Final Report > Chapter 27: Care of an Appropriate Standard > The past: an absence of standards and of monitoring > Clinical audit: the policy and the practice

Clinical audit: the policy and the practice

8 The shortcomings of this approach have increasingly come to be realised. Relying on each individual to maintain his knowledge of the latest literature, research and best practice has become an unrealistic proposition with, on the one hand, the increasing complexity and variety of information, and, on the other, the growing demands on professionals' time to care for patients. Meanwhile, the variations in the outcome of healthcare which exist across the country today (to the extent that they are understood), serve as an indictment of the old way of doing things. In a patient-centred healthcare system, the standard of care patients can expect should be determined by something more than the capabilities of individual healthcare professionals and the vagaries of individual hospitals.

9 In 1989 the first attempt was made to introduce a more systematic approach to improving the quality of clinical care in the NHS. The DoH formally adopted a policy of requiring hospitals, and later trusts, to undertake medical, later extended to clinical, audit. The idea that clinicians should take time to reflect on their practice and make any necessary change to it was well accepted (if not widely practised or supported). The new policy introduced an element of formality. It was accompanied by ring-fenced funding, and local co-ordinating committees were established. At the time this was a significant step, but with the benefit of hindsight and experience we can now see how limited a step it was.

10 The story of the initiative to introduce a national system of clinical audit has not been a happy one. The ring-fenced resources were not always used effectively, and were sometimes deployed for other pressing needs, given the extremely tight financial constraints in the NHS generally at the time. Furthermore, the whole initiative was suspected by healthcare professionals of being a tool of managerial control. And, because participation was voluntary, the implementation of audit in any given hospital was fragmentary, with some clinicians participating and others not. The practice of clinical audit, if not the policy, came to be regarded by many as at worst a failure, at best, not a signal success. [6] Thus if clinical audit was the tool whereby performance and outcome were to be measured, both locally and nationally, its relative failure meant that, by the late 1990s, the NHS was almost as ill-equipped as ever to address the issue of quality. Patients have not been well served.

Footnotes

[6] See the Expert paper prepared for the Inquiry: Walshe K and Offen N. `An evaluative commentary on systems for review and audit at the United Bristol Hospitals/NHS Trust 1984-1995'. See Annex B 10m