Times Editorial - Medical Audit - MAM criticised - 27/4/2006

The benefits of medical audit
The government recently said it planned to introduce medical audits within the health system, something it has had on the cards since the early 1990s.

Sadly, the immediate reaction of the Medical Association of Malta was to warn that if such a practice were introduced, doctors would not want to see difficult cases.

Clinical or medical audit, however, is nothing to do with holding big sticks over the heads of medical practitioners but everything to go with ensuring that health care is effective, efficient and credible.

Say that, internationally, 80 per cent of patients survive a particular operation... If an audit shows that it is 75 per cent in Malta, shouldn't someone be asking why? If it is 85 per cent, wouldn't others want to learn why?

The medical profession is no different to any other when it comes to change. The initial reaction to any form of review is always fear. However, it must certainly know that there is 13 years' worth of peer articles on clinical audit and its effectiveness.

In the UK, things changed - albeit reluctantly - once doctors realised there is more to audit than pointing out errors and that there are strong links between audit and research. Much of medicine is based on protocols of care, a process of diagnosis and treatment. What if it is not as effective as it could be? What if doctors understood more about why things were not going as well as they should?

Take, for example, patients who are prescribed a particular medication. Can doctors say for sure that the patient is taking the medication? That the patient turns up for regular reviews or diagnostic tests? That the patient still needs the medication? Clinical audit - which goes back to individual patients' records - would not only look at the doctor's behaviour but that of the patient, often identifying terrifying lacunae in the process that a doctor may take so much for granted.

Just as a financial audit may highlight shortcomings (or optimistic profits) that a board knew nothing about, a clinical audit can discover all manner of things before they get worse (or better). Being able to benchmark practice against other countries' should be seen as a fabulous opportunity to understand the gaps between expected and real outcomes.

Perhaps this is why clinical audit is now seen in the wider context of clinical governance. Patients have a right to best practice and any doctor worth his/her salt would want to know s/he is doing things in the best possible way, whether it is prescribing heart tablets or curbing a post-operative infection.

Of course, self-regulation is always better than imposed regulation; the MAM's reaction would have been far more impressive had it proposed clinical audit itself. The medical profession has successfully resisted - directly or indirectly - clinical audit for far too long.

That is only half the story though. The government wants to introduce medical audit, but has it got the tools to do so? Effective audit relies on data and that on patients are sorely lacking. The most glaring deficiencies start at the health centre, where scant or no records are kept of a patient's medical history or prescriptions. This is complicated by the fact that so many people use private care - whose records may not be available to the public sector.

Clinical audit can save time and money: ours as patients and as taxpayers, and doctors' as the providers of care. We have waited over a decade. There is no justification to wait any longer.

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