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Chief Executive's Blog: HQIP, clinical audit and quality improvement

Welcome to the HQIP CEO Blog, where HQIP's Chief Executive will give regular updates on the latest news and events regarding HQIP, clinical audit and the wider spheres of health, social care and QI. You can also follow on twitter @ceohqip

You can contact HQIP's Interim CEO via: jane.ingham@hqip.org.uk or find out more here >

LATEST BLOG ENTRY:

14 February 2013: Thoughts after Clinical Audit for Improvement 2013
By: Robin Burgess

We have just completed our annual conference for those working in local audit, which I chaired, and I think this has been a major success. Many people came up to me during the two days and said that is was equally, if not more invigorating than previous years and the evaluations, which we looked at before we left, overwhelmingly good or excellent.

A range of high level speakers, including Sir Bruce Keogh, Niall Dickson, Val Moore and Nick Black, gave their views and encouragement to audit practice. Before I even opened the second day I’d had an email from the lead at a major teaching hospital who had attended day one only, and was now back at work, saying that she had come away with new ideas for developing audit which she had already started discussing locally. That's the impact these conferences have, energising peoples' work. We were really pleased and hope all those who attended, more than 250 people, got a lot out of it.

All the presentations are already available at www.hqip.org.uk/previous-events/.

The conference was obviously rightly mindful of the Francis report and the post-Francis world of healthcare. I have been careful not to rush into tweeting or blogging about Francis before there was time to reflect. As Nick Black pointed out, there are relatively few references to clinical audit specifically.

This is not however because Robert Francis does not understand or know about audit. Having worked on the Bristol enquiry he is very well informed and aware of the contribution audit can make, which is why he asked me to attend a session to speak about audit work during the enquiry phase. There are numerous statements about audit and information which reflect his deep understanding of the role of audit.

As was said at the conference, I think we as healthcare leaders need to spend less time positioning ourselves about how shocked we are with the Francis findings and solemnly pledging change. Instead we should focus on how we achieve change, in concrete proposals and solutions to improve attention to quality, using audit and other data, by boards.

The conference heard interesting examples of how this might be done and we will gather, showcase and promote these. Boards that wish to enact change on the back of Francis need look no further than the many tools already on the HQIP site, which set out how they can monitor and improve quality through effective use of audit. It is a matter of just doing it.

22 January 2013: HQIP advisory group
By: Robin Burgess

HQIP held its advisory group last Thursday, helping set our strategic direction within and beyond our audit contract. This is a great meeting, ably chaired this time by Roland Valori of the RCP, and involving key, senior people from so many HQIP stakeholders - patients, local audit staff, researchers, doctors, nurses, NCDs, Royal Colleges, NICE, peer organisations (Kings Fund, IHM).

It never stops surprising me the commitment and energy this group offers us to help shape what we do and give of their time and ideas to help HQIP find its right place in the current, fast moving healthcare world.

Key themes:

the need to collaborate and work with people - a major priority of mine, as I always want to co-work and co-operate, not compete
the need to raise awareness with senior managers, to get them to accept that clinical quality data is not something for doctors (Francis might have more to say on this!)
the need to keep saying just how good the data HQIP commissions is - its simply the very best there is
the need to keep giving patients information and involving them
the need to work on the ground with providers, in the NHS, independents and social enterprises, to help them act on data and make changes to care

Along with other work we are carrying out - our own internal strategic planning is well underway, to help us make the new contract delivery better and our external consultancy, led by Paul Barach - the work of the advisory group members is wise, insightful, and encouraging. Thanks to all who came and who inspire me and as they said, each other.

18 January 2013: Patient and consumer involvement in audit
By: Robin Burgess

This week has seen a range of patient related issues come into the spotlight. We are preparing for our annual review of our accreditation for the Information Standard, which reviews the information we publish for and about patients. We have a lot of great work this year to talk about which we think have improved the level of reporting of audit findings to patients and consumers. Notable within this is the guidance on developing a patient audit report at the national level. Whilst some audits have done this for years, including the National Joint Registry in the last couple, it is pleasing to see other national audits also producing similar reports - and writing in to thank us for the guidance and how much it helped them produce their own. We want to see, over time, one produced for every audit.

On a related theme, just to remind everyone of our continuing work to ensure all audit reports are published on data.gov at the lowest level of granularity as soon as can be organised. This project, part of the Transparency and Open Government work, continues apace.

Don't forget as well that the announcement in the Commissioning Board Planning Guidance (pdf), to publish surgeon level data by this summer, has speeded this work up in the case of certain audits. This piece of work is also moving on rapidly, getting surgical community buy-in to make this happen. A joint meeting, co-hosted with the Royal College of Surgeons, with the affected societies and Sir Bruce Keogh attending, is booked for the 4th February. When these data are published it will be a big boost to the volume of data available to patients. As well as involving patients, we have to provide them with access to audit findings in an easy to access and understandable fashion: it's a priority for us.

Patient consent issues are also crucial. I attended a useful review meeting hosted by the Health Research Authority this week looking for ideas on how the Section 251 exemption from patient consent that applies to national audits and research could be developed - they now have responsibility. Of course Section 251 should only be applied where patients cannot consent - where they can they should. The Caldicott commission will have something to say about this too, when it reports later this year. The key issue that emerged is that researchers and research departments at the local and academic level, need more education about why patient consent rules exist, their value, and why exemption should be avoided. However, if required, the processes needed to obtain it need to be rigorous and robust. Still, it seems to be the case that some in the research community see such necessary controls and constraints on use of unconsented patient data as just a chore. This has to change, so whilst the procedures to obtain exemption need to be efficient, researchers accept why they are in place and how important they are.

HQIP has patient and consumer interests in its DNA, and we will continue to stress the importance of patient and user involvement in health, and to come, social care audit processes. Notwithstanding the range of work to engage patients in governance and practice, and to direct data and evidence from audit to patient audiences, there is still a long way to go. CASC's annual survey of some of those primarily active in clinical audit in local trusts has recently highlighted the need to improve local participation of patients in audit; in their new 2012 report ‘59% rated patient involvement in clinical audit as ‘poor', 35% ‘average' and 6% as ‘good' (http://www.clinicalauditsupport.com/download/DraftCASCsurvey2012.pdf). This is a highly critical self-assessment of practice at the local level.

The examples and guidance on our website are here to help people address this - locally and nationally. We all know how challenging PPI is; but it has to happen.

9 January 2013: A view to the Francis report
By: Robin Burgess

It's only the start of January and we have seen the first indications of what the Francis report is likely to say being reflected in public announcements. At this stage we don't know the exact balance of the report, whether it will focus more on regulation, clinicians or management as where most action needs to occur, whilst undoubtedly covering the role of all three. Until it is published in full, it is hard to gauge whether what has been discussed so far reflects Francis' priorities or those of others.

Whatever the report finally says, we need to hear it soon. The build up is becoming an industry in itself, and I am joining in that here!

I think it inconceivable that given Robert Francis' involvement in the Bristol enquiry and what his previous report about Mid Staffs said, that this forthcoming report will not mention clinical audit as part of an endorsement of a safety and quality culture that emphasises robust information and assurance systems and procedures of which audit is one of the most reliable. I gave evidence in one session alongside others making similar pleas for systematic use of high quality clinical data at board level.

After all that has been done to promote audit and quality more generally since the 1990s, since Bristol and by HQIP since 2008, why does this still need to be said? How did Mid Staffs happen? Was it a failure from not selling the importance of patients, quality and safety enough, or more complex than this? It is very easy to lay the charge that clinical audit, and HQIP, have not always succeeded in hitting the radar of the board and senior doctors in trusts, or that audit findings have not been seen as driving quality improvement as much as they should. This may be true in some trusts; however we know that the profile of audit with trust management has risen steadily since 2008.

The reasons for why quality was sidelined and audit has not always been used as highly as it should, through the lens of analysis of one provider trust, are likely to be highlighted and solutions offered by the Francis report. The point is that these are complex and reflect the many pressures and challenges trust management face in the current climate of the NHS. Some of this is relates to the historic reduced profile of audit prior to 2008 and the range of other sources of data, government policy, influence and pressure that have emerged over the years that have undermined the focus on clinical quality and patient centrality to care. Some of this has squeezed out audit as much as audit has failed to reach people.

The point is to look to the future, not just back, and this report will be strong on solutions, not retrospection and hindsight. We hope that the report will place a new focus on the value of clinical audit data and systems; and how boards should make use of audit, supported by clinical managers at board level who give it the time, respect and resourcing it requires, aligning it to other QI work and not separating audit from other QI, safety and assurance processes. Audit done properly is QI. Anything less is not clinical audit, but just measurement. Understood properly as this, clinical audit will help prevent cultures like Mid Staffs happening again.

The mature, developed, quality focused board and senior clinical team, will already use clinical audit in the way that our various guidance resources, systems and training (including our current NEDs training) recommends. There are ready-made solutions for clinicians and boards, to the challenges Francis will highlight, on our website and in our guidance already. It is a matter of doing it.

2 January 2013: New Year, digest of clinical audit studies, review of cosmetic surgery
By: Robin Burgess

Happy New Year to all those interested in audit and registers! I have worked on and off over the Christmas period focusing on a job, neglected temporarily during the tender period, which requires concentration without too much distraction - the review of the recently published literature on clinical audit. The new digest of this is now available on the HQIP site at: http://www.hqip.org.uk/digest-of-peer-reviewed-clinical-audit-reports/. This period covers the last nine months and this gives opportunity to see in more detail the climate of audit practice worldwide.

There are studies from all over the world, some not translated, sadly, including a series in Hungarian that I was unable to read. The bulk as always, comes from the UK, some from Ireland, where increasing attention to audit is prompting new work and review; some from the States of course, a few from Europe, a significant number from the developing world, and always a stream of Australasian studies and from Italy, where there is a thriving audit culture.

The Aussie studies, although numerous, are fine in detailing specific issues highlighted in single sites, but rarely are these reports of full cycle audits where there is a programme of change implemented and the continuing results assessed. As such, few make it into our digest. I don't know the degree to which the published studies reflect audit practice, but it is a marked feature of their literature.

My interests in resource poor environments and the challenge of audit in these settings are strong and I am always pleased to see examples of the real outcome and benefits audit brings, especially in the area of maternal, child and women's health. These are matters of life and death in these environments to a far greater degree of course, and those implementing audit are keen to show that audit affects these outcomes positively. It's an area HQIP looks to get involved with in the future.

Back to Italy for a moment, where my friend Ulrich Wienand of the Italian network has completed an annual review, which though in Italian, is a good review of recent published work, and includes the Italian translation of our ‘Principles and criteria' handbook. You can download this review by clicking here (pdf) >>

So, to domestic matters, and we have lots to do. The DH summary of comments on their review of cosmetic surgery following the Breast Implants story of Christmas 2011 can be found at: http://www.dh.gov.uk/health/2012/12/responses-cosmetic-surgery/ and contains a strong statement of the need for clinical audit and registries in the private medicine environment in which so much cosmetic surgery happens. It could not be a stronger endorsement of the importance of clinical audit as the best assurance of quality and safety.

Look forward to seeing many of you in 2013.

20 December 2012: Quality Accounts, Commissioning Board plans
By: Robin Burgess

First of all a Happy Christmas to all readers and followers of HQIP.

It's been a major week for HQIP. We have been working hard on making sure our internal structures are fit for purpose going forward, with team building and strategic work underway in the organisation, plus discussions with DH/Commissioning Board about the shape and priorities of the new contract. But day to day work continues: the publication of the Quality Accounts list for next year is a major achievement by the local and national teams working together - see http://www.hqip.org.uk/2013-2014-quality-accounts-list/

We go into Christmas not just with continuing funding, but in the new Commissioning Board Planning statement (see http://www.commissioningboard.nhs.uk/everyonecounts/) a clear role for HQIP in a major new project, overseeing groundbreaking publication of surgeon level data in ten key disciplines. This is exciting, but also challenging, as much of this data is not all produced through national audits funded under NCAPOP but independently through specialist societies. We will be working closely with these bodies, most of whom we have excellent relationships with already, to work out how this can be done within the deadline set by the Commissioning board of summer next year. This release of meaningful data is a good thing and patients have the right to be able to see data of this type about the procedures they are going to have and the performance of the clinician who is to operate.

We know the degree of clinical feeling about this - as an example from this week, see http://www.bmj.com/content/345/bmj.e8377/rr/620768 - but we have to work with clinical groups to ensure the data that is published is understandable and not misinterpreted. The value of such release in terms of patient outcomes for some disciplines has been proven (see, for example, Ben Bridgewater in Heart. 2007 June; 93(6): 744-748); but as experts in registry practice we understand the fears surgeons have about inappropriate and misleading data and the risk that there will be selectivity in selection of patients for operations, which may already be happening for other reasons, as MacMillan have suggested today (see http://www.bbc.co.uk/news/health-20780581). Our job is to ensure these fears are managed and the data issued improves patient care. The importance of this work can't be overstated and it is a key priority for the board which will affect how we prioritise work.

Finally I would like to mention some work we have done for the College of Psychiatrists - some online learning resources for mental health specialists: http://www.psychiatrycpd.co.uk/. Remember too to sign up to my tweets on @ceohqip.

10 December 2012: News for the week
By: Robin Burgess

A catch up this week, of various things happening at the moment:

1) I am now actively tweeting - follow me on @ceohqip

2) One of the major tasks for us is to support the Transparency agenda for Open Government, given the central role of clinical audit as a source of data of sufficient quality to be shared widely. This week we support a DoH event for audit suppliers to remind them of the expectations on them from this programme, which are to publish data to the agreed level of detail that is appropriate for their audit, and to upload this to data.gov.uk by a date that needs to be agreed with HQIP.

We have also helped define a workable way in which data can be shared with data intermediaries (Dr Foster and others), which will be tested in pilot work in the New year; and later on, starting to work with non-funded audits to see how their data can be shared in the same way.

3) Have a look at the article in 6th Dec HSJ which reports on the work on clinical audit at Moorfields Eye hospital. The authors talk extensively about how their audit programme was revitalised as part of an overall approach to clinical governance - a project that included an expansion in their level of resourcing for clinical audit. Where the commitment is there, and the value identified, and where senior staff see the value of clinical audit, the resources can be found for audit work. It's an inspiring story for anyone who despairs of the future of audit in the current economic climate. For others interested in this kind of transformational work at an organisational level, have a look at the various reading and e-learning resources on our website at http://hqip.org.uk/boards-and-clinical-audit/ and http://www.hqip.org.uk/guidance-support/online-learning-resources.html and a reminder of our current training programme for NEDS which looks at how the provider board can use audit as part of quality improvement, governance and information strategies (see https://login.hqip.org.uk/multievents/layout5.asp).

4) We have not lost sight of necessary work on accreditation of clinical services, although inevitably our tender work on clinical audit pushed this back. We have restarted this work, convening the steering group for work on accreditation and looking to commence some work mapping and scoping accreditation support in the new year, working closely with partners in colleges.

All of these major themes illustrate the crucial role clinical audit and other data sources play in helping these initiatives to happen. Clinical Governance and Transparency require high quality data to support them, and audit data is the best there is. Accreditation likewise needs high quality audit data as a major source of evidence. Building up to the imminent launch of the Francis report in 2013, its quite clear that Trust or provider management, regulator performance, and commissioning activities need to ensure they actively look at and use the evidence that is available to them. This means that no provider can afford to overlook - or under-resource - the supply of audit evidence to underpin strategic change, compliance and achievement of quality.

27 November 2012: Working with and for the audit community to deliver QI that makes a real difference
By: Robin Burgess

As you will see on this website, we have been formally told that we have been successful in being re-commissioned to run the programme of support for national and local clinical audit for a further period of three years in the first instance.

This is obviously great news for all of us here at HQIP, because we have been validated to continue delivering exciting, effective programmes of promotion of audit and quality improvement that make a real difference to people's lives.

We hope this is a decision that will be welcomed amongst those who work on audit and improvement. When we surveyed stakeholders earlier in the year, a significant majority said that they hoped we would win this tender and continue with our work. I hope this reflected their recognition of the work we have delivered over the last four years. I hope the decision will justify their faith in us. In winning this tender I would like to pay tribute to our board, our stakeholders and of course our staff, including the team which worked so hard on the bid we submitted, in collectively helping us to achieve this.

However, we will not simply carry on providing the same services as before, excellent though many of these are. Our work will radically change and improve. We tendered on a programme that will have new elements. These will include:

A sub-contracted partner in the Centre for Healthcare Improvement and Research (CHIR) unit at Imperial College, who will help us to review and improve the methodological quality and outputs of our national audits
Far greater integration with the other work of our new commissioners, the NHS Commissioning Board, including a new-look website hosted by them
A new part-time medical director to lead our work with clinicians at all levels, enabling that reach with clinical groups and specialities that underpins audit and change
A new post at Improvement Science London, leading improvements in quality improvement activity amongst junior doctors
A formal new responsibility to work on promoting audit methods in social care, working with sub-contractors at the Social Care Institute for Excellence (SCIE) to achieve this, starting with work on a national level improvement project on addressing dementia in care homes
A new focus of work with audits not funded by DH through HQIP
New ways of reaching out and supporting audit at the local level
A greater degree of involvement from our board partner organisations

As well as all these new programme elements, the culture of HQIP will change:

We will work far more across our teams, especially in relation to national and local audit, to join our programmes together more seamlessly
We will strive to reduce bureaucracy and speed up the way we work, offering better customer handling and communication
We will be more visible and active at the local level
We will offer more practical, less academic support to audit practice
We will work in a more integrated way across board and staff team

We are doing a great deal of work internally to review staff and team practice, our management, our processes, our skills and our training levels. We are reviewing our strategic purpose, taking into account staff, board, and stakeholder views, which we have been gathering over the autumn through our advisory group and interviews conducted by our consultant, Professor Paul Barach.

This work will involve root and branch internal regeneration of our practice, which will ensure HQIP delivers more effective service to raise the profile and quality of clinical audit, with resulting impact on quality of patient and service user care and outcomes.

It is an exciting, pivotal moment for us, and for clinical audit. We are grateful to the Department for their continued faith in us; we will strive very hard to deliver an excellent service.

23 November 2012: Improving audit, improving its impacts and communicating those impacts
By: Robin Burgess

In the last week or so, I have been part of a variety of practical business meetings where I have been able to promote the value of clinical audit and work to get audit recognised alongside other key healthcare policies related to productivity, research, data and quality improvement more generally.

This included a consultation exercise regarding research priorities for NHS operational activity, led by the National Institute of Health Research (NIHR) Health Services and Delivery Research Programme. This programme commissions and invites research into a wide variety of issues of NHS practice, and getting audit to be recognised in that range is quite a challenge. There is a real need to get research into audit, but realistically, we have to ensure audit is covered in wider studies looking at how data is used, or quality improvement is evidenced, rather than studies of audit per se.

I also spoke at a clinical coding and data quality conference looking at the links between coding and quality improvement, and was able both to communicate the importance of good coding for audit, and also how audit uses coding data to improve elements such as data accuracy and case ascertainment. The day proved a fascinating insight into a closely related area to quality improvement, and some of that data community's concerns and interests - training and professional status for instance - were directly parallel to the world of clinical audit. Better linkage between these two groups must be desirable, and I am sure it is the case at the operational level in many providers.

A third meeting was the Royal College of Physicians Clinical Effectiveness Forum and seminar. This is always a great event and also a great opportunity to network with the specialist societies below the college level - many of whom we work with on audit or registers. An excellent presentation on the UK Primary Immunodeficiency Network (UKPIN, which covers rare immune disorders and HQIP funds), was well received and really highlighted the value of this small but essential resource.

The second part of the RCP session was a series of presentations on the future of clinical audit and the Clinical Outcome Review Programmes (CORP) - from Marisa Mason of NCEPOD, Professor Derek Bell from Imperial, and from Nick Black, who helpfully set out his views on the challenges for audit, covering topics such as improving participation rates, data quality and methodology, linking audit staff to other quality improvement work at Trust level, etc), and I was able to reflect positively on how we are addressing these in our work programme.

I also attended the relaunched meeting of the quality leads from Royal Colleges of Medicine (and Nursing), run through the Academy of Medical Royal Colleges (AoMRC). This is a vital forum, and this meeting was progressive in taking this agenda forward. Colleges share a real desire to work on quality improvement, and are exploring again exactly how they can do so with energy and imagination.

The theme running through all these meetings? Key opinion formers in a wide variety of settings are grappling with how they can improve performance and quality, and how to work within their own networks and systems to improve quality of care and outcomes.

Being invited to attend reflects our prominence, and my attendance is part of my personal role within HQIP. In such meetings I, or other staff who attend, represent audit and data interests in so many national groups and forums, and attending these is crucial to raising the profile and importance of clinical audit and data among those who have wider interests. We have to use every opportunity of this sort to sell the idea, the potential, and the contribution of audit work, and we do.

30 October 2012: The need for parsimony in data collection
By: Robin Burgess

I was struck by a recent article by Meyer et al in the BMJ Journal of Quality and Safety in Healthcare - see http://qualitysafety.bmj.com/content/21/11/964.full - which argues, from a US perspective, the need for the requirements for data collection to be driven from two angles, balance and parsimony. Any study should be appraised against a set of standards which include the value of the data supporting internal and local QI activity, and criteria such as "select measures taking into account the cost of data collection and reporting relative to the measure's impact on quality, outcomes and costs".

They argue there is simply too much, unwanted and unnecessary data being collected, and conclude: "We must stop the avalanche of an ever-increasing number of mandated quality metrics so we can get to work on using measures that really matter and thereby focus on what we need to do for our patients, our communities and our country to provide better health outcomes, better care and lower per capita costs".

This is a perspective HQIP fully endorses and which we argue on an ongoing basis ought to be behind decisions made in selection of audit topics and their subsequent methodology. We know that these are sentiments overburdened local audit staff and clinicians support and which we reflect in dealing with DH policy makers and NAGCAE members. We think, and very much hope, that this is gradually coming to be accepted as a key principle, and if we win the tender on the ongoing contract (the decision is due next month) then we will very much emphasise this approach in the future.

20 September 2012: Focus on Information Governance
By: Robin Burgess

Now that the deadline has passed for HQIP to submit its tender for the contract to support clinical audit, I am able to restart this blog, which this week is about Information Governance.

As data controllers for the whole group of national clinical audits and enquiries we commission, we have a heavy burden of responsibility to ensure data is properly governed by our contractors, and that requests for access to the data are considered properly and released where appropriate to secondary users. Our role in relation to information governance very much looks both ways: the narrow and precise role of ensuring data is protected and the secondary role of promoting and facilitating appropriate access to these data by a larger number of users. HQIP is completely committed to this process. Over the summer we have stepped up our processes here, speeding up the time taken to review requests and approve release, working very closely the NHS Information Centre (NHSIC). We think the processes are much better, and the log of this process can be seen on this site under the national audit pages.

I was also invited to give evidence to the Caldicott review this week in the session on Linkage. The panel theme for this session related to supply of data from Trusts for analysis by national or regional teams, such as those those running national audits, those at Public Health Observatories, research centres and data intermediaries. The precise issue under debate was how these data can be made secure either at source or at point of receipt, ensuring that risk from this process of transfer of personal data can be reduced or avoided. It will be very interesting to see the panel's final recommendations.

This debate about the volume of data about patients that is passed to others, and in what form, is also central to the Governmental discussion about Transparency and Open Government. The Government's stated intention is that a greater volume of the data collected about patients should be available for use and re-use through secondary or different data intermediaries and researchers. At the same time, the need to protect confidentiality and risk of patient identification is crucial, and also not to allow misleading analysis of the data through inappropriate release.

It's a balancing act, and HQIP, assisted by representatives of audit suppliers and colleges, and working with the NHSIC, is actively involved in helping the Department and Cabinet office understand the issues and form a workable policy. We fully support the aspiration as, through being a patient professional partnership, its our aim to get more and better data in to the hand of the patient. The devil is of course in the detail, not in the broad principle, and the challenge of getting this right yet meeting the needs of all the key stakeholders is considerable. We believe that as a result of our considerable practical experience of Information Governance through this contract we are well placed to offer sensible advice and a nuanced perspective.

13 July 2012: Social care White Paper gives audit the green light
By: Robin Burgess

After a long wait, the Department of Health have released the Social Care White Paper this week.

The paper includes a section on quality and sets out that the Department is going to support development of audit within the sector as part of this area of work, including a dementia in residential care project (see HQIP's news announcement for more).

This audit will be carried out locally according to the same, nationally-agreed, standards and using a common set of tools, but the data will not be analysed centrally nor will there be any national benchmarking, although it is intended that local providers will be able to benchmark themselves.

This represents a significant move forward as until now social care has had no systematic, centrally directed approach to audit within the sector.

HQIP has been working closely with the Department to develop these ideas and it is intended that we will play a role in helping the dementia audit develop, with a big stakeholder event in planning for the autumn. NICE, whose Quality Standard will inform the audit standards, are closely involved as partners, which mirrors our close working relationship with them in regard to healthcare (see more on HQIP's work on social care here).

More generally, the Department is keen to support the work we have been doing to develop and promote audit methods, and to see this expanded. Our manual for audit practice in the sector has been through various rounds of drafting and consultation with social care professionals and this is ready to go to design and print, with a view to an autumn launch as well.

We have been very excited about this whole work programme and we have a strong commitment to helping local social care staff to learn the benefits of audit and to start their practice with good quality, helpful materials and advice.

The result, we hope, will be that the practice is taken up widely by the sector, and there are gains in terms of quality of care and service user outcomes and experience. It is still a very long road to travel but it is one that we are pleased to be involved right from the start.

To find out more about HQIP's work in social care quality improvement, please contact Development Officer Eve Riley.

4 July 2012: Architecture of assurance quality and Principles of Quality
By: Robin Burgess

I would like this week to highlight two new pieces on the website, which whilst very different, have a direct relationship.

The first is a new position paper, found here. This attempts to take a very high level view about the necessary architecture of quality in healthcare that is needed to support strategic action to improve quality. This covers much beyond audit. The vast list of methodologies this discusses illustrates that the potential range of approaches that can be tried is huge. Others have tried to review the relative effectiveness of different methods, but such endeavours have usually restricted themselves to a tiny part of this vast array, leaving any overall analysis of the relative value of the different approaches to be of itself, limited value.

The point of this work is to illustrate the need for strategic vision, of taking an international perspective of different approaches, in order to form policy and strategy. Our first HQIP external advisory meeting of last week, which attracted a diverse mix of people at senior level with lots of ideas about how HQIP needs to position itself in a confusing web of agencies and stakeholders, considered this issue. It was clear of the need for an organisation to stand up and position itself as a cross disciplinary, credible voice for such a strategic approach, as an independent, but supportive advisor to government, which this paper argues is the body which needs to have the strategic policy role. Several of those external persons present suggested HQIP is well positioned to be a body.

The other document released this week is the final version of the Principles of Quality in National Clinical Audit. This document has been in development for about seven months, in which time we have refined and improved the Australian original for the British market. What this sets out is HQIP definitive take on what quality is measured by: the key criteria for how quality in national audit should be measured. We will use this in advising, informing and assisting audits we work with, and any new audit in development should consider the criteria given. The development of these standards is a statement of HQIP’s ability to produce consensus statements of where the science of audit is, based on collective opinion, not simply our own, in recognition that clinical audit, at national level, is an emerging science. As time goes by we will add detail to how these criteria are measured, and use these in our commissioning and contract management, as we continue to drive up the quality of national audit. This document is an important milestone, and reflects HQIPs place as the national centre for clinical audit in the UK, if not internationally. Perhaps its emergence is an example of our possible credentials for taking the role identified above.

Do let us know your views on this potential role, either by emailing us direct at communications@hqip.org.uk or by starting a new discussion thread on NCAF.

12 June 2012: Imagination, innovation and energy key to HQIP work programme to support clinical audit
By: Robin Burgess

It is a summer of major events, with the Jubilee, Euro 2012, and the Olympics. And for HQIP, this summer represents a similarly exciting period, as we prepare to re-tender for the national clinical audit contract.

Having initially been given a three-year contract by the Department of Health in 2008, HQIP was subsequently awarded a two-year extension and now, in line with the initial agreement, the contract has to be put out for tender by the Department. It provides a unique opportunity to take stock, evaluate our own findings and our stakeholders’ feedback, and push on to the next stage; we very much look forward to preparing and submitting our tender.

Equally exciting for us is our ongoing work programme packed with new ideas, energy and imagination.

Our main focus is on driving change at the local level from clinical audit, and to do so, engaging with clinicians even more than in the past. Our newly-published strategic plan sets out the direction of travel which will carry through into the new contract, if we are successful. It centres on building momentum for change amongst local clinical leaders. Audit must be seen as a quality improvement process and local organisational structures need to reflect this, with proper linkage between audit teams and QI teams, and with real clinical engagement from medical director through to FY doctors.

To achieve this we will be recruiting a Medical Director to focus our engagement with doctors, adding to the Clinical Fellows and Clinical Champions HQIP already has in place. To do this we are developing a joint post with the London Deanery and the Academic Health Centres to emphasise the scientific aspects of audit practice for doctors. We are also working now with Professor Paul Barach, an international expert in healthcare improvement to focus a national-level improvement project about how we can get clinicians to act on the findings of clinical audits. We are also running an extended series of regional workshops for clinicians in the autumn and issuing our resources for GPs.

And these activities are just one aspect of a strategy that will see more than 20 events being planned by HQIP across 2012/13.

We will engage methodological expertise from a specialist academic team and there is also new work regarding patient involvement, with new practical guidance complementing regional workshops. For clinical commissioners we will issue new guidance and our manual for audit practice in social care is near completion, scheduled for publication this autumn.

All of this work of course looks to highlight and re-emphasis best practice – it is fitting then to flag up the HQIP Clinical Audit Awards, the submission deadline for which is very soon – 5pm on Tuesday 26 June. We have already seen a fantastic response and I would urge as many of you as possible to celebrate the great work carried out by you and your teams by entering.

We’ve got lots to do. Our work continues to expand and breaks new ground throughout the rest of this year.

25 May 2012: Global views on local quality improvement challenges
By: Robin Burgess

I have been attending the World Healthcare Congress (Europe) in Amsterdam this week as Chair of several sessions. I should make clear at the outset I only attend such events if I am speaking or chairing and where there is no cost to attend, as otherwise they are unjustifiable - and I am glad to report this was indeed a very interesting and worthwhile conference.

Attendees came from all over the world, rather than just Europe, and it was educational to hear about the development of healthcare in places where there is already a great deal of advancement to a partly privatised model.

There were numerous speakers from Britain, including Lesley Doherty and Ann Schenk from Bolton NHS FT, and Agnelo Fernandes representing the RCGP and Croydon Clinical Commissioning Group, both of whom showcased great practice, on Lean in the former and GP commissioning in the latter.

Agnelo described in detail how the RCGP clinical audit template is now being made a requirement in huge parts of the emergency care sector in London - and HQIP will write this up as a separate case study of audit as the safeguard of quality in unplanned care.

DH National Director for Improvement and Efficiency Jim Easton spoke about QIPP and Michael Marmot, Director of the Institute of Health Equity and Research Professor in Epidemiology at University College London, splendid as always, spoke about inequalities in healthcare - a compelling message and something that needs to be taken into account at all times. David Gilbert of InHealth spoke passionately about the user experience of healthcare and developing better and focused patient engagement, which of course we fully endorse.

Outside of the UK, there was good material on integrated health and social care in the US Veterans Health system; on work to provide better healthcare in India, on a private, but low-cost model; and on exciting work in Singapore on integrated care for the elderly.

One of the sessions I chaired also included three speakers focusing on various aspects of improving standards collectively. Gary Young, Director at the Northeastern University Center for Health Policy and Healthcare Research in Boston, spoke about a collaborative approach to quality improvement involving the voluntary participation of a group of hospitals and it was an example of the kind of work that happens outside of the government sector and the issues it throws up - unwillingness to share or publish data and benchmarking for example.

In practice, in the UK clinical audit sector, we have moved far faster to making such collaboration and the result is that issues like transparency will happen here, far faster than where it is a local, clinically determined decision whether you share your findings.

Manuel Pais Clemente, secretary general of the European Medical Association, spoke about the value of accreditation in healthcare - and the need for some European level accreditation; and Joao De Deus, also from Portugal spoke about good efforts to get doctors more actively involved in management.

As with any congress, networking outside sessions is useful, including in this case conversations about the French healthcare system, on integrated care in Canada, and useful discussion with the global orthopaedics devices lead of a major manufacturer about the National Joint Registry and post-market surveillance.

The quality of speakers as a whole was high, and I felt the event was thoroughly worthwhile, and came back with lots of ideas.

16 May 2012: Launch of the NHS Wales National Clinical Audit and Outcome Review Plan 2012/13
By: Robin Burgess

I had the pleasure of attending an event in Wales last Thursday, the Clinical Audit and Effectiveness seminar which officially launched the NHS Wales National Clinical Audit and Outcome Review Plan 2012/13. This formal plan for the promotion of clinical audit from within government, which HQIP was involved in helping produce, alongside people involved in direct delivery of care in Wales, is a welcome step forward for Wales, and one which England could usefully follow. Of course HQIP produces its own strategy for our work in England, but the added value of this jointly produced document is that everyone in health service delivery, alongside health policy leads in the Welsh Assembly Government, have all collaborated to set out a high level vision of how clinical audit fits into a broader integrated plan for healthcare in Wales.

The exciting thing about this strategy is the link between clinical audit and quality improvement, it is explicitly stated and emphasised and a way to ensure audit findings are acted on is created. Audit is seen as firmly being what we believe it to be: a quality improvement process in itself, not simply the spur to one. It's all very well assuming that the production of high quality data about variance in delivery of care will automatically improve quality, by local people acting on the findings in some sort of spontaneous way. In Wales they have recognised that the findings of the measurement phase of national audit need to be supported by targeted quality improvement activity on the ground. They are doing this by encouraging functional and organisational links between the audit teams and their quality improvement teams within their local health boards; and by assisting local change through deployment of the Welsh quality improvement organisation, Thousand Lives Plus, to help local providers enact change when audit findings encourage it.

HQIP has clearly identified that there is a gap between the findings of the national audits we commission and change activity. Some NCAs drive change effectively by simply producing good data, but there is a good case to be made for applying specialist QI capacity to support and facilitate local clinicians and managers to enact changes or improvements in services suggested by the data. In some trusts in England that capacity is there and they apply the learning from NCAs quickly and well; but it is not always the case and they may need some additional help. We believe its time this extra capacity was in place. The Welsh have recognised this and are taking the right steps, through a tightly integrated programme, to support local change activities, both through organisational restructuring on the ground and by application of specialist QI support external to the individual provider. This achieves the location of audit activity within a broader spectrum of health service activity, rather than seeing it operate within an audit ‘bubble'. To break out of the bubble requires governmental action and vision, to lead and direct provider activity. We support the Welsh in this programme and believe it will lead to greater improvements in use of audit findings.

Read the NHS Wales National Clinical Audit and Outcome Review Plan 2012/13 here >>

Presentations from the day are available here >> and abstract booklet here >>

We have also created a specific Welsh page on this site were we can share further information on the their plan and share other items of interest. Click here to visit >>

30 April 2012: Registry/national clinical audit development in Europe
By: Robin Burgess

We will shortly add a detailed report about our conference held last week (26-27 April 2012) on registry (or clinical audit, as we call it here) development across Europe, and presentations are available, but I wanted to use this column to give a quick personal view on this event.

HQIP had been interested in getting involved in developing registry practice in Europe for some time, but the conference came about because we are involved in the European Society of Quality in Healthcare (ESQH), whom we saw as a conduit for this. However the specific spur was the very similar role played by the Danish lead at ESQH (and then ESQH president) Paul Bartels, in registers in his own country, as I do.

The development of registry practice is much the same in Denmark as it is in the UK, and we soon realised we had much in common and a shared agenda. So, at Paul's suggestion, we set to work to organise this event at high speed, to also form the content of our annual Summit for national clinical audits, since there is so much to be gained from sharing practice.

The event went well and we filled the venue, with a 1:2 mix of European and British delegates, all with practical experience of running projects of this type or responsibilities to do so. Although you would expect me to say this, I think the event was a real success.

The quality of the discussion, and the quality of the programmes being discussed, was a stimulus to us in HQIP as there were things described (especially in the Swedish and Danish systems) that we know we can consider doing here.

We are grappling with the same issues Europe-wide, and looking for similar solutions; we can all learn from each other. I came away excited, pleased (in that we had organised it and, with ESQH, shown the leadership needed), energised, and also challenged. I am sure the majority of delegates went away with similar feelings.

We will work with key colleagues in Europe to keep the discussion going and look for opportunities to work together, involving ESQH as part of that - we see this as the beginning of European work. I have viewed some international work on quality as a little remote from our practice, lacking in discussion as it often is of data and evidence; but through this event we have created a channel of discussion useful to us and also to many others involved in the same approaches.

I would like to take the opportunity to thank all staff at HQIP who worked so hard on this event - notably Becky - Rebecca Beaumont.

24 April 2012: Harmonisation of accreditation schemes
By: Robin Burgess

HQIP is an agency focused on a variety of related methods of quality improvement in health and social care - and one of the main ones of these is accreditation of clinical services.

A couple of years ago, with the Academy of Medical Royal Colleges, we created a model of how the disparate clinical accreditation schemes (typically run by Royal Colleges) could be harmonised and aligned under a single accredited system. This would mean that anyone seeing the mark of accreditation could take a view of what it meant and how valid this was in terms of assurance it provided.

However, whilst the model received strong support, notably at the National Quality Board, there were no funds available to take it forward. Yet the interest in accreditation does not diminish, with new schemes in pilot stages and some schemes increasing their profile, so the need for an integrated approach remains.

The relationship of such schemes with regulatory minimum standards remains unclear, and the precise position of accreditation as a quality improvement methodology as part of a national architecture of quality, remains in debate, partly because such an architecture does not yet exist. Individual schemes may negotiate their own relationship with CQC and other regulatory processes, but there is clearly a need to speak collectively with regulators, commissioners and government.

HQIP hosted a meeting this week (working with the Royal College of Psychiatrists) of colleges from medicine, nursing and allied health to discuss these issues. There was opportunity to hear about the best research into effectiveness in accreditation and best practice internationally.

Overall, it was clear that much remains to be done and that a collective approach is welcome and supported. It was agreed that HQIP, working closely with the Academy and the other disciplines, would take a lead in engaging with regulators, commissioners and the Department to cement accreditation's place in their thinking as the vital tool it is in driving improvement. This was clearly illustrated by the international review of literature, by David Greenfield at the University of New South Wales, which was presented on the day.

If anyone not present at his meeting wants to stay involved, please contact Eve Riley, our Development Officer on accreditation at eve.riley@hqip.org.uk.

19 April 2012: Clinical engagement in audit
By: Robin Burgess

One of the most interesting and complex issues in the development of clinical audit is the exact role and active participation of clinicians.

HQIP, as an organisation with clear interest in the engagement of clinicians of all disciplines, has consistently argued that we see both national and local clinical audit as being part of clinical governance: a process to review the effectiveness of clinical care and to continually drive change and improvement. All audit should be of value to clinicians and where audits fail in this regard then that is clearly a moment to review the utility of that specific activity or type of activity.

Most local audit (other than by junior doctors) is instigated and led by clinicians, is linked into clinical governance and trust strategy and as such generally meets the criteria for its utility given above. If there are issues, it's with junior doctor audit or with national audits.

HQIP has done a lot of work to make junior doctor audit more relevant. It's still the case that a proportion of junior doctor audit is still largely a wasted opportunity because the cycle is not complete, it feels like a tick box exercise, and little change results.

This is often where local Trusts have failed to do the very sensible things recommended by HQIP in its joint guidance with the Foundation years programme. There is a role for Deaneries here and we have started engaging with them afresh to talk about these issues, including some training being organised for Yorkshire and Humber. We are keen to ensure that throughout the country there is a common standard of practice and the same old ways do not continue; there is no reason why junior doctor involvement in audit should remain a problem. If any Deaneries want to do more then please contact us.

At national level, we know that there is concern from some clinicians about some of the national audit programme; they share some of the views of local audit staff about the real value of such large, ongoing data collections, especially where practice seemingly varies little from year to year. Also, many would like the opportunity to opt-out where the performance is consistently better than most.

We hear these concerns and raise them with the Department. Yet it needs to be remembered that every audit programme we commission is designed and led by keen, enthusiastic clinical experts, and approved by the professional body or specialist society concerned prior to roll-out, and then refined in practice.

If local clinicians want to tell us about issues they have with national audits, then use our new feedback mechanism. Clinicians can also raise concerns directly with the audit concerned, or via their professional body or specialist society: the channels are there.

It is perhaps a reflection of reality that there is a diversity of opinion about the desirable features of these projects which our recent consultation on the ideal principles of national audits was designed to address. The second version of this is out now for consultation.

More pertinently, local Trusts don't get much help in acting on the findings of national audit. We publish a range of material to help people do so and the audit providers help to a degree as well; but more needs to be done. We think there is a real need to resource this area, perhaps from the centre, to develop Trust responses. One thing we will be doing is to host some work to help clinicians respond to audit findings. This will be carried out this the autumn, with the involvement of Dr Paul Barach, an international expert of quality improvement.

More generally, many clinicians are not actively involved in audit as much as they should be. Revalidation, as it becomes a reality, will help address this, but there is still room as part of specific development work in individual disciplines. For this reason we have appointed two new clinical fellows, Dr Maeve Lawrence and Dr Rish Prasad, to help promote audit amongst GPs, looking to develop ways to enable GPs to learn about audit, in the training and as part of their ongoing practice.

28 March 2012: Transparency and patient reporting
By: Robin Burgess

Last Friday (23 March) saw the official launch of the National Joint Registry's patient report. Many national audits produce material directly aimed at patients, and the new NJR publication joins this list - although the report has been out for a while.

The launch and the scope of the report mark this out as quite a significant addition to the roster of patient reporting. It is very much a product of work by those with experience of joint replacement, working with the clinical and analytical team, to make difficult information available for a wide, lay audience. It's a big, ambitious and comprehensive template for what patient friendly reporting should or could look like.

The engagement of patients in audits of all types remains challenging. Their engagement in the governance of all national audits is a given these days; increasingly patient organisations are also prominent in the management of the audits, and the assessment of patient experience and perception of outcomes is also a requirement in national audits we are commissioning. The demands of the transparency programme are to require reports to be put in the public domain for patients to use.

Yet still there are national audits which don't report openly; access to their reporting is via closed websites, or is sent to clinicians only. This type of project will not be able to be included in the Quality Accounts list and will not receive national funding. If any national audits collect data that is not in their open reporting but it is in their reporting to clinicians, this will have to change - not least of all because FOI requests will open it up anyway.

We are working on some E-learning for patients and some more practical guidance on involving patients in audit; our own in-house patient group is a massive help in this, and they have just elected an independent chair. They, alongside other national patient bodies will be invited to join our new advisory group, announced via our e-bulletin and website. We will also be producing some guidance on patient consent and information in regard to data on them collected for national audits, for local staff to give to patients to inform them, to add to what is on our site already.

Of course there is still lots to do; but we are confident the principle of involving patients in audit is much more established in 2012 than it was in 2008. There are practical issues in recruitment of committed patients who can shoulder the burden of demand participation places on them; but the principle, and the mechanics of how to do so, are much more in the open and understood than four years ago. It's progress, and the NJR report is one further marker of this.

16 March 2012: The role of audit in patient safety
By: Robin Burgess

In recent years patient safety and protection has emerged as one of the dominant themes of quality improvement, and whole conferences devoted to QI are dominated by consideration of avoidance of serious events and prevention of deaths and accidents. This is of course a hugely important topic; but its not all there is to QI. Ensuring your work is of high quality and meets quality standards and guidelines is also a major part.

It is the case that clinical audit and registries are largely not seen as having much to say about patient safety and protection. Text books of patient safety entirely fail to mention its contribution. Yet audit does help and this week we have seen a very significant example of this delivered with world wide impact. This is the publication this week in the Lancet of a study based on National Joint Registry (NJR) data about metal-on-metal hip replacements. The potential risks of these products have been known about for some time at an anecdotal, case report or research level, but their impact at a mass level needs careful examination of large blocks of data about a significant body of patients over time.

Two years ago, after previous less definitive warnings from the Australian equivalent register, the publication of findings from the NJR in this country led to the withdrawal world wide of a particular brand of hip joint - the ASR. In recent months, some other data has led to their use only in a segment of patient receiving hip replacements. This week a study entirely based on the massive volume of cases reported to the NJR over time has shown definitively that metal-on-metal hips should not be used in any cases.

This is patient safety and protection in action via audit. Its about marshalling large data sets to identify clear definitive risk, and pinpointing this with scientific rigour and accuracy. Through this action thousands of patient at risk will be protected, and if they need action because of implants they previously received, they will be able to obtain the attention they need to remedy any problem. Without this register, this would not have happened.

Its very easy to critique national projects as collecting lots of information for dubious benefit, as my last blog discussed. People forget the vital role of these registers in using those large data sets to identify and prevent harm. They don't just collect; they drive policy and practice. National registers are a patient safety mechanism of demonstrable power. Their data volume and quality makes them incontestable.

But audit does not just ensure safety at the national level. Many local audit projects look at aspects of patient safety; we covered this in the review of the literature available on our website by Loughlan, but day in and day out at the local level, that evidence based is added to and we always welcome examples of studies which reflect this. Identifying unwise and unsafe practice is one feature of audit that is not often cited. Let's celebrate it, knowing that many thousands of people will be the beneficiaries.

8 March 2012: Why I think national audit quality is improving
By: Robin Burgess

HQIP is currently consulting on a set of standards for quality in national clinical audit. This is designed to achieve consensus to enable a sensible discussion of what quality is.

As I have said repeatedly, judgement on quality depends on your perspective. For some, the NCAs are not even audits, just research; some others think their quality suffers because they are not enough like research projects. Others again emphasise the degree to which people act on the findings, taking a view on quality based on how the projects are used, rather than how they collect, analyse and promote their data. It's a minefield of competing priorities; and we need consensus to make balanced, informed judgements on what quality means and what quality is.

My own views are that the quality of NCAs is improving across the board. You can express your own view via our Stakeholder Survey 2012, which is currently underway (please do have your say if you've not done so already) - and also the Principles of Quality in NCA Consultation, which closed this week (thank you to all those that provided feedback).

The survey again asks for progress on NCAs (or otherwise) since HQIP's inception in 2008. As I say, I do think national audit quality, as a whole, is now much higher than in it was four years ago. I base this on HQIP's factors for consideration set out in our ‘HQIP Guide to Assessing and Improving Quality in Clinical Audit' guidance.

That document reviews a range of factors that could be taken into account in determining quality. On two of these, 'does the topic have substantial value' and 'is there a clear purpose for the audit' - these are assessed prior to commissioning by the Department of Health and NAGCAE (previously NCAAG) and on these HQIP does not have a role in the degree to which a bid meets these. Again though, my own view, in the main, is that most NCAs meet these criteria.

In regard to cost, HQIP achieves substantial economies within the commissioning and contracting process, ensuring value for money as far and often as possible. We hold bidders to strict cost envelopes. The wider question of whether the cost is justified by impact is a more complex one. A substantial economic analysis would be required. However it's demonstrable that if an audit achieves improvements in mortality and morbidity, or avoids revisions and readmissions, then there is potential to recoup the relatively small cost of collecting and analysing audit data. This is a research question that could usefully be answered.

Are they led by professional bodies? Since HQIP started we have systematically moved ownership of these projects to professional bodies. This criteria is largely met.

Methodological quality - well here is one for debate. The audits are subject to far greater challenge in regard to their methodological quality at commissioning stage, at review and during ongoing contract oversight. NAGCAE has rightly emphasised this and they play a significant role in ensuring quality in this regard is improving, as does HQIP. In key areas, such as case ascertainment, information governance, reliability and data quality, there have been substantial improvements year on year. Are they all perfect? No. Are most of them adequate for the primary task of driving improvement? I'd say yes.

If you spend time talking with projects about how they address methodological and quality issues, there is a real commitment to continuous improvement. When I look at the progress of the National Joint Registry (NJR) for example, the audit with which we have most engagement, the quality of the data is simply vastly better than five years ago. All the audits are wrangling with quality issues all the time and finding improvement solutions - whether it's their ability to detect outliers, case mix adjustment, their data release and linkage systems, or their consideration and awareness of ethical issues. There is greater awareness of these issues and attempts at addressing them progress all the time or we, NAGCAE and the Department would not be able to renew them. It's an ongoing, Forth Bridge kind of improvement process.

Reporting of findings? They are all better at reporting, and they report in more detail than in the past. NCAs have had a lot of guidance in this regard - and requirements built into their contracts. They are much better at using the media and they get more impact - look at an example like the last Dementia audit report in December, which received a phenomenal amount of media coverage. New requirements regarding transparency and speed of reporting, and for patient reports such as the one NJR has just issued, will further increase this area of improvement. Are these reports more accessible? Yes they are all far more widely available, distributed and read, not least of all via our website.

Do they involve patients in governance? Much more so, and more routinely than in the past.

Do they routinely measure outcomes? Yes, far more than previously.

Do they drive change at the local level? How well do they fit with local needs? Well, this is the area where there is probably even more debate to be had. There is a body of local feeling that some audits are not appropriate for their needs, and are, in essence, research exercises collecting data that has little impact on local practice. As said above, the decisions on funding are made by the Department after taking advice about the exact shape each audit has - its balance of data, the standards it uses and so on. There is no doubt that some of the national projects are more akin to research projects - this is something I have acknowledged from the start because this is what we are asked to commission. There will always be a tension between the perceptions of those focused on the slightly different beast that is local clinical audit from the one that is national audit. On some people's criteria, the programme is less well regarded because of this. It's a matter of perception.

However there is one area where I think there has been inadequate progress, and that is the implementation of findings at the local level from national audit.

In some cases there is little to work on, as the last point suggested, but in far more others, there are plenty of useful findings waiting to be implemented. Why is this the case? It's down to a vast range of reasons, too great to list here, but one is that there is clearly a lack of capacity or staff, to work at the local level with trusts to put in place the change programmes needed to implement the recommendations. In many Trusts, with some audits, the audit is of excellent quality and action flows from the report - stroke care is the best example. It's not always the case. We think there is a need for Trusts to get help from the centre. This should involve those who lead the audits in professional bodies, but it also needs people skilled in quality improvement and change programmes, skills not always present in the teams that lead the audit, nor at the local level. I think this is the main area in which the overall impact of national audits has not improved enough in the last five years.

This is a long blog on a difficult subject, and one on which we all have views. Debate will of course run and run, but it is important we recognise were improvements have been made and it is crucial we continue to identify where improvement is still needed - and take positive action to make those improvements, wherever it is we fit into the national clinical audit picture.

24 February 2012: NCAF
By: Robin Burgess

When we first started, we worked with the Department of Health to come up with ideas for a new kind of forum for those working in clinical audit, to be able to talk with each other and share views, and represent themselves collectively. Hence NCAF was born, using social networking software to provide an online space that avoids travelling and enables better sharing of documents and information.

Three and a half years on, and its clear that NCAF still offers this capacity and is used well by many people to do all the things listed above. The majority of use is respectful, useful and professional.

However it is also true that the use of the Forum is sometimes not, as we aspired it to be, professional. It is a matter of some shame that on a website which seeks to contribute to promoting the professionalism of clinical auditors some people choose to use NCAF in a highly unprofessional way. It is sad that I have to use this public blog to comment on the behaviour of those in the audit field in a negative way. I am not saying that people should not use the forum to criticise HQIP, or me in particular; it is right and proper that the Forum is used as a place for expressing views, both negative and positive, of HQIP, me, or anyone else closely involved in audit. However, all too often, what is posted is not constructive, its deliberately and wilfully critical, and these criticisms are not substantiated or evidenced - such as that we deliberately delete critical posts; that we are somehow profiting from audit when we are not for profit and this is evident in our published accounts. It is also the case that some people posting use false names and are not even prepared to use their real ones.

The number of people acting in this way is low, at a hard core of about eight people, but they disfigure the site and give a very negative image of what clinical auditors are like: the impression is of rudeness, lack of balance and churlishness. There at times appears an almost irrational vituperation of what HQIP is trying honestly to do on the behalf of clinical audit and those who work in it.

This has to stop. People are welcome to make criticisms of us: please do - indeed we are inviting people to review the quality of our work via a systematic review that starts next week, and your identity will be invisible to us when you do. But if you are going to post on NCAF and leave your comments for ever on the site, you have to be prepared to say who you are, make constructive remarks, evidence what you say, and be prepared to justify your comments. I will systematically invite anyone posting direct critique of me, with whom I have not met, to meet me personally to discuss their views and find out why they feel the way they do. But I want everyone using the site to start behaving in a professional way, posting sensible critique under their own names; to be mature, like any other profession using a professional site should be. NCAF is not Facebook; this is the public window into the world of clinical audit, and at present, it is pretty ugly viewing.

13 February 2012: CAI event reaffirms audit value for health and social care
By: Robin Burgess

Last week saw the annual Clinical Audit & Improvement meeting on audit both local and national. HQIP sponsored and subsidised places, and the meeting offered a great opportunity for communication, sharing best practice, hearing updates, and networking. Speaking as objectively as I can, I would say that we remain pleased to be associated with an event which has proved durable and which continues to attract a good audience - including people from Italy, Ireland and the Channel Islands as well as England and Wales.

Highlights included a splendid reaffirmation of the value of national audits based on continuous data collection, with a presentation by the Hip Fracture Database. There was general agreement from the floor that this audit was central to enabling England to be an international leader in quality of treatment for hip fracture; this is an audit which has strong stakeholder support, drives change, is methodologically adequate, and delivers improvements in outcomes.

There was also a HQIP workshop on the application of audit approaches in social care - as I have talked about before, this is a major development opportunity for HQIP and we are pleased to see such welcoming of the approach from social care people present. There was real enthusiasm to see us do the work we are - and recognition of how much the sector needs it!

Quality, Improvement and Development team lead Kate Godfrey started the process of sharing the revised standards and curriculum guidance for training in clinical audit; there was complete welcome for these documents, final versions of which will be issued taking into account valuable points made.

Elsewhere, there were valuable presentations on legal issues, junior doctor audit, and how that is being improved, and how audit contributes to patient safety.

The Department of Health sent over a presentation which I was happy to deliver, which set out the key issues at national level. Once again transparency was highlighted, but more importantly, the Department emphasised the importance of audit, both nationally and locally. They were keen to stress how local providers must ensure they enable an adequate level of resource is present to meet the need for audit work - both local audit and national audit. It was very pleasing to see them make the case for local audit in this way. In the near future HQIP will be working to promote to providers how they must ensure that this capacity is not weakened in the pressure to make economies - audit is a mandatory function that simply can't be removed.

26 January 2012: Realising national policy commitments - subscription funding and the transparency agenda
By: Robin Burgess

This week and last, you will have seen major announcements about the national clinical audit programme; one about subscription and one about transparency. We have been working on these issues for some time with the Department, helping them to realise national policy commitments for the move of some audits to a new model of funding and to present audit data in an open, granular way.

Subscription: the clinical audits moving to subscription are all long established, well regarded projects. They form part of the core datastreams used to measure the effectiveness of these clinical services. These are mainstream audits and it is right that NHS trusts support their operation as part of their core service delivery. The inclusion of payment within tariff for this ensures the ability to do so is covered and means that no Trust should need to make cuts, for example in the staffing of clinical audit teams, in order to pay for this. This would be a false economy.

Over time we will work with the Department to determine which other audits, if any, should also move to this form of funding and the first place to hear such news is here, on this site.

Transparency: the announcements mark profound changes to the national programme. We will be requiring all funded audits to start publishing their results at the most detailed level of granularity that is possible, taking into account the robustness of the data and the risk of patient identifiability. It is entirely right that data is released that enables patients and the public to see the comparative performance of clinical teams, where the funding for such projects is from the public purse or such projects otherwise supported or facilitated by government.

Alongside this promise, we have added extra features: coming soon, an improved PARCAR participation database; and the new feedback system - because openness is two way, on the one hand national projects sharing information about local provider performance but on the other being open to comment and discussion about how data is collected and reported.

The last area in this announcement is about how national audit projects report their findings. We are issuing all national providers we fund with a requirement to produce reports that have common features and characteristics, and communicate well to patients. This is a further step in the direction of having one nationally integrated system of projects funded by the state. They will be easier to read and to understand as a result, and in visual terms the suite of audits will form a more coherent and linked set of reports to the same purpose of improving services.

As well as this, next week will see the issue of the consultation on the promised ‘Principles of quality in national clinical audit'. In addition to addressing the visual coherence of the communications aspects of the programme through the above, the methodological and governance functionality of the individual projects is gradually being brought to a common, agreed pattern. This includes of course the requirement to measure outcomes, which we have been building into audits steadily over time. The common level of granularity and a movement to use of patient consented data wherever possible are others. This new document will seek to gain overt public consensus on a raft of others as well.

It is time we collectively decided and agreed what are the features of good national clinical audit that should be present in both the ones we commission and others in the public domain. We hope very many of you will contribute to this exciting debate.

16 January 2012: Breast implant crisis highlights crucial need for effective registry management
By: Robin Burgess

The new year promises much hard work from HQIP as we continue to advance the re-invigoration of audit on a variety of fronts.

We are pleased to be launching the new Good Governance Guide, adding to our range of materials aimed at providers to ensure they make best use of clinical governance in their work. That followed on from the first audit (Lung cancer) to be placed under the Transparency programme on data.gov.uk, and the launch of the in-depth patient guide to the NJR and last annual report. These are all firsts - groundbreaking new ways of showcasing audit data for a variety of audiences. We are proud of all of these.

Shortly to come are the revised education standards and curricula guide, the next annual Clinical Audit and Improvement conference (organised by Healthcare Conferences) in early February, and lots more, including a consultation on principles of quality in national audits and registries.

Of course, over Christmas, a storm broke in the form of the PIP breast implant issue, and the solution that everyone thinks would have prevented the storm breaking is the existence of an effective clinical registry. Indeed it is fair to say that it reached the stage in the media where it was taken as read that ‘this would not have happened with a registry'.

Registers of course play a crucial role in identifying substandard devices - the National Joint Registry's work was the reason DePuy's ASR hip was taken off the market, worldwide, saving harm to many thousands of people - and so a very pleasing reaction.

However, it must be remembered that there is still a window whilst data builds up before any register identifies such hazards. It was very satisfying to see such universal endorsement and championing of what HQIP trades in, but also a concern that we had been talking about the need for a new breast implant register for some time and it took a crisis to make it come to the top of priorities.

National audits and registers are long term investments, and they need a strategic vision, not based on crisis, to see their long term potential but also that they need time. They are not a quick fix. We are delighted the Department of Health in England continues to have a strong commitment to the audit programme.

My last word this week is regarding an event on 26-27 April, a joint conference in London between HQIP and the European Society of Quality in Healthcare (ESQH), about national clinical registers across Europe - look out for further details shortly and keep the date in your diary.

19 December 2011: Dementia audit illustrates profile of clinical audit
By: Robin Burgess

Anyone who had a television or radio on last Friday will have been aware of the release of the report from the national clinical audit of Dementia, led by the Royal College of Psychiatrists with partners. This audit explores the care and treatment of those with dementia not in specialist units but in general wards in hospital.

This report has some hard hitting messages about the need for better training, awareness and general standards in treating this group of patients with significant needs. I won't repeat these; the report is found on this site as a main news item.

As well as being very proud to be associated with this report in relation to a clinical audit of care of profound interest to so many, and having a hand in helping it achieve the publicity it did, HQIP is also very proud of the impact our reports are now having. This audit led the news on the BBC Today programme, described clearly as a clinical audit, not a ‘study' nor research, and had a presence high in the placing of news stories in various media. Its testimony to the increasing recognition of the power of clinical audit data, and the profile of clinical audit that was not there when we started just over three years ago. This is a conclusion backed by the evidence of ever increasing visitors to our website, both daily and periodic. We now have over 15,000 visits per month for the first time (and just under 10,000 unique users).

This is up from roughly 7,400/5,000 for the same period in 2010 and up from around 5,000/3,000 in 2009. Our daily user numbers have been steadily increasing too (now around 500 a day). People see the buzz about clinical audit; it has impact and can galvanise attention.

This profile is of course also testimony to the skill and dedication of our providers. This dementia audit is from a highly professional and credible school, at the RC Psych. This is also an example of a specific type of clinical audit, in that it collects a sample of data from a number of centres rather than collecting large volumes of outcome data on a permanent basis. Some question the value of audits like the dementia one. What the Dementia study shows is that the main purpose of clinical audit is change in practice for the better, and that simple, sample based periodic studies can achieve a phenomenal amount of impact. Whilst outcomes data is useful, we should not lose sight of the tremendous value of audits of the type of the Dementia audit in making the lives of patients better. That's what counts above all. Yes, all audits should have high methodological quality, and be rigorous, but most of all, more than all of that, they need to change the practice of care. The Dementia audit, I am sure, will do this, and as our elderly population increases, and dementia increases also, I intend that HQIP and our partners will have an impact on this most of all.

Happy Christmas everyone.

12 December 2011: Focus on engagement
By: Robin Burgess

The engagement of clinicians in audit is a tricky issue. Those who work in clinical audit sometimes fail to understand the perceptions clinicians have of audit support staff and the audit function compared to their own. Interest in clinical audit amongst rank and file clinicians is very variable, with many seeing audit as a function of exciting potential and far too many seeing it as a very boring part of their working lives, up there with targets and trust reporting as the part of their job they least enjoy.

HQIP has done a great deal of work engaging with the clinical audit community, listening to their concerns, seeking to improve communication, creating dialogue and enabling them, through the recent changes to the national audit programme, a greater say. But we need to balance this, reflecting that audit staff are only a part of the wider community that do, could and should get involved in audit. At the simplest level, the perceptions of clinicians about the value of various national audits is markedly different than that of clinical audit staff. Both need adequate voice and recognition.

Its vital that we continue to engage more and more actively with clinicians to promote audit and to get their interest, and hear their views. Colleges and professional organisations play a major role in securing their interest and this is why we are currently working with the Royal College of GPs to recruit two new clinical fellows to help support clinical engagement in that part of the clinician spectrum. These also ensure that HQIP has greater internal clinical capacity. Dr Yvonne Silove who works in the national audit team has brought a great deal to the organisation in this regard, as have some of our clinical champions. We will also be exploring the recruitment of a full time clinical specialist to help us reach out to doctors earlier in their careers to generate enthusiasm in audit.

21 November 2011: Audit practice bolstered by international links
By: Robin Burgess

Last week, I was invited to Warsaw by the Polish Ministry of Health to attend an expert seminar on healthcare quality as part of their EU presidency period. This event was combined with a meeting of the European Society of Quality in Healthcare, of which I am an executive member. The seminar gave a very brief picture of some of the challenges facing many other European jurisdictions in improving their healthcare systems. Of course, despite our financial restrictions at present, many of the states of the East still face immense challenges in providing good quality healthcare, marked by the necessary architecture of quality I have referred to in previous blogs - standards, regulation, measurement and change programmes.

Nonetheless, the commitment to patient ownership and leadership is admirable. In some settings, such as Poland itself, the lack of good handover and common IT systems means that the patient will often carry their notes between primary and secondary providers. Where there are no existing systems, but a commitment to patient interest, quite radical solutions like this have been put into place.

It was a week of international liaison. Earlier on, I was visited in London by my equivalent for the Australian safety and quality commission, who play a similar role to us in improving audit quality and commissioning. If you have read the latest eBulletin, with the major actions contained to improve and extend what we are doing, especially to improve national audit, you will know that we will be using the statement of operating principles produced by the Australians as a base document for a similar set of principles for national audits here. We are currently adapting this document and it will be out for consultation as soon as it is ready. We think this is crucial for defining what quality is for national audits, on a consensus basis. Meeting my equivalent, and being able to discuss really significant common issues in audit development, and share ideas, experience and strategic goals, was invaluable.

Put alongside the visit to Warsaw, these two meetings illustrate the immense value of looking beyond the UK's borders. With minimal cost enabled by on-line meetings, low cost airlines, free places, and sharing material with others, the practice of audit can only be enhanced and improved.

11 November 2011: Social care: getting to grips with measuring quality
By: Robin Burgess

We are moving to the greater integration of health and social care and with that there are many challenges and one very good opportunity, which is to develop better ways of measuring and improving quality in social care settings. There is much scope for learning both ways between the two sectors on improving quality, with the person centred approach and staff supervision culture of social care being two examples that should travel into health. However healthcare is very good at measuring the quality of the care they provide and using that information as part of a dynamic cycle of quality improvement. Nothing really like this exists in a systematic way in the social care field, and with the integration agenda now so real, especially at the local level, social care should move to adapt the techniques HQIP promotes to the social care setting, not least of all because they effectively measure outcomes, demonstrate good quality care, mark individual professionalism, offer assurance to service users, and help support performance and outcome monitoring.

We have been consulting and discussing these issues extensively with policy, regulatory and opinion forming leaders in the sector over the last 12 months, and the next stage of this work is to produce a manual for service managers and practitioners about how the method can work in social care. Julie Fenner is working with us to produce this manual, which will be out in 2012, and we will be including lots of case studies of current good practice, examples, and practical ‘how-to' sections to enable the methodology to be used more actively within the sector.

We are also discussing how at a strategic level the Department of Health can explore the wider use of these approaches in the sector. We are exploring how the involvement of the social care sector in national clinical audit can be improved, and audit methods can be further trialled in the sector.

We are also pleased to see the inclusion of the need to conduct review of your practice in a systematic way in the new Social Work Reform Board framework for the continuing professional development of social workers in England.

It's an exciting time, and it's a time for real cultural change. If you are interested in working with us on this area and helping us advance this type of work in social care, please contact us via eve.riley@hqip.org.uk.

4 November 2011: Revitalising clinical audit and QI
By: Robin Burgess

You will all have seen a range of new material announced this week on our website. There will be a large volume of detailed announcements, products and consultations coming out in subsequent weeks. Much of this is about new activity in revitalising clinical audit, especially the national audits, but some is about the relationship between audit and other government policy and within quality improvement as a whole.

Within the audit area, the things we have announced mark out a new era, a step change perhaps - one where there is far greater engagement in informing policy by a wider range of stakeholders. We will be asking people to give feedback in a formal way about national audits, and to give their views about their inclusion in the new Quality Accounts list for next year. We will also be consulting on common principles that should underpin national audits, using as our starting point some really excellent work done in Australia. We will also be forcing the pace on transparency.

Turning to the broader context, on Monday I spoke at an event at the Royal Society of Medicine along with Mike Farrar and Martin Marshall which was looking at the overall organisation of QI - whether there was, or needed to be a ‘grand plan'. As QI develops I think we need to be more strategic. The issue is the degree to which there should be a really strategic approach to deploying, evaluating and managing QI rather than a few uncoordinated organisations casting a wide handful of seeds of (unproven) ideas and hoping a few things work and take root.

I believe in strategy, research and management, and with that co-ordination and partnership. HQIP is one of the major organisations in QI with a budget of nearly £18m Departmental funds to resource QI approaches but we still need to work alongside other organisations to deliver combined programmes within the wider, bigger world of QI beyond HQIP's contract business of audit. In the near future we will start raising questions about training in QI, for example. Watch out for this.

I have also taken part in a seminar led by the MHRA about how registries and audits can play a greater role in ensuring products don't enter the market without effective testing. There is no question that products should be subject to benchmarking review, such as registers provide, before they get used, and various partners such as NICE have a stake in this. Making this happen for a wider range of products is however, demanding.

NCAF will be running specific announcements and inviting comment on specific topics - but if there is interest in new discussion threads about any of the topics raised here, go ahead.

Next week's blog will focus on social care issues: and in subsequent weeks I will turn to learning from other healthcare systems.

25 October 2011: Audit data - getting the best out of the excellent
By: Robin Burgess

Over the past two weeks I have very much been engaged with discussion about three related policy drives within government and how they can be achieved; the wider context of information for a variety of health purposes, including clinical quality, commissioning and public health; measurement to support achievement of better outcomes in health; and transparency, whereby data is more open and released more accurately and in better detail.

The types of data we commission or promote are directly related to this. Clinical audit data is of unrivalled quality to achieve these aims; it measures outcomes; it drives quality. We have to strive to ensure it is publicly released to the appropriate level of granularity too, and is well used for a variety of purposes. We are developing clear plans with national audits to ensure they meet these aspirations.

However the debate here is big one, and audit, registries and confidential enquiries are just one set of available data within these policy contexts. I have taken part in a series of events - firstly at the Kings Fund, chairing a Capita Conference on outcomes, and secondly participating in the information seminar that was part of the Francis public enquiry into Mid Staffordshire - that have really focused my mind on how much we who work in audit and registers need to relate to this wider context.

We have to remind everyone that these data sources we specialise in are crucial within these wider aspirations - major sources of good, reliable data, incredibly valuable to achieve these policy aims. We have to ensure that those working on broader strategies understand our collective contribution, and also our expertise and knowledge that we can use to help other data sources make the same impact. We have a vital voice on these matters that needs to be heard - in these national events certainly - but in trust board rooms, in clinical meetings, in college discussions - and internationally. We're world leaders; let's celebrate that.

You may like to pick up these issues for discussion on NCAF, our interactive networking portal, available via this site. A detailed discussion of views about information, outcomes and transparency as a whole, and our data's role within it, from HQIP will appear on this site shortly.

13 October 2011: Feeding back on national clinical audits
By: Robin Burgess

This week has seen the national HQIP conference for those involved in supporting audit at the local level. We felt it went well and having read the evaluations and spoken with many delegates, the vast majority of you thought so too.

It was great to see Bruce Keogh to reaffirm how important audit is at the centre of the Department's priorities.

We included a lot of discussion of patient engagement - in recognition of how far we all need to travel in this direction. Thanks for all members of our patient network who attended.

Inevitably there was a lot of discussion about national clinical audit, and I was keen to say from the platform, that at HQIP we listen carefully to some of the concerns of those who feel that there are major issues with the Quality Accounts list and in the quality of some national audits. We have agreed with the Department of Health prior to the conference that HQIP will take over the process of agreeing which audits will be required reporting within the QAs, gathering views from various stakeholders to ensure the final list is a consensus based on various special interests. We will get this list out as soon as possible after the consultation is complete.

This marks part of a wider process of review of the national audits working with the Department. They share our view that collectively we have to agree a consensus view on quality in national audit from various perspectives. However some principles about quality are fixed - one being that there must be a move to open reporting from all audits at an appropriate level of granularity in an open way, with reports in formats and style for various audiences to understand and use - not just clinicians. We are working with every audit we fund to get to this point as quickly as is achievable.

Separately I attended and spoke at a Kings Fund conference on Information. I was keen to get over that information has to be seen not as separate, but part of a process. You can't reify information and discuss it out of context for its purpose. You collect what is useful, and audit data is only as useful as how much it is used to drive improvement in patient care and outcomes. We have to get better at sharing information, certainly, as the conference stressed, but it seems to me too much information, in the wrong form, can be unhelpful too. Next week I am speaking at the Francis Enquiry on these very issues.

By the way I am helpfully reminded by one of our NCAF contributors, that NCAF is perhaps a great way to discuss any of the issues I raise in this blog. If anything I say here strikes a chord, you can always spark discussion in that media with others.

7 October 2011: Improving routine data to benefit QI
By: Robin Burgess

I attended two interesting discussions this week, one to discuss what we could learn from the Swedish network of clinical registers, and the second to help define the research topics for the National Institute for Health Research (NIHR) Health Services and delivery research programme, which researches organisational aspects of NHS provision. Both brought together groups of interested stakeholders for what provided to be very valuable and high quality debates.

The first focused on how data is collected within the NHS for QI purposes and the issues of HES quality, data linkage, and the value of specialist databases, as well as transparency issues. I put in a lot of time preparing for this; from our mapping of audits and registers one of the important things to emerge was how far advanced we are in the UK, with well over 220 registers; and in comparison with the reporting level and data quality of the Swedish group we have a lot of good things going for our programme.

That's not to say we can't learn and we are in contact directly with the Swedish equivalents of HQIP to see in more detail what we might take from what they do. As a whole, the main thing that came through was the same as at the RCP seminar reported in a previous blog; how important it is that we improve routine data - such as HES - to align with collection of QI data for audit and research. We have to find ways to streamline data collection.

The research meeting was an attempt to synthesise the views of many stakeholders and advance these ideas into a more detailed review. I was very pleased to be invited to attend this and a previous event and to hear the ideas under discussion, many of which covered some of the same data issues. As the programme also covers social care, I was keen to see research into quality improvement in social care and methods used there currently as an aide to the work we are doing to promote audit in social care.

Anyhow, its our national conference of local audit staff next week, which I am looking forward to immensely. I look forward to seeing lots of you there.

28 September 2011: Handover practice
By: Robin Burgess

On the 2nd September by invitation, and paid for by the project, I attended an international expert group on Handover, the conclusion of a three year project, funded by the EU, to improve handover practice across Europe. The project has funded some useful review work on systems and approaches, and has focused on training and protocols as the main ways of improving handover. Although the project has now ended, the team of European researchers have produced an online toolbox of resources and approaches, based on a model like our own NCAF, to enable people to share best practice on handover. This product will be refined and then made freely available. All materials are in English and it's a useful compendium of approaches, many derived from the UK but also useful work from Australia and elsewhere.

Issues of effective handover are important for all organisations, and especially those, who like HQIP promote methods of quality improvement. We have actively supported audit of case notes as one contribution to effective handover. However, inspired by this seminar, it may be that HQIP develops more work on this important topic in the future.

One side project, involving a team from Birmingham University led by Professor Lilford, has carried out useful modelling of the challenges of carrying out evaluations of the impact of quality improvement strategies, with the basic conclusion that such studies need to be very large and expensive to be able to show the impact of specific approaches in a crowded healthcare system. This is relevant to our own work in evaluation of audit, where any study to explore the impact of audit on practice will need to be very large.

15 September 2011: Health Informatics Unit
By: Robin Burgess

I attended a really important and valuable seminar at the Royal College of Physicians today which celebrated the 10th anniversary of the Health Informatics Unit.

For ten years the team there has been doing first rate work promoting the importance of good practice in basic record keeping. Their work is simple, yet offers a real contribution to patient safety and quality. One of the main things they stress is the need for basic, routine collection of data, ideally electronically, that is rich enough in detail to also form part of the dataset needed for research and clinical audit. Over the years they have clearly identified the limits of the existing data sets collected in secondary care, and how, with the weaknesses of that data source, research and audit has to create new and additional data sources. The session usefully addressed the patient perspective and the opportunities for patients to see their own data and to collect it - and it was great to see two members of HQIP's patient group, Margaret Hughes and Phil Willan present.

However, patients, like clinicians, will wait a long time for any change from the centre, so the development of a single, high quality electronic collection of routine data with value for audit is still a long way off. In the absence of that, attempts by clinical communities to at least establish a single core data set within their speciality, to reduce the burden of recording and form a common platform on which to build audit and research, offer the only, albeit partial solutions. So it was really good to hear Will Dixon speak about the Arthritis UK Inbank project, which tries to do exactly that, establishing a common platform for arthritis research and audit and links between relevant databases in that area.

This is an exciting development and offers great opportunities for similar work in other specialties. HQIP is fully engaged with Inbank, through a link to the National Joint Registry, and cooperation with Arthritis UK on research. If other opportunities emerge to support joint data platforms with funding it would seem a good idea.

14 September 2011: Westminster Health Forum
By: Robin Burgess

I was invited to speak at a Westminster Health Forum event on the 8September.

Chaired by influential political figures, a great line up of speakers included the chair and medical director from Mid Staffs Trust as the theme was the implications for quality in the NHS arising from the public inquiry into inspection and regulation of NHS providers.

I spoke about the role of clinical audit and the need for professional leadership of quality data. I was most struck by the succession of high profile speakers who endorsed the value of clinical audit and the key role of professionals in leading investigation and improvement of quality. Successive speakers - Fergus MacBeth from NICE, Niall Dickson from the GMC, Cynthia Bower for CQC, Linda Patterson from the RCP, all emphasised how important clinical audit now was, reflecting the important partnership work we have carried out with these bodies and their name checking of HQIP gave recognition of the profile of clinical audit and HQIP within it.

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