National Clinical Audit: Change, improvement and impact

17 Jan 2023

In this interview, HQIP Medical Director and Associate Medical Director to the Manchester University Hospitals, Professor Danny Keenan, explains the role of the national clinical audit programme in influencing improvements in healthcare. In particular, he focuses on changes to the National Clinical Audit and Patient Outcomes Programme (NCAPOP) and its importance in ensuring that resultant services are both relevant and meaningful and, critically, lead to improved outcomes for patients. 

Q: First, for those who are less familiar, please explain the National Clinical Audit and Patient Outcomes Programme (NCAPOP)? 

A: The NCAPOP comprises of circa 40 audits and programmes on a range of clinical disciplines that collate healthcare data and other evidence, and are commissioned by the Healthcare Quality Improvement Partnership  (HQIP) on behalf of NHS England, the Welsh Government and, in some cases, other devolved authorities. These programmes align closely with the aspirations of the NHS Long Term Plan. 

Q: What are the benefits of the NCAPOP to patients and the healthcare service? 

A: The programme will only flourish if it continues to show that, by its presence, outcomes for patients continue to improve. To do that, it needs to continue to provide the knowledge-base that our patients and others, such as clinicians, service providers and commissioners, need in order to effect meaningful change. We keep a record of improvements, as do the audit providers. The impact of these benefits can be viewed on four levels: National; system; local; and public.  

Q: Can you be more specific about, for example, the national improvements that have been realised as a result of programme? 

A: Sure; here are some examples:  

• Interventional: 1. An increase in the numbers of breast cancer patients with positive oestrogen receptors having surgery which implies increased surgery in the elderly; 2. Decreasing mortality after bowel cancer surgery with an increasing use of robotic techniques; and 3. In response to NICE guidance, 96% of patients with prostate cancer received specialist radiotherapy while increased numbers received specialist chemotherapy. 

• Patient outcomes: 1. Maternal deaths have dropped due to hypertensive pregnancy disorders; 2. The wait for stroke patients to see a consultant has dropped by 4.5 hours; and 3. There has been an improvement in the attainment of the three key standards for inflammatory arthritis. 

• Use of Data: 1. Hip fracture services have developed SPC charts showing units their performance both at high and low levels; 2. COVID-centred data has been used by PICANet to characterise the disease in children; and 3. We have seen an increased uptake of the audit and data acquisition in psychosis. 

• Process improvements: 1. A doubling of access to palliative care at the end of life; 2. Transition for those with epilepsy improved with involvement of adult neurologists; and 3. 91% of patients rated their prostatic cancer treatment as 8/10. 

Q: What changes are taking place in the NCAPOP? 

A: During the early days of the pandemic, we undertook a critical review of the programme and considered if it was still fit for purpose, asking if it was ready to move into the truly digital era? In consultation with our audits and data providers, we concluded that some things needed to change, to make it more effective at supporting improvement in patient outcomes. These were: 

• Reducing burden: 1. Reducing the number of metrics down to ten and, if there is a requirement for more than this, requiring justification; and 2. Ensuring that routine data is used if at all possible (currently 67% of input is routine). This requires linkage with NHS Digital to ensure the smooth flow of such data and linking with electronic patient records in the future.  

• Outputs: 1. Changes to slim down annual reports so that they are much more succinct, more easily readable, and focused on a major finding from the latest review (with complementary websites used to display more in-depth findings and data); and 2. Increasing impact by using infographics and getting outputs out via as many different partners as possible. 

• Timeliness: A further output from the review was the need to get data back to the service as quickly as possible. This was hotly debated, as faster data is likely less assured. But we have reached a solution, with getting prompt data out (which may be subject to subsequent adjustments), while still having the assurance of annual data. Specifically, we are specifying that, whilst there should be an annual report focusing on the main message of the year, quarterly online data outputs should also be made available. 

• Patient outcomes: There are very important outcomes currently included such as mortality, post-operative sepsis and readmission, but there are omissions and we intend to help audit providers to bridge this gap as we re-commission audits within the NCAPOP. In addition, we need to include many more patient reported outcomes in the programme. 

Q: Which developments in the healthcare system will the changes to NCAPOP address?  

A: We have made these changes to respond to a wide number of developments across the system in recent years, including: The merger of NHS England and NHS Improvement; NHS Digital and X moving into NHS England; the move of Public Health England to the UK Health Security Agency; the transfer of the National Disease Registration Service from PHE (as was) to NHSD (as was); and the transfer of the National Cardiac Audit Programme, including TAVI, run by NICOR, from Barts, to be managed by Arden & Gem CSU. However, above all, the changes to NCAPOP come in response to the COVID-19 pandemic.  

Q: Why was the COVID-19 a key factor in changing the NCAPOP? 

A: It was inevitable that the effect of the pandemic and, in particular, what we learned about the use of data, would escalate change. For example, it proved the necessity for more immediate data (as was necessary with the National Child Mortality Database (NCMD), which moved to live surveillance during the COVID-19 pandemic). We are now able to determine how, with strategic thinking, we can reap important benefits for our patients by the wise use of such data. These lessons have led to this wholescale reorganisation. 

Q: Why are the changes to the NCAPOP important?  

A: Change is only useful if it leads to improvement and, for us, that means better outcomes for patients. We monitor outcomes and, to be honest, these improvements are often now minimal, as big gains as a result of national clinical audit have often been realised. There is one key exception to this: Health inequalities and, more specifically, the influence of ethnicity and deprivation on healthcare outcomes. That is something that we, in national clinical audit, believe we can have a positive impact on, working with data providers to highlight differences exposed by the pandemic and enabling us to tailor services to address them.

This article was originally featured in HQIP’s quality improvement magazine, CORNERSTONE volume 1.