Duty of Care Governance: a conceptual framework for aligning health system scale with the clinician-patient relationship.

Modern health systems possess advanced scientific and technological capabilities, yet they often struggle to preserve the ethical basis of clinical care: the clinician's primary obligation to the patient. When systems prioritize efficiency and large-scale growth, centralized authority can create structural tensions that may weaken the patient-clinician relationship, widening the gap between decision-making and patient outcomes. Duty of Care Governance is proposed as a conceptual structural model intended to re-anchor institutional design around this obligation. The framework organizes health systems around the clinician-patient relationship as the primary site of accountability. System integrity is conceptualized as being maintained through four interrelated governance functions: Sensing (interpretation of Clinical Signals), Responsibility (identifiable clinician accountability), Escalation (access to additional expertise without transfer of decision authority), and Feedback (longitudinal reassessment of outcomes). The system operates as a coordinated governance structure linking Clinical Signals with institutional guidance. Legitimacy depends on collaborative design, in which patients and clinicians co-author governing structures such as an organizational charter. This approach is intended to reduce relational displacement and organizational inertia. The manuscript introduces a financial perspective: the requirements of Duty of Care Governance can be understood not as administrative overhead, but as strategic investments that mitigate long-term liabilities such as clinician burnout, system failure, and patient burden. By contrast, evidence suggests systems that preserve relational continuity generate measurable value through improved outcomes and sustained trust. By maintaining structural discipline and anchoring authority at the site of care, the model is designed to preserve alignment between clinical decision-making and patient outcomes.