NEWS FOCUS: The number of organisations jostling for the right to audit parts of the NHS has reached epidemic proportions.But if the future brings a cull, where will the knife fall? Lyn Whitfield takes a look

Never let it be said that the world of bean-counting is dull. Behind the smooth facades of the health service's scrutiny bodies lies a world of plot and intrigue. An exaggeration?

Not according to one source. 'Turf wars' are being fought in Whitehall, he claims, and 'cries of anguish' can be heard as organisations jockey for position.

One factor responsible for this unlikely situation is the sheer proliferation of bodies with a remit to pore over the workings of the NHS (see pages 10-11).

The Institute of Healthcare Management submitted a list of 20 to 'part two' of the Bristol Royal Infirmary Inquiry - and chief executive Stuart Marples admits he could 'come up with 20 more if I put my thinking cap on.'

Audit and scrutiny is now a crowded market, and there is widespread concern about overload.

As Mr Marples puts it: 'There is a danger of us having more people looking at the doing than people doing the doing.'

And There is the rub. Rationalisation dictates that some organisations must lose parts of their 'empire' and/or work to new agendas. Hence the 'turf wars' - which have intensified since the publication of the Kennedy report into the Bristol tragedy.

The report, Learning from Bristol, sums up the state of play, saying 'there is no effective coordination of the various external inspections and assessments that trusts are required to undergo.'

What is needed is 'a single, coherent co-ordinated set of standards with which NHS organisations have to comply, overseen by a single validation process and a single validating body.'

The Commission for Health Improvement, 'suitably structured so as to give it the necessary authority and independence, is well placed to adopt this role', while 'the Audit Commission is a specific example of the case for rationalisation'.

Nobody doubts the value of the Audit Commission's financial work, or District AudIt is inspections. But questions about the rest of its health work have been asked before. Eighteen months ago, the Audit Commission launched Health Strategy 20002003, in which it aimed to align its work more closely with the 'new' NHS, refocus its value for money activity and work more closely with the NHS Executive to ensure that its recommendations were met.

Questions were asked about how the commission would work with CHI - and whether the newer body might take over in the areas where their work overlapped.

Last month, the Audit Commission launched Delivering Improvement Together. This strategy sets out how it 'intends to help the improvement drive by changing itself and the way it works with others'.

Meanwhile, the commission has come under sustained fire from local councils for the way it has inspected Labour's 'best value' regime. And this month it lost its chair, Dame Helena Shovelton, who made it clear that local government minister Nick Raynsford had turned down her request to stay on for another three years.

HSJ's well-placed source says: 'I do not think Professor Kennedy knew how many toes he was treading on.' He says senior figures are now touring Whitehall to set out their positions.

'The commission's view is that everything Kennedy wants can be done by the commission and CHI working together.

'CHI's view is that it makes less and less sense to have experts at the commission undertaking studies in the health service and experts at CHI doing the same thing. The most sensible thing is for that work to sit with CHI.'

This does not chime with the official position of either organisation.

Andy Vowles, an associate director of the commission, acknowledges that a number of things changed between the publication of its two strategies. CHI started work, the NHS plan came out and the local government world 'moved on'. The Kennedy report, he says, has 'added to all that' and put forward a 'specific solution'.

However, Mr Vowles says the Audit Commission, CHI and other bodies have not only recognised the overload problem, but have taken steps to deal with it.

The commission and CHI will publish a joint report on cancer services this October and are working with the Social Services Inspectorate on national service frameworks inspections. They are also developing 'local and national commentaries on performance'.

Mr Vowles acknowledges that so much joint work 'does prompt the question' of why one body could not do all of it.

But he adds: 'One thing we have found is that different organisations bring different strengths.

CHI tends to look at clinical work, while we tend to look at the management of bodies as a whole.'

CHI director of policy and development Jocelyn Cornwel makes similar points about recognising the 'fragmentary and burdensome' inspection regime and working with others to improve things.

New bodies are appearing all the time.Dr Cornwell says CHI spends 'an awful lot of time explaining to stakeholders how we fit in with the new National Patient Safety Agency or whatever'.

She feels the regulatory burden cannot be reduced just by 'everybody working together. It needs a working group with a clear remit to make it happen.'

The government is already considering an independent report on audit and accountability in central government.

Holding to Account, produced by Lord Sharman of Redlynch, and published in February, touches on the role of the Audit Commission in relation to the National Audit Office.

The NAO investigates specific projects, but it also produces reports on wider issues: medical workforce training and waiting lists are recent NHS examples.

Some commentators feel these have strayed onto Audit Commission ground, though an NAO spokesperson said they dealt 'with national issues' and were therefore 'within our territory'.

The government is likely to look at NHS regulation as part of its autumn response to the Kennedy report. If there is rationalisation, what should emerge?

Howard Glennerster, professor of social administration at the London School of Economics, notes that the 'single validating body' demanded by the report could add yet another layer of audit and control. However, he feels the commission is not well placed to take on the role, and instead could develop as Ofsted, the education inspection body, has done. It now publishes reports on national topics, based on findings from individual reviews.

'CHI should get that sort of expertise under its belt, ' he says.

'Then it can make detailed recommendations from good analysis.'

There are wider issues to be addressed.

One is the question of who the scrutiny bodies answer to. Much of the NAO's clout comes from its relationship with the Commons' public accounts committee.

If the government really wanted to make a 'single validating body' independent, it could let it report to the health select committee; an unlikely scenario.

Another question is who will ensure the reports of the various inspection bodies are acted on.

NHS Executive regional offices are being rationalised. Strategic health authorities are still at the concept stage. It is not yet clear whether the Modernisation Agency will have a 'big stick' with which to force improvement.

Meanwhile, there is something of a vacuum when it comes to giving individual organisations the information they need to drive change.

This can be seen from the number of private sector organisations, such as KPMG, and more recently Dr Foster, rushing in to fill it.

Professor Glennerster says the government behaves as though establishing a new body will automatically sort out the latest problem.

In practice, somebody has to force change. Professor Glennerster believes the levers lie with patients, guided by GPs, who should have 'the freedom to refer anywhere.'

This prescription for a return to something remarkably like fundholding is not an isolated one.

Health Quality Service chief executive Peter Griffiths says: 'I have sympathy for the Glennerster view.

'What we do not have at the moment is a means of increasing innovation and control at the end.

We are moving back towards a more competitive environment.

'I was reading a report from the Institute for Public Policy Research the other day, and it was the Conservative manifesto 1991.

It is like flares: keep wearing them long enough and they will come back into fashion.'

The big question for the government, then, is not just whether it can fight a good battle and rationalise audit, but whether it can win the war.

Can it link the inspection system to centralised agencies and get change on the ground? More interesting times ahead.

Out for the count National Audit Office History: The NAO's website reveals that the earliest surviving mention of a public official charged with auditing government expenditure hails from 1314.But modern audit has Victorian grandparents.The post of comptroller and auditor general (C&AG), reporting to the Commons'committee of public accounts, was established in 1866.

The NAO took on its current form in 1983, when the C&AG was made an officer of Parliament and allowed to investigate the use of public funds 'on his own authority'.

Role: The C&AG and NAO are responsible for auditing the accounts of all government departments and agencies and reporting the work to parliament.They audit 550 accounts per year, covering expenditure of£650bn.The NAO also conducts 50 reports a year on the economy, efficiency and effectiveness of public spending and claims to save£8 for every£1 spent on administration.

Audit Commission History: The Audit Commission website contents itself with looking back to the 17th century, when local justices checked that no unlawful use was made of local funds.District Audit was established in 1846 to examine the accounts of the Poor Law unions.The Audit Commission was also established in its modern form 1983, and its role was extended to the NHS in 1990.

Role: The Audit Commission appoints auditors to all local government and NHS bodies in England and Wales and sets standards for them.It also carries out best value inspections of local authorities and carries out national studies to promote the economy, efficiency and effectiveness of local government and NHS services.

The Audit Commission gave District Audit agency status in 1994.

It now manages its own affairs 'at arm's length'.

Parliament has allowed local authorities to choose their auditors since 1972, but 400 select District Audit.Its clients also include many police, probation and fire authorities,400 trusts and health authorities and 'the majority of 'primary care groups.

Commission for Health Improvement History: CHI is rather new.Announced in 1997 as 'the boldest step yet'in the government's modernisation programme, it started work in April last year.

Role: CHI's remit is to 'monitor and improve'the quality of patient care by undertaking clinical governance reviews.This means visiting every trust and health authority (or similar body) in England and Wales - something is should do every four years. It also investigates serious service failures, leading to the 'Ofsted of the health service'tag it hates.

Are NHS managers paranoid, or is everybody looking at them? Laura Donnelly lists some of those with a remit to examine the workings of the NHS Who can make checks on you?

Commission for Health Improvement Audit Commission National Audit Office Regional office performance management teams Health and Safety Executive Royal colleges Postgraduate deans Clinical Pathology Accreditation (UK) National task forces checking on standards for clinical groups Complaints investigations panels Environmental health departments Chair and non-executive directors within the organisation Coroner VAT inspectorate Local MP Local community health council National Patients'Access Team Modernisation Agency Patient Environment Action Teams National Clinical Assessment Authority Mental Health Act Commission Clinical negligence scheme for trusts National Confidential Inquiries Ombudsman National Patient Safety Agency Police Parliamentary committees - in particular the Commons health select committee Social Services Inspectorate Or you could ask one of these companies to spell out exactly what they think of you:

District Audit Health Quality Service Private auditors such as PriceWaterhouseCoopers and KPMG Charter Mark Investors in People But surely It is the people who need keeping an eye on, not the organisations?

do not worry, they've thought of that: this month the government announced plans to set up a new umbrella regulatory body to oversee the work of existing regulatory bodies.The Council for the Regulation of Healthcare will oversee:

General Medical Council General Dental Council General Optical Council Nursing and Midwifery Council Health Professions Council Royal Pharmaceutical Society of Great Britain General Chiropractic Council General Osteopathic Council It will also form links with the General Social Care Council.

And coming soon. . .

A patients'body to replace community health councils Patient advocacy and liaison services Local government scrutiny committees What difference has devolution made?

England and Wales The three main bodies - CHI, the Audit Commission and the National Audit Office - cover England and Wales.The NAO examines Wales separately, last month identifying potential savings of£17m within Welsh healthcare.

Clinical standards:

Northern Ireland CHI is understood to be in discussions with the Northern Ireland Assembly about extending its work to cover Northern Ireland.

Clinical standards: Scotland North of the border, the Clinical Standards Board for Scotland has taken on a role similar - but not identical - to that of CHI.

When CSBS was set up in 1999, chair Lord Patel said it would give the public more involvement in performance monitoring.But its future is now in doubt.HSJ understands that a review of current bodies which scrutinise clinical effectiveness is due to report soon.Scottish health minister Susan Deacon has spoken to chief medical officer Dr Mac Armstrong and Scottish NHS chief executive Trevor Jones about creating a new body bringing together the work of the CSBS, the Scottish Health Advisory Service, the Clinical Research and Audit Group and the Scottish Intercollegiate Guidelines Network.But last month, in the Bristol Inquiry report, Professor Ian Kennedy urged England to emulate the CSBS model as a system by which trusts could be validated and revalidated.

Cost audit: NI and Scotland Both Northern Ireland and Scotland have one body that does the combined work of the Audit Commission and the National Audit Office.The Northern Ireland Assembly has its public accounts committee, while the Scottish Parliament has its audit committee.

Audit Scotland was formed in April 2000 following the creation of the Scottish Parliament.It provides services to auditor general Robert W Black, and the Accounts Commission, chaired by Professor Ian Percy.It publishes audits of public sector bodies and performance information on public services, and overview reports on local government, central government, the NHS and further education.It reports to the Scottish Parliament's audit committee.

The Northern Ireland Assembly also has its own public accounts committee, which earlier this year put out a hard-hitting report criticising the 'excessive'salaries paid to senior managers in the NHS.

The head of the Northern Ireland Audit Office is John Dowdall, comptroller and auditor general.