The emerging role of clinical audit.

Over the last twenty years the NHS has been coming to terms with a plethora of initiatives designed specifically to improve the quality of clinical practice. The names have changed frequently as new groups of management gurus have come up with remixes of old tunes. One set of activities has been about determining and prescribing what to do and how to do it. Approaches such as evidence-based medicine and getting research into practice have led to the production of clinical protocols, guidelines and standards. Process re-engineering has led to clinical pathways that ensure care is focused or centred on the patient and thus appropriately managed. Other initiatives have been concerned with reviewing what went on. Medical audit rapidly metamorphosed into clinical audit. Indicators have been developed to measure and assess clinical performance, some of which are related to health outcomes. External benchmarking has been introduced so that local activity can be compared with that elsewhere. Until recently, these initiatives were being implemented piecemeal without an overarching methodology. This has now been corrected by the mechanisms described in A first class service: quality in the new NHS1. Underlying an integrated approach to the improvement of clinical care are a number of basic processes, shown in Box 1, that have now been brought together within the national service frameworks and are being implemented by the clinical governance approach. Thus, involvement in clinical audit is now compulsory, involving all health professionals. It is no longer solely an educational pursuit but, through clinical governance, a mainstream part of management. In addition to local studies, clinicians are expected to audit nationally chosen topics laid out in the service frameworks that involve comparisons with other places. The progression from the first mention of reviews of clinical practice, to the 1960/1970s (cogwheel) reports of the joint working party on the organisation of medical work in hospitals2, to the present day has been a triumph of pragmatism and opportunism. Although coherent theories of how best to evaluate care have been around for a long time, actual practice has been determined mainly by the tension between a profession fighting a rearguard action to keep these matters professional, and politicians and senior NHS managers bent on taking a central role in the review process.