Dr Mark Charny answers some frequently asked questions on clinical audit in general practice
How would audit be affected by a move to CHI?
Q What are the implications for audit if it is moved to the Commission for Health Improvement?
A In the NHS Reform Bill, the Government proposes the establishment of an Office for Information on Healthcare Performance (OIHP) within the Commission for Health Improvement (CHI). This follows the recommendations in Professor Ian Kennedy's reports1 on paediatric cardiothoracic surgery. It is not yet clear whether clinical audit will be included in the remit of the OIHP.
Whether or not clinical audit is moved to CHI, there is growing evidence of the Government's centralisation of information and performance management. For example, at the recent NICE conference Lord Hunt announced that implementation of NICE technology appraisal guidance would become compulsory for HAs and PCTs.
Central monitoring of clinical practice through audit is certainly unsettling to those who are not used to it. It has its dangers: for example, tight central control of prescriptions and referrals may mean that the doctor is no longer an independent advocate of the patient's needs but an instrument of bureaucratic policy.
On the other hand, there are changes in society which make this general trend entirely understandable and, perhaps, inevitable.
One of the obvious cyclical changes in the NHS is the tendency for centralisation to be followed by devolution, which is in turn followed by centralisation. I do not think that centralisation of information should cause any reasonably competent clinician to lose sleep.
As new treatments become available and new protocols are established, it is important for practitioners and their patients to keep up to date. Reasonable efforts to do this should avoid a situation in which one is found to be at the back of the pack. If this should prove to be the case in a particular area, demonstrating one's general competence will mean that improvements will be educational rather than disciplinary.
- Bristol Royal Infirmary Inquiry. The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995. Final Report. 2001. Summary at www.bristol-inquiry.org.uk
Role of patients in audit
Q Where do patients fit into clinical audit?
A Patients should be at the heart of clinical audit. Their views should form the basis of service standards and service organisation.
No enterprise can prosper unless it makes its customers central to its thinking and its design. That is not to say that patients' views should be accepted uncritically, but where professionals have other views, services are improved by working with patients to change their views rather than substituting their views for those of professionals.
Six new NICE National Collaborating Centres have recently been announced, with a remit to develop clinical guidelines and audit advice to the NHS. These cover acute care, chronic conditions, nursing and supportive care, mental health, primary care, and women and children's health. They all include patient groups as well as professionals.
Making patients central to audit is vital. Every clinician, in every encounter with a patient, should strive to see things as the patient does, and take it from there.