Medical Education 1990, 24, 81-89

REPORT

ASSOCIATION FOR T H E S T U D Y OF MEDICAL E D U C A T I O N

Workshop on Medical Audit, Royal College of Physicians, London, 19 May 1989

K. M . PARRY

Scottish Council for Postgraduate Medical Education

The Chairman, Mr Terence English, introducing the workshop, indicated a change in emphasis in medical audit, from its long-established pro- fessional educational purpose towards better documentation of practice for the determination of the use of resources and the cost implications. This required more sophisticated outcome measurements than are presently available to enable proper cost-benefit analyses to be undertaken.

Government and audit

Dr Geoffrey Rivett outlined the Government’s proposals in its Working Papers on Medical Audit (1989a, b). The Department ofHealth was keen to stimulate discussion, as indicated in the earlier White Paper on primary health care (1987). The Government’s responsibilities were to provide good quality service and to take any necessary steps needed to ensure public money was well spent. As shown in many other coun- tries and in other spheres of work, the search for quality should transcend merely the rejection of work products and the pursuit of basic consumer satisfaction - it should be an endeavour to achieve the best possible results. Such an aim could not be imposed but should arise from within human activities. Audit was solely about the achievement of standards; it involved per- sonal responsibility for the ‘systematic, critical analysis of the quality o f medical care, including

Correspondence: Dr K. M. Parry, Scottish Council for Postgraduate Medical Education, 8 Queen Street, Edinburgh EH2 lJE, UK.

the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and quality oflife for the patient (Working Paper on Medical Audit 1989a, b)

There was open acceptance of a need for cooperation between managers of the health service and the medical profession on audit. Doctors should own, design and oversee medical audit and should investigate problems o f care, tackling them within a framework and with resources provided by management. This should not be a paper-chase; problems which really mattered needed to be clearly identified, within the context of confidentiality to patients and doctors, as enshrined in the long-established maternal mortality reviews. Audit was about peer review and needed effective organization. It was basically an educational matter, and remedial action should not be ignored. The profession accepted that audit was not an optional extra and should be accepted as an essential part of pro- fessional work. It was reasonable for the public to expect National Health Service (NHS) staff to be self-critical. Many doctors were involved in some form of audit, and it was now time for this to be undertaken by the whole profession.

Dr Charles Shaw described the general accept- ance worldwide o f quality assurance. It was part of professionalism, and although established long before the present Government’s White Paper, it now needed the better use o f peer review in which doctors gained practical experi- ence. The public was also interested in quality assurance in health care for its own interests - just as it rightly expected that airline pilots provided a ‘safe’ service. Government influence

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over the development of audit should be seen both as an overall strategy for quality assurance and as a means of providing evidence to improve resource management.

Quality assurance followed a cycle of compar- ing practice with the expectations of health care, leading to the implementation of change, and a redefinition of expectations. It was of no value to embark on issues, often behavioural, unless there were reasonable expectations of change, and such changes should be vigorously pursued. Inputs - such as manpower, the number of beds, and equipment - should be measured together with the process of care, set against definitive out- comes. These should be expressed in terms relating to patients’ as well as to doctors’ wishes, which may not necessarily comply with each other.

District health authorities were only indirectly concerned with clinical review, many factors of which were beyond managers’ comprehension. External review should be explicit in terms of quality assessment, to which remedial action should be directed, with direct action under managerial control. Clinical review should be more specific, and include explicit criteria, objective assessment and comparison between peers leading to specific changes through critical discussion and identified responsibility. Docu- mentary processes were important so as to ensure that initiatives were not lost, and verifiable evidence provided to, for instance, royal colleges for their use in accrediting training programmes. Brief audit summaries should indicate clearly what had been found out and what was to be done.

Key factors in medical audit were agreement as to responsibility, including links with medical education and with general management. Its medical organization should be efficient and not overweighted with committee work, allowing scope for participation by both junior and senior doctors. Procedures should be seen to be effective, and adequate resources of time and technical facilities fully provided. Documen- tation should show that the system worked well, bringing about demonstrable changes which should be adequately evaluatex

In discussion, Dr Shaw proposed that the application of audit should depend on the sever- ity and importance of a particular health condi-

tion, which should usually be by way of a sampling process. Usually it was unrealistic to audit every incident of care, but particular issues - such as high cost care, issues with wide discrepancies, and matters of general concern - warranted investigation. Audit differed from research; the latter was in pursuit of universal truth, and needed a vigorous approach, whereas audit applied principally to local circumstances. Professor Ronald Harden suggested an earlier stage for the preparation of doctors €or change, and their awareness of anticipated adaptation. Agreeing, Dr Shaw stressed that lack of know- ledge was far less at the root of problems than willingness and ability to adapt.

Physicians and audit

Dr Peter Beck described the work of the Royal College of Physicians audit group (1985). Many general physicians were uncertain as to the value of audit and were concerned about the purpose for which it would be used. The Alment Com- mittee’s (1976) definition of audit was less threat- ening than a strictly legal interpretation, and medical audit should be accepted as the ‘sharing by a group of peers of information gained from personal experience and/or medical records in order to assess the care provided to their patients, to improve their own learning and to contribute to medical knowledge’. Evaluation was des- cribed by the World Health Organization as ‘the systematic‘and scientific process of determining the extent to which an action or set ofactions was successful in the achievement of pre-determined objectives’. The College’s Working Party had described the structure of audit, which included input (e.g. resources, such as equipment, staff, etc.), process (e.g. activities such as the adequacy of case-notes, appropriateness of investigations, the suitability of medication) and outcome (e.g. results of clinical interventions, infections rates, residual disability, etc.).

An enquiry by questionnaire to college tutors had given an indication of the extent to which physicians were taking part in audit activities, and a number of reasons why there was antipathy to some of the Working Party’s proposals, including audit mechanisms, how patients and doctors would benefit, and some doubt as to whether auditing procedures provided better

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solutions to other methods of clinical review. The College’s overall proposal was that the medical audit recommendations should ensure that the practice of individual doctors complied with the highest standards. Specific proposals included audit being established for all physicians as soon as possible in all regions, that it should be required by accrediting bodies, that clinical. review should be established on a regular basis within each medical division, and that the College’s Research Unit should identify topic areas for larger-scale studies. Medical audit should be a regular activity, with the random selection of cases and a review of specific activi- ties. Criteria for the latter should include common conditions and those of particular importance, both of which should be readily defined and assessed. Outline proformas had been prepared for regular audit meetings, which included details of in-patient admissions, basic documentation, lists of investigations and treat- ment, descriptions of patient education and welfare, and discharge information to general practitioners.

The College’s proposals for medical audit applied particularly to consultant practice, which although closely related to the Government’s initiative, had a different emphasis. The main thrust was to improve the care of patients and medical education.

General practice

Dr Donald Irvine described the situation in general practice. Over the past 20 years the Royal College of General Practitioners had developed its interest in the assessment offamily doctors as a direct consequence of the evolution of vocational training for general practice. An important element in such training was the period spent with a general practitioner trainer who was chosen on the basis of his personal attributes as a doctor and teacher, and on the quality of his practice. It was the recognition of the individual trainer rather than the training post - different from the custom in other specialties- which had led inevitably to the system of peer-based stan- dard setting and performance review which was currently operated by the regional postgraduate organizations co-ordinated by the Joint Com- mittee on Postgraduate Training for General

Practice. This standard setting and monitoring system could alter the behaviour of trainers in general practice, partly because participating doctors wanted to make it work, and partly because the regional postgraduate committees had the responsibility for reviewing and re- newing individual trainer appointments regularly. In the early years the criteria (stan- dards) for selecting trainers were essentially structural, concerned with such matters as the practice premises, stafing, equipment and records.

More recently there had been more emphasis on the processes of care as demonstrated, for example, through the appraisal of randomly selected patient records and the analysis of prac- tice activities such as prescribing, hospital referrals and the use of laboratories. Work had only just begun on the development of outcome measures in primary care and the task - as for physicians and psychiatrists - seemed more difficult than for surgeons because of the nature of the clinical problems which were most fre- quently presented to the family doctor. In the early 1980s the College, concerned about the very wide variations in care provided by general practitioners, began its ‘Quality Initiative’ (Council of the Royal College of General Prac- titioners 1983). This was an invitation to College members to develop the habit of setting explicit working standards for patient care in their own practices, and to monitor their compliance with these through clinical audit. Subsequently, standard setting and clinical audit were put in the context of a broader College policy for the development of quality in general practice (Royal College of General Practitioners 1985).

At about the same time the College began to develop its ‘What Sort of Doctor’ method (1985) of practice appraisal, essentially a structured practice inspection in which the practitioner was asked to report on andjustify the results ofcare to visiting colleagues. Meanwhile, Northern Region trainers were joining with paediatricians and health-care researchers to begin the Northern Regional Study of Standards and Per- formance in General Practice (Irvine et al. 1986). The object of this study was to develop methods for working out clinical standards for common conditions in childhood, incorporating both pro- cess and outcome measures, and also the means

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for measuring physician compliance with such standards through the feedback of data abstracted from patient records. The study, incidentally, also included a large-scale survey of the parents of the children involved, designed to assess parent satisfaction with care given and to give an independent appraisal of the outcomes of care.

Looking ahead, it seemed that general practice was fast becoming a managed system of primary health care in which practices were expected to have the capacity for knowing what they were trying to do, where they were, and whether they achieved their objectives. Setting working stan- dards and auditing compliance with these were, therefore, becoming an integral part of the management process. It would inevitably be difficult, therefore, to separate the clinical and educational aspects of audit from managerial issues. Elements of quality involved general managerial arrangements, individual doctor’s practice management, responsiveness to change, and lines of accountability, including linkage with other professions. A change of attitude was necessary, coming to terms with external in- fluences in general medical practice. Audit methods were not confined to testing a clinician but included measures of finding out ways of responding to questions for which there may not be clear solutions, and this involved more than the doctor concerned, including other pro- fessions with whom he worked, and resources for practice. It was important to compare objectives with actual results, so that audit became an educational process, enabling bodies such as the College and regional postgraduate committees to determine explicitly its effect upon practice.

Maternal and perinatal mortality

Dr John Lawson described medical audit by maternal and perinatal mortality enquiries. Obstetricians had a long tradition of auditing results, based on the intention that there should not be casualties in child-bearing. Audits of obstetric and perinatal care were based on a defined end-point - that of death - which may not be entirely appropriate for other clinical disciplines, in which care could not always be life-saving. Audit of maternal and perinatal

deaths was intended to be educative, for which very exact diagnoses of causation were required. Identification of failures in preventing deaths because of defects in clinical practice was educa- tive, but inevitably a shortage of resources and administrative failures also came to light.

The results of the confidential enquiries into maternal deaths in England and Wales had been published triennially by the Department of Health since 1952 (Irvine et al. 1986), and would in future include maternal deaths in Scotland and Northern Ireland. Enquiries into a maternal death were initiated by a district medical officer who sent large enquiry forms to the consultant concerned, providing him with an opportunity of reviewing errors of management or faults in the organization of the service to prevent a similar death in future. The comments of the general practitioner, midwife, health visitor or community physician involved were included, and the completed form sent to a regional obstetric assessor. He added his comments and opinions on the cause or causes of death and the completed forms sent to the chief medical officer of the Department of Health, with the exclusion of all names to ensure confidentiality. A small panel of central assessors made final assessment of the factors leading to the death. This included identification of ‘substandard care’, which may be either deficiencies in clinical care or admini- strative failures in the maternity services. Mater- nal mortality due to direct, indirect and fortuitous causes was assessed accurately, but case morality, e.g. from Caesarian section, ecto- pic pregnancy, obstetric operations, could only be estimated from the 10% sample in the hospital in-patient enquiry. These denominational defi- ciencies limit the education value of this system of audit.

When published the triennial reports were widely circulated though the extent they were responded to was not known. T o ensure co- operation criticism of clinical management of identifiable cases was avoided, and no comment or advice on individual cases from the regional assessors presented to the clinicians involved. The confidential enquiry system was an external audit, and thus did not have the educational advantages of internal audit or peer review. Decline in maternal deaths in England and Wales had been spectacular (maternal mortality of 69.1

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per 100000 total births in 1952/4 to 8.6 in 1982/4). The general standard o f obstetric care had cer- tainly improved, but it would be wrong to attribute much of the decline in mortality to the educational effect of the enquiries. The main factors had been the virtual elimination of home delivery, the discontinuation of criminal abor- tion since the 1967 Abortion Act, and great reduction in the number of high-risk elderly grand multiparae due to the wider use of steri- lization and other forms of contraception.

Regular meetings to review perinatal deaths were held in most obstetric units, attended by obstetricians and paediatricians and their junior and associated professional staffs. This form of internal audit was intended to be educative. In Scotland a national perinatal mortality survey was based at the General Register Office where details of still births and neonatal deaths were received monthly. Requests for clinical infor- mation were sent to obstetric and paediatric consultants in 25 major maternity units in Scot- land, and an annual report published. Each hospital unit had a nominated coordinator who supplied detailed information, the results for each clinical heading being shown separately for each health board. In 1980 the Northern Regional Perinatal Mortality Survey had been developed from the monthly reviews of perinatal deaths conducted in nearly all the 20 consultant obstetric units in the region. A central coordinating com- mittee worked with local review teams consist- ing in each unit ofan obstetrician, a paediatrician, a senior midwife and usually a community physician. The local team completed details of each perinatal death which was sent to the regional headquarters and reviewed by one or two key members o f the central committee. Minatory comments on individual perinatal deaths were not made, judgement on preventa- bility being left to the local review teams. An annual report was published as quickly as pos- sible by the regional health authority, widely circulated and discussed at a well-attended open meeting each year. The purpose of the survey was to analyse clinical factors responsible for perinatal deaths rather than to investigate the facilities available for dealing with them, although service provision needing to be cor- rected could come to light. Topics for special enquiry were identified each year, and these had

included antepartum still births, neonatal deaths associated with very low birth weight, intra- partum infection, twin pregnancies and congeni- tal malformation. Since the survey had been in operation perinatal mortality has declined by 10% annually, from 13.4 per 1000 births in 1981 to 8.3 in 1987. The outcome for very small babies had improved and long-term morbidity was being investigated. This study, unlike the main perinatal mortality survey, required special funding by the regional health authority. The collaborative review oflocal experience provided all the educational advantages of internal audit, but its continued success depended on the interest and enthusiasm of all participating obstetricians and paediatricians and good cooperation with the officers of the Regional Health Authority.

Audit in surgery

Mr Stephen Nixon outlined the evolution of surgical audit in Lothian. Particular attention was being given to variation in the percentage o f deaths which were regarded as potentially avoidable, as shown in the Confidential Enquiry into Perioperative Deaths (CEPOD) (1988). Interest in audit was in the quality of care provided, not simply the efficiency with which services were used. Audit required the collection of data, their analysis and discussion, followed by conclusions which included the implemen- tation of effective action. The system should be reliable, rapid and relevant to surgical practice. Data had tended to be collected inadequately despite audit activities which had started at the Royal Infirmary in Edinburgh in 1946. Unit annual reports had been issued from 1950, and a structured data collection introduced in 1978 which included the coding of operations. Central compilation of data was undertaken in 1983, leading to surgical/anaesthetic coding, assisted by microcomputing provided by the Health Board. Experience in the Lothian region led to the introduction of a pilot Scottish mortality study in 1988.

A coding system had been developed for all surgical operations, and this formed the basis for a special record if a death occurred, using a standard data set which had shown a high degree of accuracy. The data identified dangerous operations, faults in surgical technique, and

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causes of death attributable to the operation and to patient management factors. Aggregation of data enabled trends to be analysed, e.g. identify- ing the number of recurrent hernias as a percen- tage of total herniorrhaphies, trends in elective duodenal ulcer surgery, and the volume of colorectal resections. The data enabled individual doctors to compare their results with those of others, and the different factors which affected results, e.g. the audit had shown differences in the outcome of the work of general and vascular surgeons treating aneurysms, resulting in a signi- ficant shift in attitudes to and responsibility for surgical treatment, with a consequent change in the establishment of vascular units, accompanied by a fall in mortality from vascular treatment. The annual audit reports, using an agreed oper- ative/pathology index, had significant effect on manpower planning.

The surgical audit was providing a basic foundation for an overall view ofperformance. It now needed to be extended from mortality studies to morbidity. This had to be simple to ensure the willing cooperation of all surgeons, relying on basic, factual information. The dis- tribution of morbidity parameters should be plotted, e.g. gall bladder complications, and this should provide one way of looking at the quality of care being provided. Attempts to collect detailed information daily were generally too complicated and time consuming, and selectivity was important. The Scottish Mortality Study, supported by the Chief Scientist Organization, was a pilot scheme to collect data on deaths in general surgical units. The main purpose of this study was educative and had been greeted with enthusiasm. It differed from the CEPOD study in a variety ofways, most importantly that it was confidential rather than anonymous, compliance in completing documentation was ofthe order of 98% and data were rapidly collected, analysed and returned to contributors whilst memories remained fresh.

In discussion it was proposed that although each unit may prepare annual reports, it was important, particularly for specialties, to compare results with other units nationally, so that each could check its own data with national figures. Despite some problems of confi- dentiality mortality figures should be published for national comparative purposes. Crude death

rates were insufficient, and epidemiologists should analyse data to ensure their validity.

Patient ‘satisfaction’ should be taken into account, and as this was in relation to personal contacts as well as technical proficiency, it would be a matter for both clinical and managerial audit. Doctors work with nursing staff and others in patient care. Each health-care professional was able to make a significant contribution to audit studies and close cooperation should be encouraged.

Management and education: a balance in audit

Dr C@od Batstone discussed the balance between education and management issues in medical audit. Although there was general enthusiasm for audit, some consultants doubted its value, and ‘fitted in’ with arrangements rather than dealt with clinical matters appropriately. Perso- nal interest needed to include conviction of the value of audit, and corporate effort to make sure that it worked effectively, with adequate pressure to ensure participation. However, making audit mandatory would only elicit grudging, token responses which would be neither educationally nor managerially valuable. Lack of time was the most likely response, and it was important to make audit activities exciting, not burdensome, relevant, and seem to be to improve the quality of care. Consultants’ percep- tion should be that participation was not just a time commitment, with participation having a clear educational or managerial significance without adversely affecting clinical freedom.

An educational orientation of audit should promote universal medical acceptance, and this may require linkage to programmes of con- tinuing medical education. The latter was at present somewhat disorganized, and district education committees should identify gaps in medical knowledge which should be remedied. Task-based learning should link clinical work with educational activity, and this should apply equally to audit, setting up programmes linked with tutorials for education.

The managerial aspects of audit could lead to changes in clinical practice, but this should be promoted and/or effected by medical direction.

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To promote the development of audit consul- tants should be prepared to reorganize their time in a working day for audit purposes, and audit committees should work under the umbrella of an educational organization, with the appoint- ment of a consultant as an audit facilitator who would need an assistant. Computing services needed to be appropriate for recording consul- tants’ work, and information technology developed to accommodate data for specific audit purposes. The consequences would be a dimi- nution of time for some clinical services, and commitment to district financial contribution for the audit facilitator, his assistant, computing and information technology. A model cost for a district serving a population of 300000 may be a half session for each of 60 consultants and 60 junior staff, three sessions for the audit facilitator and, say, &20000 for the assistant and computing facilities - a total of C212000, together with support from postgraduate centres, their staff and hospital information systems. In terms of value for money this should be acceptable if audit improved clinical services, enhancing quality and promoted total quality control.

Open questions about the nature of audit included whether it should apply to single or multidisciplinary groups, to single or multi- professional activities, whether it should con- sider process as well as the outcome of care, and whether audit groups should deal with specific cases, process groups or general issues. In his view, Dr Batstone felt that audit should be multidisciplinary and professional, with a gen- eral approach as a way into developing audit activities. The first task in audit design should be to set standards for the conduct of audit activities, to collect adequate data, prepare their analysis so as to identify specific problems on which re- medial action should be taken and followed up. As to choice of topic he proposed the frequency ofa disorder (e.g. asthma) should be considered, risks associated with poor practice, perceived problems, advances in forms of treatment and diagnosis, the use of drugs, and the deployment of resources which raised quality issues. The appropriate response to problems would be to ensure feedback for information and discussion. Lack ofknowledge and skills should be remedied educationally, motivation by counselling, adapt- ation of procedures by way ofspecific protocols,

changes of systems of care through the restruc- turing of services, and the adaptation of resources by reordering priorities.

Audit skills

D r Gerald Fowkes described skills and expertise for audit in clinical practice. There were basic mechanisms for undertaking audit, which needed key skills. The Government’s working paper defined audit as a ‘systematic, critical analysis of the quality of medical care. . .’ but this definition did not emphasize the purpose of audit. Dr Fowkes felt that the purpose was more than that stated in the Alment Report (1976). ‘a means of ensuring through peer review that information gained from personal experience and/or medical records of the care provided to patients improved learning and contributed to medical knowledge’. But the most important purpose was for improved practice. The audit cycle was involved in more than observing practice; it included setting standards of practice, comparing this with actual practice, deciding on and implementing change, and following up by further observation of practice (Fowkes 1982).

What to audit should relate to the use of resources and the outcomes of care, selecting common conditions, which should include those which were measurable and definable, and accessible to data collection. Standards should be agreed and changes made possible through effective action. Clinical practice should be observed through representative samples, and measurements valid and reproducible. Data col- lection should be from identifiable sources, using standardized forms, and should be effectively managed and analysed through statistical tests. Standards may be set at different levels - ideal, normative and minimal - and the format of standards should be predetermined, whether a general guideline or a specific one such as an algorithm. Comparing practice with standards affected the audit procedure. An explicit method required objective assessment, leading to direct comparison between an agreed standard and observed practice, e. g. determining the manage- ment of hypertension or urinary tract infections, an explicit method would assess whether pre- defined criteria were being met. An alternative approach was through an implicit method,

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assessing subjectively, in which the quality of observed practice was assessed without a pre- defined standard being set. Changes in practice should be implemented by traditional edu- cational methods or by feedback to clinicians on their individual performance. Alternatively protocols could be prepared providing guidelines, check-lists and/or algorithms for changes in practice.

These changes could be induced by providing incentives or by imposing sanctions; in some schemes in the United States certain criteria were checked daily by an auditor, and sanctions applied if they were not applied, e.g. the length of patients’ stay in hospitals. Strategies for imple- menting guidelines had been published, e.g. on the use of pre-operative chest X-rays (Fowkes et al . 1986) and included the establishment of a utilization review committee, direct feedback provided to consultants, to the introduction of a new X-ray request form, and concurrent review of requests by radiologists. Dr Fowkes stresses the value of audit in determining constructively how the quality of care was improved. To be effective audit needed a formal mechanism, with specific knowledge and skill of audit procedures, backed by epidemiological and statistical methods.

In discussion it was agreed that standards should not be rigidly determined or imposed, allowing for innovation and adaptation to local circumstances. Audit should compare what was done with what could and should be done, and effective changes promoted by an illuminative process. Guidelines should be backed by research into alternative solutions, which should also create a climate of opinion acceptable to the profession which would encourage adaptation to change. Much of medical practice was not audi- table, and it was essential to adapt medical records for effective audit purposes.

Professor David Shaw discussed the question of audit in relation to the universities. Clinical academics had roles that were often similar to those of their NHS colleagues but the pro- portions of their time devoted to service, teaching and research tended to differ. By virtue of their academic interests they were inclined to find themselves involved in scientific meetings, examinations, research committees, College working parties and suchlike, probably to a

greater extent than the majority of their NHS counterparts; absenteeism amongst the pro- fessoriate was a feature of most medical schools. The prospect ofthe tightly defined commitments that could result from management audit in a contract-based service was thus a source of some anxiety - not least because of the unpredictabi- lity of many of these outside activities. Just as audit was now high on the agenda in relation to medical care, so too it was becoming a require- ment in the realms of teaching and research within the universities. The development of performance indicators in relation to teaching, although fraught with difficulties, was being pursued; academic staff appraisal was now a standard requirement in universities and the promotions procedures gave a competitive edge to performance. So too in research, better methods of management and greater insistence on value for money were becoming accepted. Completion rates for PhDs were now monitored by Research Councils.

The 1980 ASME Conference on ‘Audit as Continuing Medical Education’ had recognized the important relationship between the two. It had identified many of the steps to be taken to achieve the conceptual linkage and it had noted some of the potential barriers to progress. It had recognized that the universities had a particular responsibility to ensure that their undergraduate students were attuned to the concept of an education that continued throughout their working lives.

Whilst some progress had been mad,e, there was still a long way to go. The difficulties were not to be underestimated, but it was probably true that the tardier the development of audit as an educational process, the more powerfully it would emerge as a management tool.

General discussion

The Department of Health was looking at the NHS as a whole and should make statements about overall objectives to assist in identifying the need for change. This could best be led by the royal colleges, with audit being a means of monitoring clinical practice. The assessment of practice should differentiate between intuitive judgements and objective criteria for evaluation. In education generally assessment methods could

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have a negative effect, and should differentiate from a participant’s ‘wants’ and ‘needs’ - it was educationally beneficial if a ‘teacher’ enabled a ‘student’ to discover what he needed to know. As the General Medical Council’s (1987) ‘Recom- mendations on Specialist Training’ had indicated audit should include ‘staff assessment as well as ‘work’ assessment, and this should be taken into account in peer review. Personal check-lists should be designed for ‘self-audit’ to enable participants to prepare themselves systema- tically.

The link between education and professional practice was a crucial issue. The mood of the profession was to develop audit as part of an educational process, but this differed from audit for managerial purposes, which tended to over- ride personal preferences and was a challenge to professional independence. There was genuine concern in overcoming poor practice but did this require a contractual commitment to participate in audit? Audit activities were widespread, and these needed to be related to the Government’s proposals, taking into account managerial issues. The general sympathy was for audit to be medically led, but managers should be associated in a constructive way. The profession, with the support of the royal colleges, should tackle without delay the audit issues raised by the Government. This should include defining the resource implications which had not been detailed in the Government’s Working Paper. It was agreed that this should receive much more detailed attention.

Summarizing, Sir Peter Froggatt proposed that the workshop proceedings should be widely publicized so that medical audit could be seen clearly in a socioeconomic perspective. The doctor-patient relationship should be perceived in a supplier-consumer context, with public expectations given greater emphasis than a restricted professional one. There was today

much public interest in the professions, and a populist view of sharpened public accountability. The overriding issue should be the maintenance of the profession’s standing through education, but concern for malpractice could become inhibiting to professional free- dom, with the imposition of externally applied regulatory mechanisms.

References

Competence to Practise (1976) Report of a Committee of Enquiry set up for the medical profession in the United Kingdom (Chairman: E.A.J. Alment) What sort of doctor? Assessing quality of care in general practice (1985). Report from General Practice No 23. Royal College of General Practitioners, London.

Confidential Enquiry into Penoperative Deaths (1988) Report, Nuffield Provincial Hospitals Trust and King’s Fund.

Council of the Royal College of General Practitioners (1983) Council policy on quality in general practice. Royal College of General Practitioners 33, 523-4

Fowkes F.G.R. (1982) Medical audit cycle: a review of methods and research in clinical practice. ASME Medical Education Booklet No 15, Dundee. ASME, Medical Education 16, 22S38.

Fowkes F.G.R., Davies E.R., Evans K.T. et al. (1986) Multi-centre trial of four strategies to reduce use of a radiological test. Loncet i, 367-70.

Guidelines to Clinical Audit in Surgical Practice (1989) Royal College of Surgeons of England.

HMSO (1987) White Paper on Primary Health Care. Promoting Better Health.

HMSO (1989a) Working Paper on Medical Audit No 6. Working for Patients.

HMSO (1989b) Scottish Working Paper on Medical Audit No 2. Working for Patients.

Irvine D.H., Russell I.T., Hutchinson A. et al. (1986) Educational development and evaluation research in the Northern Region. In: In Pursuit of Quality: Approaches to Perjormance Review in General Practice (ed. by D. A. Pendleton, T.P.C. Schofield & M.C. Marinker). Royal College of General Practitioners, London.

Royal College of General Practitioners (1985) Quality in General Practice, Policy Statement 2. Royal College of General Practitioners, London.