical information (systems) is correct (chapter 17).

Taken overall this book serves as a good comprehensive guide to contemporary (quality) management in the NHS. There is something here for many different consumers, from trainees (it will be an invaluable aid in teaching and supervising trainees for many of the non-clinical competencies) through to recently appointed clinical directors. There is some overlap in content between chapters, but frequently this gives an opportunity for the expression and consideration of different approaches to the same processes. Perhaps, though, a loose-leaf format would have provided better opportunity to keep abreast of policy change. Consider how quickly the CHI has come and gone!

The absorption and use of this guide will enable the commencement (if not already begun) of the cultural shift necessary to make the consistent and dependable delivery of high-quality services that is at the heart of clinical governance happen.