Evaluating healthcare policies: the case of clinical audit

Introduction

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.