Ben Bridgewater on why funding clinical audit is essential

“Observation affects reality” - the theory that the act of studying a process alters the outcome is well proven. In a healthcare system where the primary strategies for driving improvement have been target setting and researching new treatments, does this mean an opportunity has been missed? Can healthcare be improved simply by clinicians properly observing current practice?

Cardiac surgeons set about collecting simple data in 1977 but in recent years they have developed a professionally led audit database that benchmarks mortality outcomes. All units report and the database now includes outcomes on over 400,000 operations.

The sixth Society of Cardiothoracic Surgery national database report published this week, the first for five years, is a comprehensive analysis of this data, and includes examination of trends, risks and outcomes of patients undergoing adult cardiac surgery.

The results suggest that the very process of collecting, analysing and feeding back data to units has markedly driven improvements.

From 2001-08 the mortality rates decreased from 2.3 per cent to 1.5 per cent for isolated coronary artery bypass surgery, 5.2 per cent to 3.5 per cent for isolated valve surgery and 8.3 per cent to 6.1 per cent for combined valve and coronary artery bypass.

All these improvements are clinically important and statistically significant and are seen across the spectrum of risk - more elderly, obese and diabetic patients who might have been considered unsuitable for surgery in the past are being treated successfully.

It was accepted early on that the benefits were not just about bringing poor performers “into the pack”, but larger effects in improving the performance of the pack as a whole. This strategy seems to have worked.

The data will be useful for cardiac care teams and will support the informed consent process. As well as procedure specific analyses, the report investigates methodology for adjusting for case mix, essential to comparisons between hospitals or surgeons.

The society’s database initiative is clinically driven but the professional and political agendas are now converging, with Lord Darzi’s High Quality Care for All putting clinical quality at the core of healthcare delivery and at the heart of the Department of Health. Quality accounts are a core ingredient of this policy, and the data in the society’s audit will directly populate these accounts. That will drive quality further. And with the introduction of professional recertification these issues loom larger on the agenda of the surgical royal colleges.

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Clinicians and managers must recognise that some improvements are made just by reporting data, but accept that improvement is greatest and fastest if the concepts are embraced by the “team” and the team is managed well; there needs to be full clinical and managerial buy-in to the highest level of the trust, with good leadership supported by decent local and national IT with real time benchmarking and some local analytical capability.

So it is recognised that the process of reporting quality information drives quality improvement when led by the professions and funded nationally, but successful audits are few and many high profile audits, some funded by subscription or levy, do not have complete coverage of all hospitals. We must also wonder about organisations which decide not to submit to programmes designed to assure and improve quality.

Comprehensive nationally funded audit must be the goal, with transparency and public reporting.

Until recently the database initiative and other similar projects, while supported by national funding, have never seemed to really be an important part of NHS and trust policy, and developments were often solely due to local clinical champions.

Some groups had difficulty getting local resource, despite money available nationally through the DH.

While about £2.4bn is spent each year on educating the clinical workforce and £800m on research by the NHS, clinical audit attracts only about £6m of central funds. In an age of squeezed funding, there are strong arguments for national clinical audit as the most cost effective measure for ensuring patients receive maximum benefit for every pound spent.