Annex A > Chapter 18 - Medical and Clinical Audit > Audit: the national perspective > The South West Region and audit
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The South West Region and audit
1988-1990 The Regional Hospital Medical Advisory Committee (RHMAC)
151 In 1988, the Regional Medical Advisory Committee (RHMAC) took the responsibility at regional level for promoting the introduction of medical audit. [179] It produced its first report in June 1989. The account set out in this section therefore deals first with the role of the Region in the introduction of audit, before addressing the topics of the District and the UBHT.
152 In January 1989, the Government's White Paper `Working for Patients; Medical Audit Working Paper 6' [180] expressed the desire that within two years all hospitals would participate in audit. Funding was announced for the development of medical audit in all healthcare providers, with funds to be distributed by the RHAs.
153 The `Working Paper 6' stated that arrangements to support medical audit would need to be made at regional level, through a professionally led `Audit Advisory Committee'. It further stated that the committee's role was to:
`... organise audit of the smaller specialties on a regional basis in order to facilitate peer review and to maintain the confidentiality of results.
`... arrange for clinicians to undertake the external peer review of particular problem services in Districts.
`... advise on and support the development of audit across the Region.
`While this committee will need to be supported and serviced by the RHA, it should be clearly seen as working on behalf of the District committees, enabling them to discharge their responsibility for ensuring that suitable comprehensive audit covers all services. Membership of the Regional committee will need to be determined locally to include a representative of each District committee, chosen to ensure that the main specialty interests are all covered. Whether the remit and membership of this committee should also cover the needs of primary care requires consideration.' [181]
154 The RHMAC was given responsibility for the centrally allocated funds and for reporting on progress to the DoH.
155 At this time it was the prevailing view amongst those seeking to introduce audit programmes that audit was essentially a professional educational activity and that the profession should lead its development. In his written evidence to the Inquiry, Mr David McCoy, Chairman of the RHMAC 1990-1994, stated:
`Clinical Audit and its importance were recognised, but these were relatively early days and we were concerned with establishing the mechanism of audit. It was understood that the results would remain confidential.' [182]
`The picture of audit at its inception was resented by some, and completely clouded by uncertainty of patient confidentiality, and the legal situation, with the risk of action for defamation as the result of published results.' [183]
156 The RHMAC did not delegate the development of audit to a sub-committee as it regarded audit as central to its own professional advisory function. In June 1989, it issued regional guidelines entitled `The Regional Approach to Medical Audit'. [184]
157 The RHMAC's report stated that `There is no need for a separate audit committee to be set up at regional level.' [185] It outlined the programme of work that had already been started. It spoke of the need for district audit committees to advise and implement medical audit procedures. [186] The report further stated that staff in each hospital or group of hospitals should formally agree to accept corporate responsibility for the quality of medical care and the general implementation of audit. [187]
158 The report accepted that audit was essentially a professional and educational activity and that the profession should lead its development. It stated that:
`Health authorities and managers are held responsible for the overall running of the hospital service, but they are not competent to make judgments on the technical quality of medical care. They must therefore entrust this function to the medical staff, with an agreed level of feedback and assurance that professional self-review does exist and is effective in improving patient care.' [188]
`Clinicians should be provided with the resources required for medical audit. At least one session of any full time consultant's programme may be ascribed to education activities, including medical audit. This should be acknowledged in a formal allocation of sessional time ... Current, accurate patient-based data should be available to doctors for medical audit in each specialty. These should include local, diagnostic, operation and mortality listings as well as national data, such as performance indicators for "avoidance of deaths".
`Clerical and computer support should be available to doctors in order to minimise the investment of clinical time in medical audit.' [189]
160 The RHMAC's programme included the appointment of two senior lecturers to the Bristol University Department of Public Health to assist the Committee: Dr Charles Shaw (clinical audit) and Dr D Pheby (clinical computing). [190] The Regional Medical Officer (RMO) was to set their objectives and to meet them regularly to review their progress.
161 Dr Shaw was appointed in January 1989 to a part-time post. Dr Shaw's appointment was also as an advisor to the District Audit Committees, when these were set up. He was responsible on behalf of the RHMAC for preparing the annual audit reports to the DoH to account for how the central funds had been spent. These reports were approved by the RHMAC before submission. [191]
162 Dr Thomas Hargreaves, a member of the RHMAC from 1987 until January 1991, [192] stated in his written evidence to the Inquiry that:
`... the key issues addressed at local level were: 1) Audit committees had been set up in each district 2) Reorganising support staff into groups supporting clinical unit 3) Introducing audit assistants 4) Training support staff to abstract and code clinical data 5) introducing the clinical workstation/medical data index 6) Improving library facilities.' [193]
163 Medical audit had already commenced prior to the 1989 White Paper. The structures and procedures being put in place were consistent with the directions later to be contained in HC(91)2, `Medical Audit in the Hospital and Community Health Services'. Dr Shaw stated:
`As in other regions at that time, local audit committees were consultant-led, predominantly medical, and with little direct management involvement. The philosophy was to encourage and support doctors to participate in increasingly systematic evaluation of their own work, to the benefit of patients and of their own professional development.' [194]
Dr Baker stated that, at this stage:
`... The development of audit locally and nationally was slow in general, individual enthusiasts for audit stood out by exception e.g. radiologists, anaesthetists, surgeons. Funds were spent on audit assistants but co-ordination of the development of audit was difficult at all levels and output was limited. Preparation for the purchaser/provider split and the establishment of NHS Trusts strained the task further.' [195]
Dr Baker told the Inquiry that one of the main obstacles standing in the way of audit
`... was the feeling that audit was going to become some form of inspectorial management tool of professional practice. I think, in general, the medical profession, and possibly others, closed ranks to some extent to take ownership of this process to try and accept it as something which was educational and related to training and practice in that way, rather than a more general approach to quality assessment.' [196]
`The Regional Hospital Medical Advisory Committee assumed responsibility for medical audit in 1989, before it became a general requirement in the NHS. Before audit moved from "medical to clinical", committee structures and chairmen were established by the profession and they generally reported to medical staff committees; part of the transition [from medical to clinical audit] was to redesign structures to become accountable to trust boards, such as through the medical directors, and thus to chief executives.' [197]
165 Dr Marianne Pitman [198] saw the role of Region in the audit system as ensuring` ... that there was an audit system which was appropriate to each specialty.' [199] She could not say who would select the topics to be audited, because some of the topics were agreed District-wide rather than Region-wide. She told the Inquiry: `I was not totally involved with the auditing system; I just knew that we had some that were labelled "regional audits"and some which were labelled "hospital audits".' [200]
166 Miss Catherine Hawkins, Chief Executive of the SWRHA from 1984 to 1992, stated in her written evidence to the Inquiry that:
`The RHMAC produced the SWRHA first series of service strategic statements in November 1989. This covered 6 specialist services including cardiac services. This report was a strategic statement with input from a variety of cardiologists and cardiac surgeons Region wide. This committee did not identify problems at the BRI unit.
`Item 20 of that report recommends "that the Bristol Centre, while it is the only Unit in the South West[, ] be fully utilised by the Districts in the Region and that the London Hospitals only be used to take excess demand". During 1986 the RMO identified that basic statistics appeared to show less good outcomes from surgery at the BRI than other acute units.' [201]
167 Audit is addressed in the Cardiac Services section of the 1989 Service Strategic Statement where it says:
`... There is a continuing need to monitor the outcome of established treatments.' [202]
168 In 1990 the RMO assigned a doctor on his staff to the task of promoting the processes of audit in the BRI as the first Acute Unit and then to follow through to all the other Acute Units. [203]
169 In September 1990 the RHMAC published a further document, `Hospital Audit Update 1990' [204] summarising the progress to that date.
170 After trust status was introduced in 1991, the BRI moved out of RHA supervision to become part of a trust, the UBHT, and as such was under direct DoH monitoring. According to Miss Hawkins, the residual role of Region in the financing and supervision of audit was from then on only on the basis of devolved responsibility from the DoH. Audit would apply equally to all the units in the geographical area, whether they were trusts or non-trusts. Accordingly, to avoid unnecessary complication and duplication of work, responsibility for audit with respect to the trusts was devolved on to the RHA. [205]
171 This meant that the responsibility of the Region to monitor the quality of services after 1991 changed:
`There was a shift of emphasis on monitoring which would move away from the providing of the service to the purchasing of the service, because we would be working through the purchasing DHAs, whereas the performance monitoring of the provider was the DHSS [206] if they were a Trust.' [207]
172 Nonetheless, according to Dr Morgan: `Throughout the period 1991-1994, the Regional Health Authority maintained a relationship with NHS trusts quite independently of purchaser Health Authorities.' [208]
`The initial clarity of the medical audit programme and its regional structure was reduced by the transition to multi-disciplinary clinical audit (from 1992), the growing independence of the new trusts, devolution of budgets to purchasers, the reduced role of the RHA, and thus the waning influence of the RHMAC.' [209]
The Bristol Clinical Audit Unit
174 The Bristol Clinical Audit Unit (BCAU) was established in late 1992. Dr Shaw summarised the function of the Unit as follows:
`The Clinical Audit Unit, on behalf of RHMAC, advised hospital and community units on the preparation of the centrally required annual audit reports, analysed these for compliance with criteria for funding, and included summaries in the composite report from SWRHA to the DoH. These reports, both local and regional, aimed to disseminate effective methods and practical lessons, as well as to account for past expenditure in order to release funding for the following year.' [210]
175 The BCAU was comprised of a director, Dr Shaw, and a manager, together with representatives from the Regional GP Audit Advisory Committee and the Local Hospital Audit Committees. The BCAU contributed discussion documents on methods and resources for audit; training programmes; and, for the smaller specialties, direct support for audit projects. [211] The BCAU tried to promote effective audit through training workshops and direct co-ordination of selected specialty projects. It convened a Region-wide meeting in 1992 of doctors and nurses in paediatrics, surgery and anaesthesia to discuss the recent report of the National Confidential Enquiry into Peri-operative Deaths (NCEPOD) relating to surgery on children. The NCEPOD report developed some general principles and audit measures, for example the availability of paediatric staff and accommodation, accessibility of specialised units and the extent of surgery on children without specialised training. It also showed the weakness of routine hospital data systems for regional monitoring of surgery. [212]
176 The funding and plan of work for the BCAU and for Dr Shaw was agreed annually with the RHMAC and the RMO. Progress and any deviations from the programme were reported to the monthly meetings of the RHMAC.
177 Dr Shaw stated in his written evidence to the Inquiry that:
`... Late in 1992, RHMAC adopted the collective chairmen of local hospital audit committees (LHAC) as a regional subcommittee to advise on transition from medical to clinical audit. Also the research and development directorate began to take on the role of advising the RHA on the funding and organisation of audit, in place of the RMO and RHMAC, and increasing emphasis was put on local management of clinical audit.' [213]
178 In 1993, in preparation for the devolution of audit funding to purchasing authorities instead of directly from the RHA to the provider units, the Audit Unit drafted specifications for effective audit which were to become the basis of future three-way contracts between the Regional Health Authority, purchasers and providers. [214] Under the aegis of the RHMAC and with the agreement of the hospital audit chairman, the same principles guided a series of self-assessments and external validations by a Regional Audit Team. These assessments were aimed to assist the local development of audit, to assess local progress with respect to structure, process and outcome of audit, and to help define contract specifications for 1993/94 funding. [215]
179 The Regional Audit Team was set up to try to encourage the development of audit. Its purpose was to try to develop a source of expertise at Regional level, which would be available to the Districts `... so we were not all inventing the wheel simultaneously.' [216]
180 Up to and including March 1993, the reporting requirements for audit were as stipulated in HC(91)2. [217] The purpose of the report was to account for the funding provided and to report on the progress made. Dr Shaw was responsible, as advisor to the RHMAC, for collating District audit reports to an agreed timetable and structure, and compiling the regional annual report. This report was presented to the RHMAC for approval, and was then distributed to the DoH, the Regional General Manager (RGM) and to the DHA and Trust managers and clinicians within the Region. [218]
181 Dr Shaw wrote: [219] `During 1993, the reorganisation of the health service (in terms of regional authority and the purchaser/provider split) and of audit shifted the mechanics and accountability. The 1993/94 regional annual report "Meeting and improving standards of healthcare" was the first to address "clinical" rather than "medical" audit and to follow the format defined in EL(93)34 [220] and 59.' [221]
182 Dr Shaw reported that the final Regional annual report of 1993/94 made no reference to the involvement of or approval by the RHMAC, except that a copy was sent to the chairman of the Committee. But it did declare that it was produced on behalf of the SWRHA. [222]
183 According to Dr Morgan: `There was remarkably little contact between the activities of this [Bristol Clinical Audit]Unit and local District Health Authorities - the relationship appears to have been almost entirely directly with Trust audit mechanisms.' [223]
Effectiveness of the regional audit programme
184 Miss Hawkins was asked by Leading Counsel to the Inquiry whether she, at the level of the Region, had access to what she regarded as full data on the performance of cardiac surgery at the BRI in the period up to 1992-1993. She replied:
`Not to my knowledge. Up until the time audit was properly accepted by medical staff, data was not openly and willingly shared. It was particularly difficult around the time of contracting when they had what they called "commercial confidentialities". At regional level, it was extremely difficult to have very specific surgeon/data aligned to one individual. Normally, if data came up, it was in a block scenario so you did not know who was accountable quite for what, so you could have a surgical specialty with subspecialties.
`It is one of the reasons why - the government did have a push for audit and why we did designate an individual person from Region to actually begin to develop the audit processes within hospitals which would also give us access, as audits came forward, to make good comparisons across regions and on a national basis. But the collection of data was not as it is now.' [224]
185 A letter dated 3 June 1992 from the Deputy Regional Director of Finance concerning medical audit allocations for 1992-1993 stated: `... The fragmentation of funding arrangements and the consequent lack of clarity over the responsibilities of the regional medical audit advisor, local audit committees and the DHAs has led to some confusion.' [225]
186 Miss Hawkins told the Inquiry that this was a reflection of the situation of audit in the early 1990s:
`... because funding was coming from a variety of sources and each unit either had no audit procedures in operation, or committees, and the one that did had different approaches and there was no common agreement at that stage on how audit should be conducted.' [226]
187 At this stage the medical staff themselves were supposed to be responsible for audit. Miss Hawkins agreed that due to the suspicion and sensitivity from the profession, the prevailing idea during the 1980s was that the most appropriate level from which initiatives on audit should come would be from the RHA. The RHMAC gained the confidence of the consultant staff, and they felt that under the auspices of the RHMAC they would not be made vulnerable. [227]
188 Also influential was the introduction of the audit promoter, Dr Shaw, to assist local units and consultants to develop the process. [228]
189 According to Dr Morgan, RHAs worked directly with the trusts to develop medical audit, allocate funds and monitor progress: `There was then little contact between the South West Regional Health Authority and Bristol and District Health Authority about these initiatives.' [229]
190 From the financial year 1994/95, the funding arrangement changed and the funding which the Regions had formerly separately identified became part of the general allocation of funding to the DHAs. From then on the districts ensured that audit was part of the standards and processes which they monitored as part of their contracting arrangements, rather than being a matter separately supervised by the RHAs. [230]
191 In preparation for this shift in role, a Regional Working Group had been established in December 1993, chaired by Dr Baker. The Group reported in February 1994. [231]
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Footnotes
[179] UBHT 0068 0006; notes to the 1989 RHMAC guidelines
[180] HOME 0003 0124; `Working for Patients; Medical Audit Working Paper 6'
[181] HOME 0003 0133; ibid.
[182] WIT 0436 0002 Mr McCoy
[183] WIT 0436 0002 Mr McCoy
[184] UBHT 0068 0001; `The Regional Approach to Medical Audit'
[185] UBHT 0068 0004; `The Regional Approach to Medical Audit'
[186] UBHT 0068 0005; `The Regional Approach to Medical Audit'
[187] UBHT 0068 0006; `The Regional Approach to Medical Audit'
[188] UBHT 0068 0011; `The Regional Approach to Medical Audit'
[189] UBHT 0068 0012; `The Regional Approach to Medical Audit'
[190] WIT 0399 0002 Dr Alistair Mason, former Regional Medical Officer
[191] UBHT 0068 0006; `The Regional Approach to Medical Audit'
[192] WIT 0434 0001 Dr Hargreaves
[193] WIT 0434 0003 Dr Hargreaves
[194] WIT 0437 0001 Dr Shaw
[195] WIT 0074 0037 Dr Baker
[197] WIT 0437 0012 Dr Shaw
[198] T58 p.4; Dr Pitman worked for the SWRHA throughout the period 1984-1995
[201] WIT 0091 0001 Miss Hawkins
[202] WIT 0091 0016 Miss Hawkins
[203] WIT 0091 0003 Miss Hawkins
[205] T56 p.115-16 Miss Hawkins and WIT 0091 0005 Miss Hawkins
[206] Or DoH. In July 1988 the DHSS was split into two departments: the Department of Health and the Department of Social Security
[208] WIT 0307 0004 Dr Morgan
[209] WIT 0437 0002 Dr Shaw
[210] WIT 0437 0003 Dr Shaw
[211] WIT 0437 0002 Dr Shaw
[212] WIT 0437 0002 Dr Shaw
[213] WIT 0437 0002 Dr Shaw
[214] The draft contracts were included in the 1992/93 Regional Annual Report, for application in 1993/94; WIT 0437 0013 Dr Shaw
[215] WIT 0437 0002 Dr Shaw
[217] HAA 0164 0023; circular HC(91)2
[218] WIT 0437 0012 Dr Shaw
[219] WIT 0437 0013 Dr Shaw
[220] HAA 0164 0434; circular EL(93)34
[221] HAA 0164 0164; circular EL(93)59
[222] WIT 0437 0013 Dr Shaw. The three-way contracts between the RHA, purchaser and provider, introduced in 1993/94, required the provider units' reports to be sent to the Regional Director of Research and Development, Professor S Frankel; Dr Shaw was not involved in producing the 1993/94 regional annual report
[223] WIT 0307 0012 Dr Morgan
[225] UBHT 0026 0083; letter from the Deputy Regional Director of Finance to chief executives, 3 June 1992
[227] T56 p.113-14 Miss Hawkins
[229] WIT 0307 0007 Dr Morgan
[231] WIT 0074 0038 Dr Baker