With New Labour intent on a punishing regime of performance management in the NHS - and with a plethora of new bodies to carry out the role - what is left for the Audit Commission to contribute to healthcare delivery?
Its critics accuse it of producing headline-grabbing reports that achieve little, and suggest it should stick to finance and forget health. But the commission is having none of it.
Created in 1983 to coordinate local government audit and examine the overall management of local government, the commission's involvement with the NHS came seven years later during the enactment of the Conservative government's internal market reforms.
A decade on, the commission is rethinking its role again: partly in response to consultation among users and stakeholders, partly in response to the Labour government's NHS modernisation.
Director of public service research Terry Hanafin says consultation showed the audit service and national value for money reports were well regarded - 'a little long, but well regarded' - with a caveat that they did not always chime with national priorities.
Local VFM follow-ups, however, were seen as 'variable in the sense that you got chief executives sometimes saying they are excellent, and sometimes saying they are not'. There were question marks over how much action followed as a result.
Professor Leo Strunin, president of the Royal College of Anaesthetists, is less kind. 'All their (VFM) reports say the same thing: there are variations - which is inevitable, ' he says. 'And instead of facing up to the fact that there is not enough money, they say you can save money.
'They are desperate for soundbites - they come up with these daft titles in the hope it will get them on TV - but they dare not say there is a need for money. That would put them out of business.'
The RCA has dealt with the Audit Commission recently over two major reports on anaesthesia and critical care.
Professor Strunin claims the anaesthesia report 'perpetuated the myth' that there are not enough anaesthetists, when training has been cut back over the past two years because there are, and the critical care report made vague recommendations about staffing changes 'that do not stand up'.
Given this, he says, the Audit Commission should 'stick to finance' and 'not get involved in health matters unless they can improve'.
Generally, however, views about the Audit Commission chime with its research.
Andrew Corbett-Nolan, secretary of the Health and Social Care Quality Foundation, reflects the general view of the national VFM studies when he says the Audit Commission has 'done a good job in health over 10 years'.
Institute of Healthcare Management director Stuart Marples, until recently chief executive of Royal Bournemouth and Christchurch Hospitals trust, doubts its impact.
'Generally, the reports come forward in a blaze of publicity, saying if the service organised its operating theatres or whatever better then we could save x million pounds.
'You do wonder if anything happens as a result, and whether anything like that level of savings actually materialises.'
The Audit Commission plans to tackle these issues by tying its programme of national VFM studies more tightly to national priorities and giving them more of a user focus.
This is warmly welcomed by Donna Covey, director of the Association of Community Health Councils for England and Wales, who says CHCs already find reports useful but, 'if you could read them and get a sense of just how the service works individually, and you could use that to get improvements, that would really make a difference'.
Meanwhile, the Audit Commission plans to take a 'portfolio' approach to local VFM work, sending auditors into a trust with a 'diagnostic' tool that benchmarks its performance in a number of areas. This will allow a discussion over whether action is needed on the area covered by a national report, or not.
At the same time, it is talking to the NHS Executive about building its work into the wider performance management framework.
And it plans to address 'weaknesses in communication'.
'We get people saying: 'It was so long I never read it, '' Mr Hanafin admits. 'So we will be even tougher about looking for key messages and working out who they are for.'
The other strand to the Audit Commission's strategy is gearing up for the New NHS.
On the one hand it needs to deal with new risks - thrown up by primary care groups, the difficulties of tracking funds across health action zones and pooled budgets, and the roll-out of the private finance initiative. Mr Hanafin says it is looking at how to audit all of these.
On the other, the commission needs to adapt to a health service facing a new regime of performance management and a plethora of bodies to crack down on quality. Mr Hanafin is particularly concerned to agree an 'integrated approach' with the Commission for Health Improvement.
Peter Griffiths, director of the Health Quality Service, says this is essential because 'there is a real concern about being overwhelmed by inspection and audit', and if there is no coordination there is a risk of 'more overload, more frustration, more reports building up on the shelves with nothing happening'.
But there is a wider question: with the National Institute for Clinical Excellence giving trusts and HAs advice on drugs and treatments, national service frameworks setting out service patterns, CHI monitoring them and the NHS Executive setting its own standards, is there a role for the Audit Commission any more?
Mr Hanafin's answer is that CHI is likely to impinge most on its work but will look at slightly different things.
CHI, he argues, will look at 'service aspects and quality from their own point of view'. The Audit Commission will be 'more interested in costs and efficiency and users'.
Joint teams, he says, will provide the complete picture.
Mr Hanafin argues that the Audit Commission will still have a job to do looking at 'in-between topics', such as radiology or critical care, that are not priorities for other organisations, and 'difficult' topics, such as early retirement, that only an independent body with a wide remit could touch.
Mr Corbett-Nolan is not convinced about this. 'It would be regretful if they ducked out of clinical work, because there is really no other organisation with the resources to do what they do.'
But Mr Griffiths feels the Audit Commission's role will be 'the more traditional VFM role', integrated with other bodies.
Mr Marples says: 'In finance and probity there is a role for the Audit Commission.
'There is no doubt that people at the sharp end, people like NICE and CHI and the King's Fund quality people, duplicate some of their stuff. So I do not think the future really lies in the health quality work. I think that future may belong to CHI.'
This would not upset Professor Strunin. 'They are desperate to survive and that is why they want to get in with CHI, ' he says.
'But they should stick to finance. They are very good at that.'