Professional audit; quality control; keeping up to date

Abstract

To audit, evaluate, appraise or assess the performance of an organization or a professional man's activity is to enter a debate: a debate about how the objectives of the organization are to be defined, what criteria should be used to evaluate the performance, how the audit should be conducted, and who should conduct it. Most importantly, what benefits should be gained by participating in the debate? 'Medical audit' is currently being proclaimed as a cure for some of the ills of Western technological medicine and its escalating cost. By appealing to the 'facts' managers, politicians and the public superficially seem able to resolve the deep ethical and economic ills that beset us. Tragically, as every new 'fact' is rehearsed, the complexity of the issues increases and the legitimacy and authority of the various actors are further questioned. Unfortunately the medical process, with its mixture of behavioural and technological components, is not readily measured; data of input, process, and outcome have a meaning only when there is an agreed policy paradigm. The politicians' expectations of a Health Service are very different from the professionals', and, until we can persuade the politicians to define truthfully what the objectives are, our profession will remain unable to meet their expectations. This inherent weakness in our governmental process ensures that for the foreseeable future the medical profession must define its own standards, audit its own activities, and maintain its own professional primacy. This tension between public policy and our professional ethic has existed since time immemorial. The great king of the Assyro-Babylonians, Hammurabi (1948-1905 BC), attempted to regulate medicine and impose audit with penalties on his doctors, but he was careful not to define what the doctors should do. Like the modem state he did not prescribe how many arrowheads his surgeons would remove each year or how many fractures they would treat, but he did define the maximum fees the doctors could charge. Thus the contemporary administrative concept of controlling medicine by using economics as a proxy for ethics is very old. What is new is the rapid escalation of medical costs in the last decade and it is this inflation of the supply side of health care that is now fuelling the cry for medical audit. In the argot of today's economists and political scientists 'quality' medical care is perceived as 'efficient', 'value for money' or 'costeffective'; the reduction of waiting lists is a measure of 'efficiency', escalat