Annex A > Chapter 18 - Medical and Clinical Audit > Audit: the national perspective > The national scene: a brief history of audit

The national scene: a brief history of audit [30]

Key events

28 Prior to 1980, explicit concerns about quality appears to have been largely absent from the thinking and policy documents of the NHS.

29 The medical profession was expected to be the regulator of the quality of clinical care, and had been since the Medical Act 1858 established the General Medical Council (GMC) to regulate the medical profession on behalf of the state. This legitimated the profession's claims to autonomy and its right to self-regulation. When, in 1948, the NHS was created, the regulation of the medical profession was left largely in the hands of the profession through the GMC (and, in matters of training, the Royal Colleges).

30 Audit as a notion and a practice was conceived as being wholly associated with the activities of the medical profession until relatively recently. However, to the extent that it is concerned with quality of care, widely understood, it is inevitably concerned also with the conduct of all the other carers involved in the care of patients.

31 The `Historical Perspective' to the formal introduction of the obligation to undertake audit within the NHS was summarised by the Standing Medical Advisory Committee in 1990. [31]

`The idea of medical audit is not new: indeed, reference to it can be found in the Charter of the Royal College of Physicians of 1518 which states that one of the College's functions is to uphold the standards of medicine "both for their own honour and public benefit". Examples of medical audit which are currently taking place [in 1990] include the Confidential Enquiry into Maternal Deaths, which began in 1952 and is run jointly by the Department of Health and the Royal College of Obstetricians and Gynaecologists. The Royal College of General Practitioners was involved early on in medical audit in general practice. Much of the work of the Birmingham Research Unit in the 1950s and 1960s was concerned with designing the tools for audit. In pathology the National External Quality Assessment Scheme (NEQAS) was started in 1969 and encompasses all commonly used numerical investigations in pathology. It is a voluntary scheme open to NHS and private services. The Royal College of Physicians conducted a survey in 1980 of causes of death in medical wards of all patients under the age of 50. The Association of Anaesthetists and the Association of Surgeons together carried out an enquiry into perioperative deaths in three Regions (CEPOD); this was extended into a national confidential enquiry at the beginning of 1989. The Health Advisory Service, which was established in 1976, is an example of multidisciplinary audit; it carries out reviews of hospitals and community health services provided for the elderly and the mentally ill and makes recommendations for the improvement of care.

`The Department of Health's health service indicators include measures of activity, and some of outcome ... These provide some indication of the quality of medical care. The health service indicators also include a set of data which compares death rates by region and district for certified causes of death from conditions considered `potentially avoidable'... The incidence of potentially avoidable deaths (that is those from conditions amenable to treatment) has been analysed for each Health Authority and shows large variations between Health Authorities even after adjustment for social factors. All these may provide some indication of the quality of medical care.'

32 Dr Morgan stated:

`Recognisable medical audit has taken place throughout the Health Service for many years but a systematic approach to engaging all clinicians became evident in the NHS only in the late 1980s.' [32]

33 Prior to 1980 explicit concerns about quality appear to have been largely absent from the thinking and policy documents of the DoH. [33] Dr Graham Winyard [34] considered that the DoH's relatively limited involvement in the field of audit and outcome assessment at the time reflected the then established division of responsibility for standards of professional practice, which were set by the GMC and the medical Royal Colleges:

`... through general and specialist examinations, the inspection of training posts and involvement in consultant appointment committees. However, the prime responsibility for a doctor's ongoing standard of professional practice lay with that individual and was seen very much as a matter for him or her. General peer pressure was undoubtedly important in maintaining overall standards but could prove much less effective when an individual was, for whatever reason, resistant to criticism.' [35]

34 Thus, the evidence indicated that prior to 1989 there was a varied and patchy pattern of audit. Dr Walshe elaborated:

`... in most hospitals you would have found a small number of clinical professionals, particularly doctors, who were gathering data about their own practice, who were, if you like, audit enthusiasts and who were engaging in a process of clinical audit for themselves. You would have found, I think, in most parts of most organisations, relatively little activity. There would have been some traditional mortality and morbidity meetings or death and complication meetings going on, at which problems to do with the quality of care perhaps got reviewed, but you could not have said that in I think almost any health care organisation at that time in the NHS there was a systematic program of quality assurance or quality improvement in place. You would also have found some important national initiatives which were focused on particular areas of care and were important in those areas but were somewhat isolated in that they did not have a wider remit or impact. Examples would be the Confidential Enquiry into Maternal Deaths and the National Confidential Enquiry into Peri-operative Deaths, work done by the Royal College of General Practitioners on standards for general practice, and things like that. So there were important initiatives, but there was no system that covered even a large minority of the care being provided.' [36]

35 Attitudes began to change within the medical profession itself. For example, some parts of the medical profession gained extensive experience of quality assessment exercises set up by bodies such as the Royal Colleges, notably into anaesthetics and obstetrics, as well as confidential enquiries established on a national basis to study maternal, infant and peri-operative deaths. [37]

36 Formal arrangements for audit were in their infancy throughout the NHS during the 1980s. Progress was limited because no additional resources were allocated for audit whether for the supra regional services or in the NHS generally. It was only with the introduction of the NHS reforms in the 1990s that funding was made available for the specific purpose of introducing audit. [38]

37 The publication of the DoH's White Paper `Working for Patients' [39] in January 1989, set out plans for the creation of the internal market. Together with the `Working for Patients: Medical Audit Working Paper 6', it also set out plans for a comprehensive system of medical audit, covering both primary healthcare and the hospital and community health sector. The Government made it clear that all health-care providers in the NHS in England should develop medical audit programmes that involved all medical staff in critical examination of the quality of care and practice. Subsequently, the DoH broadened this programme to provide some funding for an audit programme in Nursing and Therapy as well. Uni-professional audit was proposed at that time; that is to say medical audit for doctors, nursing audit for nurses and their own audit for the Professions Allied to Medicine (PAMs).

38 `Working for Patients' sets out the fundamental principles, `to which the Government is committed', as follows:

`(a) Every doctor should participate in regular systematic medical audit.

`(b) The system should be medically led, with a local medical audit advisory committee chaired by a senior clinician.

`(c) The overall form of audit should be agreed locally between profession and management, which itself needs to know that an effective system of medical audit is in place and that the work of each medical team is reviewed at regular and frequent intervals to be agreed locally.

`(d) The results of medical audit in respect of individual patients and doctors must remain confidential at all times. However, the general results need to be made available to local management so that they may be able to satisfy themselves that appropriate remedial action is taken where audit results reveal problems.

`(e) Where necessary management must be able to initiate an independent audit. This may take the form of external peer review or a joint professional and managerial appraisal of a particular service.' [40]

39 It was Dr Winyard's opinion that the proposals in the working paper recognised that audit:

`... needed to be owned by the medical profession if it were to be effective in stimulating genuine peer review and changing clinical practice where that was indicated. They sought to strike a balance between this and the wider and equally legitimate interests in the quality of care by ensuring confidentiality for the audit process itself, while insisting that the "general results" of audit were made available to management.' [41]

40 The DoH's policy at the outset was that medical audit should be primarily the concern of providers, rather than district health authorities or other purchasers. As the NHS reforms took effect, structures and audit activities would therefore need to be based at a provider level:

`Health authorities are responsible for establishing a medical advisory structure. With the separation of the purchaser/provider functions, medical audit will become a provider unit based activity and it will be to unit managers that regular reports of the general results of audit are addressed.' [42]

41 The benefits of the audit programme were expected to be profound and wide ranging. An internal discussion paper in the DoH stated:

`Medical audit should trigger changes in practice within specialties, across specialties, across provider units and across boundaries including those between primary, secondary and tertiary care. The findings of medical audit should encourage comparison and challenge working practices throughout the NHS ... This should result in optimal delivery of effective and appropriate care by the right professionals, in the right combination, in the right setting and at the right time.' [43]

42 Dr Walshe identified three elements which in his opinion were the catalyst for these audit reforms in 1989, a year that many witnesses regarded as marking the introduction of audit as a formal process:

`I think there are three things that had happened. One was the rise of general management during the 1980s and the arrival of individuals, some clinically qualified, some not clinically qualified, but individuals who had general management responsibility and authority for healthcare services, and had more of a remit and a legitimate right to ask questions about the quality of care. Second was the rise of concerns about quality of performance across public services, and indeed private services. It was a theme in Government in the 1980s and a focus on the role of managers and managerialism and a concern about the power of the professions running across education and health and social services, and other sectors. I guess I would also point to the fairly positive experience of those initiatives I have described going on in the 1980s, seen as examples of good practice that perhaps we should be trying to emulate and roll out on a wider scale. I do not think I could point to one particular event or set of circumstances which led the Government then to say "we have to have systems of medical audit". It was a combination of things.' [44]

43 The aims and objectives of the DoH's audit programme from 1989 to 1993 are set out in Figure 2, below.

Figure 2: Aims and objectives set by the Department of Health for its audit programme [45]

44 In order to meet these objectives, the Department of Health allocated almost £221 million to facilitate the development and implementation of medical audit (later clinical audit) programmes in every health care provider in England, and to support central initiatives such as audit projects and programmes at the medical Royal Colleges. The provider units received £28 million, allocated for funding the newly created medical audit committees in the first two years (1989 and 1990). This rose to £48.8 million in 1991/92, the year in which the committees began to function fully. [46]

45 A separately funded Nursing and Therapy audit programme was also introduced, from 1991 onwards. It received £2.3 million in 1991/92. [47]

46 Figure 3 shows the flow of funds for clinical audit between 1990 and 1994.

Figure 3: Flow of funds for medical and later clinical audit 1990-94 [48]

Reactions to the Government's proposals

47 Medical reaction to the White Paper proposals as a whole were generally negative. The reactions are set out as follows:

• concern that the proposals failed to address the chronic under funding of the NHS;
• doubts about the need for such a major reorganisation of the system;
• scepticism about whether patients would benefit from the changes; [49]
• doubts about whether there would be adequate time for audit and whether confidentiality could be maintained;
• suspicion about the possible covert use of the policy as a diversionary device to deflect attention from insufficient resources;
• concerns about a shortage of skills, lack of interest, lack of adequate data and information systems, lack of willingness to focus on key issues such as appropriateness of treatment, reluctance among consultants to judge their peers and risk of attribution of blame to junior staff; and
• the view that, to the extent that audit remained a private activity internal to the medical profession, the need for greater public accountability would remain unmet. [50]

48 The Inquiry's expert on audit agreed that the reaction from members of the medical profession to the White Paper as a whole was generally very negative but:

`... the reaction to the ideas for audit from the Royal Colleges and others speaking on behalf of the medical profession was strikingly positive.' [51]

Thus, although medical audit was promoted by the DoH and, formally, initially led by the RHA, it was also actively promoted by the Royal Colleges. In the case of the RCSE, guidelines on audit were published in 1989 that were revised and updated in 1995. [52] The Colleges in their publications reiterated the principle that medical audit was educational, confidential and non-judgmental. [53]

49 In turn, the DoH took care to emphasise the positive aspects of medical audit, compared to existing quality control mechanisms such as the GMC's disciplinary procedures and the law. The various documents relating to medical audit avoided such terms as `mandatory' or `compulsory' and there was no mention of penalties for those who resisted.

50 Further, the endorsement of `medical' audit was not supported by all:

`At a time of increasing recognition of the importance of a team approach in clinical work, the emphasis on uni-professional audit was criticised, by the Director of the Royal College of Nursing among others, as inappropriate and potentially divisive.' [54]

51 The commentators with a management perspective went one step further and challenged the appropriateness of segregating audit from other management initiatives relating to quality, such as resource management. The Director of the Institute of Health Service Managers argued for the integration of professional audit into a much wider model of co-operative working.

52 Doubts about the wisdom of a policy focusing on the methodology rather than the purposes of clinical quality assurance were also expressed. For example, there were concerns that:

• audit would become an end in itself;
• topics chosen would be chosen because they were easy or interesting or data already existed;
• aspects of practice might be neglected entirely because they were not susceptible to audit;
• important problems might be dealt with ineffectually through audit when they could be dealt with more satisfactorily in some other way;
• the weakness of the evidence that audit could be beneficial to patients and the known difficulty of completing the audit cycle effectively. [55]

53 Following the publication of`Working for Patients' new enterprises that could be called `a healthcare quality industry', emerged, leading to a great expansion of activity. Several quality management systems began to be introduced into healthcare in the UK, including for example the King's Fund `Organisational Audit', BS5750, which was developed as a pilot for organisational accreditation within the UK. [56] Systems of Total Quality Management were also developed. In 1990, the Royal College of Nursing (RCN) launched its workbook on the Dynamic Standard Setting System or DySSSy. [57]

Creation of the NHS market

54 On 1 April 1991 the `Working for Patients' reforms came into operation. [58]

55 Although the legal framework for a hospital trust established by the NHS and Community Care Act 1990, empowered the Secretary of State, by Order, to establish bodies `to assume responsibility ... for the ownership or management of hospitals ... or to provide and manage hospitals', [59] there was nothing in that Act setting out the duties of trust directors in respect of quality or safety. In particular, no guidance on responsibility for standards of safety or quality was given to trust directors.

56 In July 1991, the then Prime Minister, John Major, launched the Citizen's Charter, aimed at promoting good quality services in the public sector. In October 1991, the `Patient's Charter' was launched by the DoH.

57 The Charter was described in its foreword as:

`... a central part of the Government's programme to improve and modernise the delivery of the service to the public whilst continuing to reaffirm the fundamental principles of the NHS.' [60]

One `right' that was newly established by the Charter was `to be given detailed information on local health services, including quality standards and maximum waiting times.' [61] The local health authority was to publish annual reports detailing how it was performing against national and local charter standards.

However, the National Charter standards were not legally enforceable. They were described in the Charter as:

`... not legal rights but major and specific standards which the Government looks to the NHS to achieve, as circumstances and resources allow.' [62]

58 The Government and other bodies undertook further work on the development of audit tools. A series of frameworks were developed centrally for different audit tools. In nursing, a `Framework of Audit for Nursing Services' was published by the NHSME. It described an eight-stage approach to nursing audit, broadly consistent with the quality assurance cycle described in DySSSy, but using significantly different terminology. [63]

The introduction of clinical audit

59 By 1993, policy had shifted to recognise that separate medical audit by doctors of medical care and nursing audit by nurses of nursing care was sub-optimal. For audit to be effective, the totality of patient care needed to be studied. All members of a team delivering a particular service should together audit the work that the team was undertaking. This multidisciplinary approach was given the name `clinical audit'. [64]

60 In November 1992 the first meeting of the Department of Health's new Clinical Outcomes Group (COG) was held. The group was chaired jointly by the Chief Medical and Chief Nursing Officers, and aimed to give strategic direction to the development of clinical audit. It advised upon the development of methodologies to identify and achieve improved outcomes. [65]

61 On 23 April 1993 the NHSME sent out a letter [66] that noted the central development of the clinical audit programme. A policy statement setting out the main strands of the clinical audit strategy had been commissioned by COG and was soon to be published. Whilst funding for medical and nursing and therapy audit was still to be separately identified in 1993/94, an additional allocation of £3.2 million had been made to facilitate the development of multi-professional clinical audit. In 1993/94, Regions were asked to promote the use of the clinical audit programme as part of the purchaser's role in contracting.

62 The letter explained that the NHSME needed to be assured that the appropriate mechanisms and procedures were in place to underpin the development of clinical audit. It required the regional general managers to set out their proposals for achieving this aim in the letters submitting the 1992/93 annual reports.

63 Annexed to the letter was a paper, `Audit and the Purchaser/Provider Interaction', [67] prepared by a working group of the Regional Medical Audit Coordinators Committee and Conference of Colleges Audit Group. [68] The paper was an aid to discussion of clinical audit. It set out the key features of clinical audit, which it was hoped would lead to improvements to the care of patients within five years:

• `Audit will be largely multidisciplinary (clinical) audit and part of hospital-wide quality management programmes.
• `Audit will be informed by purchaser/provider and public/patient as well as professional (college) priorities.
• `The findings of audit will inform service development and purchasing.
• `Audit will be an integrated part of routine activity and continuing professional education.
• `Audit will increasingly demonstrate its effectiveness and cost effectiveness to provider, purchaser and the public.
• `Audit will increasingly focus upon outcomes and their relationships to the processes of care.
• `Audit will be a shared process bridging primary and secondary care sectors.' [69]

64 Dr Walshe told the Inquiry about the shift from medical to clinical audit during 1991 to 1995. Counsel to the Inquiry asked Dr Walshe whether clinical audit replaced medical audit or whether it was common to find the two operating in tandem. He replied:

`It generally replaced and it was part of the wider shift towards for example more managerial involvement, that there was this move towards a more multi-professional approach to audit and quality improvement. The department had established, back in 1990, a separate nursing and therapies audit programme run by a separate part of the Department of Health, part run by the Chief Medical Officer's section and part by the Chief Nursing Officer's section. In 1993 they recognised, as did others, that that division did not make sense and they brought the two together and encouraged Trusts to bring the systems together. What usually emerged within a Trust was a Clinical Audit Committee with a more multi-professional membership, although the membership of those committees tended to be quite medically dominated.' [70]

65 In July 1993 the DoH published a policy document, `Clinical Audit - Meeting and Improving Standards in Healthcare'. It set out a strategy for moving towards multi-professional clinical-audit, with an emphasis on clear definitions, and quality and outcome of care. This document stated:

`A key component of demonstrating quality of clinical care is identifying the benefit of care in terms of improved health, patient satisfaction and reassurance and improved quality of life, i.e. clinical outcome. Clinical outcome usually reflects the consequence of the collective efforts of a number of professionals, consequently while it was necessary, initially, to set up the audit programme on a uni-professional basis, there is now a need to move to a more integrated approach to audit.

'Therefore while uni-professional audit will continue to be essential, where a mix of professionals are involved in the care of patients, multi-professional audit has already become established e.g. Accident & Emergency, Psychiatry and Medicine for the Elderly, as audit on any other basis would have been of limited value.' [71]

Further guidance was subsequently given by the DoH publication `The Evolution of Clinical Audit'. [72] It stated that items which would indicate that audit is developing successfully are that it is:

• `undertaken by multi-professional healthcare teams;
• `focused on the patient;
• `performed within a culture of continuing evaluation and improvement of clinical effectiveness focusing on patient outcomes.

`The first two aspects are closely related. By making the patient central to the audit process, the professions that need to be involved in the audit will automatically be identified. (There is however still a role for uni-professional audit, where professions can clearly identify their own singular contribution.)' [73]

66 Dr Walshe considered that after the introduction of clinical audit there was no longer a role for a medically orientated form of audit except in some situations:

`I think it depended on the specialty, the area and the quality issues that you were addressing, but I think most people would agree that most quality problems do not belong to an individual profession. When you start to examine why a particular problem or difficulty exists, it quickly rolls out, given the complexity of the process of care, into the territory of other professional groups. So clinical audit seemed much better fitted to dealing with the very multi-professional nature of most areas. Clearly there are some specialties who tend to work much less multi-professionally than others, and there was no purpose in having a multi-professional process if the issue simply ... affected the anaesthetists. But the default, I think, was meant to be that these processes should be multi-professional, because most of the time that was what was needed.' [74]

Changes in funding 1994/95

67 Funding for the national audit programme to 1994/95 was provided as follows:

68 On 23 April 1993 the NHSME issued EL(93)34 entitled `Clinical audit in HCHS: allocation of funds 1993/94'. This stated that:

`Funding for clinical audit from 1994/95 will be included in overall allocations to Regions. Regions will be expected to maintain and develop clinical audit and will be held accountable in this area; specific criteria on which performance will be measured after 1993/94 will be agreed at a later date.' [75]

Thus, the ring-fenced funding allocation for audit was to cease in 1994/95. [76]

69 In the following year, on 28 February 1994, the NHSME issued EL(94)20 entitled `Clinical Audit: 1994/95 and beyond'. This contained further advice about the changes in funding arrangements that were to take place in the coming year. It attached guidance upon the funding of audit through the contracting process that had been developed by a working group commissioned by COG. Whilst the advice might come too late for full implementation by many purchasers/providers in the current purchasing round, it was hoped it would assist in the future. The guidance noted that:

`From April 1994 funding for HCHS [Hospital and Community Health Services] clinical audit will be included in Regional Health Authorities (RHAs) recurrent funding on a resident population share basis. These monies will be the sum of monies previously set aside for medical and nursing and therapy audit with one major adjustment. Allocations to regions for medical audit purposes, previously calculated on a whole time consultant equivalent basis, will now be allocated on the basis of resident population.

`The cessation of ring fencing allows funding to become recurrent, allowing longer term plans for audit to be developed at provider and DHA level. It also allows audit to address more adequately questions of healthcare needs and healthcare effectiveness and to become fully integrated in the mainstream business of provider units/trusts/primary care and health purchasing authorities. [77] The transition of funding should be undertaken in such a way as to enhance the early steps in the evolution from medical to clinical audit.' [78]

The guidance also noted that the recommended approach included:

`... an agreed contract between the DHA and each service provider for clinical audit, specified in terms of facilities and including some form of indicative workload agreement.' [79]

The role and responsibilities of each group were also set out in the directive. RHAs were to be:

`... accountable from 94/95 for the maintenance and development of clinical audit. The new NHSME Regional Offices will have a performance monitoring role for both purchasers and providers in the future.' [80]

DHAs and FHSAs were told that their plans:

`... should indicate the purchasing authority's long term vision for audit and incorporate priorities which have been jointly agreed between purchaser and provider.' [81]

Units and trusts were to:

`... develop appropriate structures and processes to achieve effective clinical audit.' [82]

70 Thus, in the financial year 1994/95 the funding responsibility for audit moved from RHAs to the purchasing DHAs. Funding for audit became part of the contract between the purchaser and the provider. Furthermore, funding for medical, nursing and therapy audit was no longer separately allocated by the DoH; instead one allocation for clinical audit was made. Figure 7 shows the organisation of clinical audit after April 1994:

Figure 4: The organisation of clinical audit (after April 1994)1

Clinical effectiveness

71 Towards the end of the period of the Inquiry's Terms of Reference, the focus of the Government's guidance shifted away from the organisation and monitoring of audit to considerations of effectiveness. An effective clinical audit programme was defined as one which involved balanced topic selection, employed adequate audit processes, secured implementation of audit results and was comprehensive (involving all aspects of healthcare). [83]

72 National policy guidance had shown an increasing emphasis on the improvement of clinical effectiveness since 1993, as shown in Figure 5:

Figure 5: National policy guidance on improving clinical effectiveness [84]

73 By 1996 audit programmes were no longer seen as the central mechanism for improving the quality of care, as they had been in 1989, but rather as a part of the broader work on improving clinical effectiveness. [85]

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Footnotes

[30] The distinction between medical and clinical audit and the shift in policy from the former to the latter is discussed at paras 59-66 onwards. Medical audit carried out by doctors and the audit of nursing care by nursing staff was realised to be less instructive than the multidisciplinary approach to the examination of overall care of the patient that became known as `clinical audit'

[31] `The Quality of Care', report of the Standing Medical Advisory Committee, DoH, 1990, p. 7-8

[32] WIT 0307 0011 Dr Morgan

[33] INQ 0011 0007; `Medical and Clinical Audit in the NHS'

[34] Dr Graham Winyard was the Medical Director of the NHS Executive and Deputy Chief Medical Officer from 1993 to 1998

[35] WIT 0331 0002 Dr Winyard

[36] T62 p.13-14 Dr Walshe

[37] INQ 0011 0008; `Medical and Clinical Audit in the NHS'

[38] WIT 0049 0021 Dr Halliday

[39] HAA 0165 0145; `Working for Patients'

[40] HOME 0003 0130; `Working for Patients'

[41] WIT 0331 0004 Dr Winyard

[42] HAA 0164 0025; HC(91)2. `Medical Audit in the Hospital and Community Health Services'

[43] INQ 0011 0012; NHS Management Executive. `Steering the Audit Programme' (Internal Discussion Paper), 1991

[44] T62 p.15 Dr Walshe

[45] `Evaluating Audit: Provider audit in England: A review of twenty-nine programmes' 1995 CASPE Research. Illustration reproduced with the kind permission of CASPE Research

[46] INQ 0011 0012; `Medical and Clinical Audit in the NHS'

[47] INQ 0011 0013; `Medical and Clinical Audit in the NHS'

[48] Reproduced with permission from the author. `Evaluating clinical audit: past lessons, future directions', edited by Kieran Walshe, International Concerns and Symposium Series 212. Proceedings of a conference organised by the Royal Society of Medicine and CASPE Research, London, 27 April 1995

[49] INQ 0011 0013; `Medical and Clinical Audit in the NHS'

[50] INQ 0011 0014; `Medical and Clinical Audit in the NHS'

[51] INQ 0011 0013; `Medical and Clinical Audit in the NHS'

[52] WIT 0048 0119 Sir Barry Jackson.`The Royal College of Surgeons of England - Guidelines to Clinical Audit in Surgical Practice, March 1989' RCSE 0001 0051 (revised June 1995)

[53] INQ 0011 0013; `Medical and Clinical Audit in the NHS'

[54] INQ 0011 0014; `Medical and Clinical Audit in the NHS'

[55] INQ 0111 0015; Inquiry Paper

[56] See`The Reality of Practitioner-Based Quality Improvement', National Institute for Nursing, 1995, WIT 0042 0444 Mrs Jenkins, for an account of the development of tools for quality assurance

[57] See further below at para 117

[58] See Chapter 2 for an introduction to these reforms

[59] NHS and Community Care Act 1990, Section 5

[60] HOME 0001 0003; `The Patient's Charter'

[61] HOME 0001 0006; `The Patient's Charter'

[62] HOME 0001 0004; `The Patient's Charter'

[63] `The Reality of Practitioner-Based Quality Improvement', National Institute for Nursing, 1995, WIT 0042 0444

[64] UBHT 0273 0278; (EL(93) 59)NHSME circular, WIT 0108 0047 Dr Roylance, WIT 0120 0378 Mr Wisheart

[65] `Clinical Audit: Meeting and Improving Standards in Healthcare', DoH, 1993, p. 10

[66] UBHT 0028 0014; EL(93)34 NHSME circular

[67] UBHT 0028 0017

[68] Dr Ian Baker, then Consultant in Public Health Medicine at the B&DHA, was a member of the Working Group. He was a representative of the Faculty of Public Health Medicine on the Academy of Royal Colleges Committee on Medical Audit WIT 0074 0037

[69] HAA 0009 0089; `Audit and the purchaser provider inter-action'

[70] T62 p.51 Dr Thomas

[71] `Clinical Audit: Meeting and Improving Standards in Healthcare', DoH 1993

[72] Circulated under cover of EL(94)20, 28.2.94; HAA 0009 0026. The letter noted that the guidance was prepared by a working group of Regional Audit Co-ordinators and endorsed by COG

[73] `The Evolution of Clinical Audit', DoH 1994c

[74] T62 p.52-3 Dr Walshe

[75] UBHT 0028 0014; `Clinical Audit in HCHS'

[76] UBHT 0028 0018; `Clinical Audit in HCHS'

[77] This paper uses the terms DHA and FHSA but recognises the move towards unincorporated associations of DHAs and FHSAs in some regions which will undertake the functions described pending changes in legislation

[78] HAA 0009 0029; `Clinical Audit; 1994/5 and beyond'

[79] HAA 0009 0030; `Clinical Audit; 1994/5 and beyond'

[80] HAA 0009 0031; `Clinical Audit; 1994/5 and beyond'

[81] HAA 0009 0032; `Clinical Audit; 1994/5 and beyond'

[82] HAA 0009 0033; `Clinical Audit; 1994/5 and beyond'

[83] INQ 0011 0013; `NHS Executive: The New Health Authorities and the Clinical Audit Initiative: Outline of Planned Monitoring Arrangements' (EL(95)103) Leeds: DoH NHS Executive 1995

[84] Reproduced with the kind permission of the authors Walshe K and Ham C, `Acting on the evidence: progress in the NHS' , Health Services Management Centre, Birmingham: The NHS Confederation, 1997

[85] INQ 0011 0013