The hidden cost of clinical audit: a questionnaire study of NHS staff

Abstract

Objectives: To determine the full cost of clinical audit in one health board area and extrapolate the result to Scotland. Methods: A questionnaire was sent to a representative sample of NHS staff to determine time spent on clinical audit. This was combined with cost data from clinical audit budgets and unit cost data for staff time. Results: Seventy-two percent of staff participated in clinical audit at some point in time. Medical staff were significantly more likely to participate in audit that non medical staff (P<0.0001). Those who participated in clinical audit devoted only a small proportion of time to it. However, due to the high participation rates in clinical audit, this aggregated to a significant amount. In Forth Valley the total cost was estimated to be £1.72m (£1.37m–£2.10m) and in Scotland £36.3m (£29.6m–£44.0m). Staff time accounted for over 80% of the total cost of clinical audit. Conclusions: Clinical audit is widespread within the Scottish NHS and the total cost of staff time devoted to audit is substantial. Research is needed into the value of clinical audit and the potential cost implications of clinical governance need to be explicitly recognised.

Introduction

Since 1989, when the white paper Working for Patients promoted clinical audit as a mechanism for improving the quality of medical practice [1], audit activity has widened from its medical base to include other health care professionals and its practice has become widespread within the NHS. More recently clinical audit has been subsumed within the clinical governance agenda and has become only one component of a larger quality movement. However, it is still viewed as one of the main vehicles for the implementation of clinical governance [2], [3].

Despite its prevalence within the NHS, there is considerable uncertainty surrounding the effectiveness and cost of clinical audit [4]. The evaluation of the effectiveness of clinical audit is inherently difficult, given the problems with defining satisfactory outcome measures and with setting up controlled trials, which have been discussed elsewhere [5]. Meanwhile, little attention has been paid to the total cost of clinical audit in the NHS. Previous studies of the cost of clinical audit have been limited, ranging from attempts to identify hospital expenditure on clinical audit [6], [7] to costing staff time attending clinical audit meetings [8], [9]. No study has provided a robust and complete estimate of the cost of clinical audit within a defined area.

In this study we estimated the total costs associated with clinical audit in one health board area and extrapolated this cost estimate to Scotland. This was calculated by estimating both the financial resources allocated to clinical audit and the time spent by NHS staff on clinical audit. We surveyed a representative sample of NHS staff to estimate the time and cost of clinical audit activity.