The Bulletin of The Royal College of Pathologists printed a perceptive letter summarising the history of audit, its move from the numeracy-based professions into clinical practice, and its growing use as a tool of political oppression: “the enslavement of human thought and endeavour by numbers.”
A respondent for the College does not accept all of these points and maintains that professions need to ensure the right things are done. He offers no evidence against many of Dr East’s assertions such as how public confidence has declined in inverse proportion to the increase in auditing, or how auditing gives a false impression that everything can be measured, or the effort wasted in the eternal vortex of multiplying forms.
The quality industry designed it this way so that the problems they allege never go away; they only change. Customers and patients are usually much easier to satisfy because they know what matters.
Neither correspondent raises the issue of ISO/UKAS audits which are much less useful than clinical audits and usually only detect minor deviations from total compliance. It is likely that inter-laboratory clinical audits may in some cases offer useful insights that could lead to genuinely improved practices.
Contrast such audits with the tedious, nit-picking ISO 15189/17025 internal audits of compliance for accreditation. These are required by UKAS since the external inspectors can only visit around once a year due to the expense and staffing issues. Recruiting (without payment) the laboratory’s staff into auditing creates the impression that audit has general validity and therefore is of value. In any reasonably-run lab its contribution to improvement is minimal. Its waste of resources is considerable.
Audit is part of the professional theatrics of the inspection industry.
As I speak, the Mid-Staffordshire Trust scandal is raging with concerns about infection rates. The new Chief Executive of theTrust has pointed at the 95% infection-free target as the sourceof the problem. But for me, the issue goes much deeper, with systems now ingrained in health in which patients are regarded as numbers for the purposes of auditing. I appreciate that the audit has become a way of life in health and there are theoretical benefits to its implementation. However, any management strategy in widespread use across public service should, I believe, be open to scrutiny and honest debate.
Auditing began life in the 19th century and proved to be an ideal method of assessment in numeracy-based professions. It was only at the height of the Cold War, an age of uncertainty and paranoia, that politicians and technocrats started to use audits to predict human behaviour. Out of this came a mathematical model of humans as simplified beings who only pursue their own selfish desires and interests. The long-term implication was that people’s actions and feelings could be objectively assessed through numbers. This is the basis of auditing in the health service today. It is seen as an objective measure of success or failure in all areas of our working lives and has spread, seemingly unchallenged, throughout.
Outside the financial sector, where numbers are the unit of work, the audit as a concept has a tendency to break down. This is because it is no longer a direct measure of work but a numerical approximation of a more complex environment. Thus the audit results can become increasingly distant from the realities of the work place.
Distant results can see ineffective measures put in place as part of the audit cycle. There are also more specific problems with auditing in health. First, patients have become numbers on a page, not individuals with thoughts or feelings. Human experience cannot be captured effectively by blunt numerical scales. Second, auditing has become a quasi-research method within healthcare, used by management as a way of enforcing a stifling regime of control. Finally, it has been said by many free marketeers that it is possible to assign a monetary value to a human life. The process of auditing gives this mindset a legitimacy it does not deserve.
In 1991, John Major, the then Prime Minister, launched a policy initiative with the ‘Citizens’ Charter’ at its centre. It was designed to do two things: improve service provision in the eyes of the public, and motivate and empower public sector workers. Auditing was then in its infancy within the NHS and has grown massively since. What has been the outcome of this policy drive 20 years on?
Audits, as an objective measure, were supposed to help improve quality of service in the eyes of the public, yet public opinion has shown a corresponding loss of trust in the medical profession. Instead of empowering the public servant by providing overarching targets, the result has been a dogmatic system of management. Auditing has become a self-perpetuating monster.
Its most profound effect on the workplace has been to make everyday tasks auditable. A predictable argument in favour of its use is the idea that it provides an effective measure of how well the health service is operating. In my view, this is at best naive and at worst disingenuous. All an audit does is to assess how efficient a department is at auditing itself; the numbers will reflect the simplistic managerial inputs, not the reality. One of the most common outcomes of an audit is the implementation of yet another proforma – a piece of paperwork that will become the subject of further wrangling and endless analysis. This is not empowerment; it is the enslavement of human thought and endeavour by numbers.
The substantial change in emphasis has led, in part, to the dismantlement of the NHS as a traditional public service. Citizens have become consumers, no politician or public servant can be trusted, and only the numbers can be relied upon. This view has dominated the Western political landscape for the past 40 years and its premise is wrong on both counts. Auditing encourages a culture of dehumanisation, where private sector style management is king. The irony of the Stafford scandal in the long term is that it will weaken the political will to defend the service at the top, but play into the hands of middle management and the private health insurance sharks waiting in the wings.
The idea that our complex interactions can be boiled down to numerical results and simplistic action plans is ludicrous and damaging. Stafford demonstrates that numbers can lie, and we ignore this at our peril.
There are a number of issues where I have some disagreement. For example, I think his disparaging reference to “private sector style management” is a little awry. Many would feel the private sector often has a more enlightened approach to health issues than a monolithic public sector.
However, I think he completely misses the target in his criticism of audit, at least in relation to the form of clinical audit that this College encourages and enables. In my view, professionalism is about ownership, obligations and ethics:ownership of specialist knowledge and skills; an obligation to use those skills and knowledge for the benefit of society as a whole and to pass them on to future generations; an ethical imperative to ensure that our knowledge and skills are maintained and developed.
We cannot be truly professional without some means of measuring ourselves against the highest professional standards. This is the function of clinical audit. It should not be something imposed on us by crass management. It is something that we must own ourselves.
The implications of the recently published (at the time of writing) Francis Report on Mid-Staffordshire is clear: professionals must not disengage. In particular, the lesson for medical managers is they must stop doing what they are told and start doing what is right. If there is a difference, they must be courageous enough to challenge those at the top of the management tree and persuade them to change course. The primary obligations of medical professionals should be to their patients, not to their organisations. Clinical audit is a powerful tool in ensuring that the right things are done.
It is all too easy to blame managers when things go wrong. Few lay managers can claim expertise in, or even knowledge of, most of what goes on in their organisations. They are reliant on professional advice. That advice must be based on evidence – the sort of evidence that clinical audit provides. This is one reason
why the College and its staff have put a lot of effort into developing systems that will assist its members in carrying out appropriate audit. Now it’s up to us to show that we are professional, by engaging with audit and using it.