Clinical Governance Framework

1. Purpose

The purpose of this Clinical Governance Framework is to establish a structured approach to ensuring that all services delivered under Her Healthcare are safe, effective, and consistent with professional and regulatory standards.

Clinical governance provides the system through which Her Healthcare maintains accountability for the quality of care delivered within its service, supports clinicians in delivering high standards of practice, and ensures that risks are appropriately identified, managed, and reviewed.

As a GP-led healthcare network operating across multiple providers and settings, Her Healthcare recognises that governance must extend beyond a single organisation and instead support coordinated, multi-provider care while maintaining clear lines of responsibility.

2. Scope

This framework applies to all clinical activity delivered under Her Healthcare, including consultations provided remotely, consultations delivered within third-party clinical environments, and any care coordinated through external providers as part of the Her Healthcare pathway.

It applies to all clinicians working under or alongside Her Healthcare, as well as to administrative processes that support clinical care, including documentation, communication, referral management, and patient follow-up.

The framework covers all patient groups served by Her Healthcare, including adults and children aged 5 years and above, and incorporates safeguarding, clinical risk, information governance, and quality assurance processes.

3. Legal and Regulatory Context

Her Healthcare operates within the framework of UK healthcare legislation, statutory safeguarding duties, and professional standards.

This includes compliance with the principles set out in the Children Act 1989 and 2004, the Care Act 2014, and national safeguarding guidance, as well as adherence to General Medical Council standards, including Good Medical Practice.

In addition, Her Healthcare aligns its governance processes with the expectations set out by the Care Quality Commission (CQC), particularly in relation to the delivery of safe, effective, caring, responsive, and well-led services.

Although Her Healthcare does not operate as a single registered clinical premises, it recognises that the standards of care and governance expected of healthcare providers apply equally to distributed and network-based models.

4. Service Model and Governance Context

Her Healthcare operates as a coordinated GP-led network rather than as a traditional clinic-based provider.

Clinical services are delivered through a combination of remote consultations, in-person consultations conducted within third-party clinical environments, and collaboration with independent GPs and external providers, including specialists, mental health professionals, and diagnostic services.

Within this model, clinical governance is structured around the principle that responsibility for care rests with the clinician delivering that care, while Her Healthcare provides a framework for coordination, consistency, and oversight.

Her Healthcare is therefore responsible for ensuring that its own consultations are delivered safely and appropriately, that safeguarding concerns identified within its service are managed in accordance with statutory requirements, and that care pathways are clearly documented and communicated.

At the same time, independent clinicians and external providers remain responsible for the care they deliver within their own services, including their own safeguarding obligations and regulatory compliance.

This approach reflects national guidance that safeguarding and patient safety are dependent on effective collaboration between organisations, supported by clear communication and defined responsibilities.

5. Governance Structure

Clinical governance within Her Healthcare is maintained through a combination of structured policies, clinical oversight, and shared professional responsibility.

At the current stage of service development, formal leadership roles such as a named Safeguarding Lead are in the process of being established. In the interim, safeguarding and governance oversight are maintained through senior clinical input and adherence to established policy frameworks.

All clinicians working within the service are expected to operate within these frameworks and to take responsibility for their own clinical decision-making, while contributing to the overall governance of the service through appropriate documentation, communication, and escalation of concerns.

Governance is therefore both structured and distributed, reflecting the nature of a network-based healthcare model.

6. Clinical Safety and Risk Management

Clinical safety is achieved through the application of professional standards, clinical judgement, and structured processes for identifying and managing risk.

Within Her Healthcare, clinicians are expected to assess risk as part of every consultation, taking into account the patient’s presenting condition, medical history, and wider circumstances.

Particular attention is given to the limitations inherent in remote consultations and multi-provider care pathways. Where uncertainty exists, clinicians are expected to act cautiously, including arranging follow-up, recommending in-person assessment, or referring to appropriate services.

Risk management also includes ensuring that care is delivered within appropriate clinical scope and environment. Her Healthcare provides consultations and non-invasive examinations only, and does not undertake procedural or invasive interventions.

7. Safeguarding Governance

Safeguarding is an integral component of clinical governance and is embedded within all areas of the service.

Her Healthcare recognises that safeguarding is a statutory responsibility requiring healthcare providers to work in partnership with local authorities and other agencies to protect individuals from harm.

Clinicians are expected to identify safeguarding concerns through clinical interaction, to document these concerns accurately, and to take appropriate action in accordance with statutory guidance.

Where necessary, this includes sharing information with relevant agencies, even in the absence of patient consent, where there is a risk of harm.

In a network model, safeguarding may involve multiple providers. In such cases, Her Healthcare supports appropriate coordination and information sharing while respecting the independent responsibilities of each organisation.

8. Incident Reporting and Learning

Her Healthcare adopts a learning-based approach to incident management, recognising that continuous improvement depends on the identification and review of incidents and near misses.

All incidents, including those relating to clinical care, safeguarding, or communication, are expected to be documented in a clear and timely manner.

Incidents are reviewed to identify contributing factors, assess whether changes to processes are required, and support improvements in clinical practice.

This approach reflects the principle that governance is not only about compliance but also about learning and improvement.

9. Information Governance

Information governance within Her Healthcare is guided by UK GDPR, the Caldicott Principles, and professional confidentiality standards.

Patient information is managed securely, with access limited to those involved in the patient’s care.

In a multi-provider model, information sharing is an essential component of safe care. Information is therefore shared where necessary to support clinical decision-making or safeguarding, provided that such sharing is lawful, proportionate, and appropriately documented.

Each provider within the network maintains responsibility for their own records, while Her Healthcare maintains records relating to its own consultations and care coordination activities.

10. Referral and Partner Governance

Her Healthcare operates a curated network of external providers in order to ensure quality, consistency, and safety in patient care.

Referrals are made based on clinical judgement and an understanding of the patient’s needs, and patients are informed when they are being referred to an independent provider.

Once a referral has been made, the receiving provider assumes responsibility for the care they deliver. Her Healthcare does not assume liability for clinical decisions made outside its own consultations.

For patients receiving ongoing care through membership arrangements, Her Healthcare may remain involved in reviewing results and supporting care coordination, while maintaining clear boundaries of responsibility.

11. Clinical Practice and Professional Standards

All clinicians working within Her Healthcare are required to hold appropriate qualifications, maintain current professional registration, and practise within their scope of competence.

Clinicians are expected to adhere to professional standards, including those set by the General Medical Council, and to maintain up-to-date knowledge through ongoing professional development.

Safeguarding training is required at an appropriate level for the clinician’s role, in line with national guidance.

12. Children and Young People

Her Healthcare provides care for children aged 5 years and above.

All patients under the age of 18 must be accompanied by a parent or legal guardian during consultations, except where alternative arrangements are clinically justified and legally appropriate.

Clinicians must consider safeguarding in all interactions involving children and young people, including the wider family context and any potential indicators of harm.

13. Monitoring and Review

Clinical governance within Her Healthcare is subject to ongoing review.

This includes review of clinical outcomes, patient feedback, and incidents, as well as evaluation of processes and care pathways.

The framework itself is reviewed periodically to ensure continued alignment with regulatory expectations, professional standards, and the evolving needs of the service.

14. Continuous Improvement

Her Healthcare is committed to continuous improvement in the quality and safety of its services.

This includes learning from experience, adapting processes where necessary, and strengthening governance systems as the service develops.

In a network-based model, this commitment extends to ensuring that coordination between providers continues to support safe, effective, and patient-centred care.