Final Report > Chapter 6: Quality, Standards and Information > Audit > A national policy on audit

A national policy on audit

9 The publication in January 1989 of the Department of Health's White Paper `Working for Patients' [4] set out plans for the creation of the internal market. The White Paper `Working for Patients: Medical Audit Working Paper No. 6', [5] detailed plans for a comprehensive system of medical audit within the internal market. As a result, efforts were made to encourage and to organise medical audit. Protected funding was made available, through regional health authorities, to support it. [6] Regional and district health authorities were asked to develop strategies, to set up audit committees and to produce annual reports on audit activity within their areas. But, reflecting the `deeply-rooted reserve' referred to earlier, it was accepted that audit should be carried out by healthcare professionals, that it should be voluntary and that the results should not be made known beyond the professional group.

10 The audit that was carried out was not systematic. It covered only certain services sometimes selected by the clinicians themselves and sometimes by the relevant audit committee within a hospital. Thus, information on which a view could be based as to what was adequate clinical performance nationally, so that local hospitals could assess their own performance (and be assessed by others), was virtually non-existent.

11 Policy on audit developed in the early 1990s and in November 1992 the first meeting of the DoH's Clinical Outcomes Group (COG) was held. It aimed to give strategic direction to the development of clinical rather than merely medical audit, aimed at encompassing a multi-disciplinary approach and to develop methodologies to identify and achieve improved outcomes. The subjects considered by the Group included: the implications of multi-professional audit; management aspects of clinical audit; producing a clinical audit handbook; and the development of audit in primary care. [7]

12 Anxious to allay fears that information could fall into the hands of management (a prospect which, at the time, was judged by many professionals to be unacceptable), the process of medical audit was insulated from management and put under the direction of doctors. Audit was represented as an educational tool, not a mechanism for accountability to the profession, the employer (the NHS) or to the public. As Ms Pamela Charlwood, Chief Executive, Avon Health Authority since 1994, stated to the Inquiry in relation to the early part of the period 1984-1995: `first medical audit and then clinical audit was an area of considerable professional sensitivity'. [8]

13 In 1993 the scope of audit was expanded; medical became clinical audit. Healthcare professionals from different disciplines were encouraged to come together to review the care given to their patients. But healthcare professionals remained sceptical about the benefits of the audit process, and concerned both about the practical problems of undertaking effective clinical audit and the use to which information might be put by management.

14 In 1993 trusts were told by the DoH that while funding for medical audit, nursing and therapy audit was to continue for 1993/94, an additional sum of £3.2 million was to be allocated for the development of multi-professional clinical audit.

15 Subsequently, there were significant changes to the method of funding which had an impact on the overall availability of resources. In 1994/95 funding for clinical audit was included in the overall allocation to regions, who were expected to maintain and develop clinical audit and were to be held accountable for it. Consequently, funding for clinical audit became part of the contract between the purchaser and the provider.

Footnotes

[4] HAA 0165 0145; DoH, `Working for Patients', London: HMSO, 1989 (Cm 555)

[5] HOME 0003 0130; DoH, `Working for Patients: Medical Audit Working Paper No. 6', London: HMSO, 1989

[6] Central funds for medical audit were distributed to hospitals through regional heath authorities on a capitation basis (whole time equivalent consultant numbers). £28 million was allocated in 1989/90 and again in 1990/91. The allocation rose to £49 million in 1991/92

[7] WIT 0482 0222 Dr Moore

[8] WIT 0038 0014 Ms Charlwood