National audits (Fig 71.2)

Over the years a number of national enquiries has been undertaken. The National Confidential Enquiry into Maternal Mortality and the National Confidential Enquiry into Perinatal Death are the ‘oldest’ of these audits. The National Confidential Enquiry into Perioperative Deaths (NCEPOD), which first reported in 1988, has examined surgical and anaesthetic deaths and made various recommendations. The return of information to NCEPOD has, to some extent, been voluntary. Under the most recent NHS reforms NCEPOD and the other National Confidential Enquiries will be controlled by the National Institute for Clinical Excellence (NICE). Moreover, participation will be obligatory.

The Royal College of Surgeons of England established a comparative audit service in the early 1990s. Surgeons contributed data confidentially and voluntarily to the service based at the College. Surgeons were ranked in order of number of a particular operation or number of complications, etc. Only the surgeons themselves were able to identify their own position in the ranking. During the period for which the ser­vice was offered the audits were changed from retrospective to prospective. The main disadvantage of the audits was that few (about 20 per cent) surgeons responded to the audits —the enthusiasts took part but the others saw no benefit.

Clinical governance

In simple terms clinical governance tries to answer the fol­lowing questions.

  Are we doing the right thing?

Are we doing it right?

  Are we measuring what is going wrong?

  Are we responding to this to make things better?

The National Institute for Clinical Excellence

A new National Institute for Clinical Excellence will be established to give new coherence and prominence to information about clinical and cost effectiveness.

The main roles of NICE will be to produce guidelines for clinical practice based on clinical evidence and associated with cost effectiveness. A number of stages of the work of NICE has been identified:

stage 1 — identification — which is subdivided into the introduction of new technologies into the NHS and their impact on healthcare, and examining current practice and to look for variations in quality;

stage 2 — evidence collection — ‘undertaking research to assess the clinical and cost-effectiveness of health inter­ventions’;

stage 3 — appraisal and guidance — examining the evidence and producing guidelines;

stage 4 — dissemination — distribution of guidelines and the methods required to audit their effect;

  stage 5 implementation — at a local level, through clinical governance and other approaches;

stage 6 monitoring — the impact and keeping under review, taking into account the views of patients and their representatives and any new research findings.

It can be seen from these stages that the work of NICE is massive and far reaching and will have one of the greatest effects on healthcare delivery since the inception of the NHS.

Commission for Health Improvement (CHIP)

The Government identifies CHIP as an independent statutory body that will monitor quality issues. The commission will have extensive powers to act ‘where there is evidence of systematic failure’. For clinicians to be able to justify their actions good quality audit data will have to be available.