Dr Mark Charny answers some frequently asked questions on clinical audit in general practice
Q With more and more bean counting organisations, is there any point in doing audit?
AThe list of organisations checking up on the NHS is getting longer and longer. Right now, even an incomplete list is awesome:
- Commission for Health Improvement
- Audit Commission
- National Audit Office
- Department of Health regional office performance management teams
- Health and Safety Executive
- Royal Colleges
- Postgraduate deans
- National task forces checking on standards for clinical groups
- Complaints investigations panels
- Local MP
- Local community health council
- National Patients' Access Team
- Modernisation Agency
- National Clinical Assessment Authority
- National Confidential Inquiries
- National Patient Safety Agency
Some of these (e.g. the police or the ombudsman) investigate when something has gone wrong (or is alleged to have gone wrong). Others, such as the Royal Colleges and postgraduate deans, are intended to be more proactive. Yet others, such as the Commission for Health Improvement, have a mixed role.
This patchwork of organisations is not well coordinated. And despite the emphasis on a 'no-blame culture', and the idea that preventing mishaps is better than investigating them after they have happened, the reality is that – for practical reasons if no other – the system remains biased towards enquiring into things that have gone wrong.
None of the new bodies makes clinical audit any less important than it was. To get the best out of clinical audit, GPs should voluntarily share data about patients, to help one another get a broader perspective than anyone can get from examining their own work in isolation.
Through peer review, GPs should also discuss different ways of doing things so that audit is a learning experience as well as a data collection exercise. This is good medical practice, and will help to ensure that no-one gets too stuck in their ways, and that, where practice is not as good as it should be, it can be changed for the better before the bean counters arrive.
Q We have just completed data collection for an audit on coronary heart disease, and one of the partner's results are much worse than the rest. He now refuses to participate in peer review. What should we do?
A The answer depends on the detail of the circumstances. Assuming that the standards were adopted by all participants when the audit was planned, and there is no dispute about the data, the problem is one of handling personal relationships with the individual concerned.
It is important to make sure that the behaviour you describe is not due to ham-fisted approaches to peer review and discussion. For example, if one or more of the partners is rather domineering and there is a history of difficult interactions over clinical matters, it may be important to see the problem in a broader context than just the audit itself.
If this is the position, you may need to review the whole process of audit and peer review. I have known practices that have benefited from inviting a facilitator to help them restore personal relationships to the sound footing required to enable people to address difficult subjects.
Where someone's practice appears to be unsatisfactory, and especially when it is out of line with other colleagues' practice, as you describe, you need to be particularly careful not to make the individual concerned feel like a dunce in the classroom, and not to put them in a position where they feel humiliated and on the defensive.
In some circumstances, it can be very useful to approach a senior colleague from another practice, perhaps the clinical governance lead from your primary care organisation, and arrange for a discussion to take place outside the normal peer review arrangements.
Of course, if your colleague's practice is unsatisfactory, and you cannot find any way to engage him or her in a discussion and necessary changes, or if there are disagreements between you on the need for change, which cannot be resolved using this low-key method, you are obliged to take steps to report your concerns to someone who can take action.
If you do not, and patients come to harm as a result of your colleague's practice, you may yourself be criticised in due course for sitting on your hands.
Q What involvement does NICE have in clinical audit?
A NICE is best known for its technology appraisals, on which it has concentrated initially. However, it is also responsible for developing clinical guidelines on best practice, and for promoting clinical audit.
Specifically, it is responsible for funding and overseeing the National Confidential Enquiries, and for the audits carried out by the Royal Colleges (the 'national sentinel audit' programme funded by the Department of Health in 1997).
As the technology appraisal programme has become better established, NICE has begun to take more of a lead on clinical audit than it did in its first 18 months.
Its new audit programme, recently announced, will cover continence and parenteral nutrition. Audit topics on which NICE is already working include the myocardial infarction national audit project, and audits on caesarean section, coronary heart diseage in primary care, sudden unexpected death in epilepsy, and quality indicators for diabetes services.
There is obviously a close link between clinical guidelines and clinical audit (which many articles in Guidelines in Practice have emphasised). One of the problems for NICE is that it is not charged with implementation, and therefore it has to leave to others the responsibility for initiating and monitoring practical work at the coal face.
In due course, NICE is bound to have more influence on clinical audit as well as on standards of clinical practice generally, although this may be carried out through one or more groups, including those listed in the first question (see above).