Intended for healthcare professionals

Education And Debate

Evaluating healthcare policies: the case of clinical audit

BMJ 1997; 315 doi: (Published 13 September 1997) Cite this as: BMJ 1997;315:668
  1. Joanne Lord, health service research fellowa,
  2. Peter Littlejohns, directora
  1. a Health Care Evaluation Unit, Department of Public Health Sciences, St George's Hospital Medical School, London SW17 ORE
  • Accepted 2 February 1997


Clinicians are under increasing pressure to show that their services are effective and efficient. Some have recently suggested that policymakers should be subject to the same discipline.1 Before the introduction of radical changes in the NHS in 1991 the government's decision not to pilot the proposals or evaluate them was widely criticised. One component of the reforms was a national programme to promote clinical audit by doctors, later extended to nurses and therapy professionals. This was generally welcomed, though dissenting voices questioned the underlying political motivations2 and pointed to a lack of evidence on the value of clinical audit.3 4 5

Since then there have been repeated calls for the evaluation of audit,6 and the public accounts committee has expressed concern at the failure to assess the overall cost effectiveness of the programme.7 In fact, the NHS Executive has commissioned several evaluations of audit,8 9 as well as monitoring progress through local and regional annual reports. However, it has not been possible to use scientifically rigorous methods to quantify the overall costs or benefits of national or local programmes of audit.10 This paper describes the various approaches that have been tried (see box) and outlines the merits and disadvantages of each approach.

Box 1: Methods used to evaluate clinical audit and examples

Experimental studies of specific audit projects

  • Lomas et al's randomised controlled trial of “opinion leader education” and “audit with feedback” used to implement a caesarean section guideline11

Before-after studies of specific audit projects

  • Lothian surgical audit: study of the impact of a surgical audit system on outcome indicators, clinical practice, and service organisation12

Quantitative observational studies of audit programmes

  • Oxfordshire medical audit advisory group: annual review of primary care audit with appraisal of projects against criteria relating to progress around the audit cycle13

Qualitative studies of audit programmes …

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