Thuvaraka Ware is a GP Registrar working in Camden. She tutors medical students at UCL in community medicine and believes primary care research will shape clinical and public health policy over the coming years.
The audit process is an important part of clinical governance to ensure standardised, high quality care. It is encouraged by medical schools and a necessity of training programmes. But for our generation of paint-by-numbers medicine and algorithm based practice, clinical audit has become another hoop to jump through for the eportfolio. I recently completed an audit looking at the prescription of statins in patients with chronic kidney disease (CKD). The standards were taken from the 2014 Lipid Modification NICE guidelines which advised all patients with CKD to be on atorvastatin 20mg or an equivalent regardless of age, comorbidity or qrisk.
My search revealed several high risk vasculopaths who weren’t on statins. Yet, the largest proportion was octogenarians for whom improving 10 year survival seemed questionable. The guidelines did not make allowances for multiple morbidity, polypharmacy or compliance in this cohort. I marched on nevertheless as per my ARCP requirements; however, it became clear that patients are particularly astute at nuance and picking up indecision on the clinician’s part. I found it difficult to convince those on the fence to take the statin because of my own ambivalence about its benefit. The implementation of change was therefore weak leaving the audit suboptimal.
The need to complete an audit for the sake of it is just one facet in the NHS and its increasing ‘obsession with grip’ (as Keith McNeil, former chief executive of Addenbrookes Hospital, puts it). The benefits of good patient care and effective training is secondary to outcomes, stringent documentation and rigorous regulation; the art and apprenticeship of medicine is being eroded. Yes, regulation is important and safety paramount. But experience, skill and judgement – those things we only ever learn through autonomous practice and reflection – appears to have little value in the current climate.
In this context, one thing we can do to make clinical audit more relevant than just a CV exercise, is to bring a bit of ourselves into the process and have a little faith in the cycle. Find something that piques curiosity and is not just a recent topical guideline; an idea that makes tangible sense to you as something that could actually improve practice rather than promising to do so. This belief and commitment will be visible to and appreciated by patients and other relevant stakeholders; which in turn will provide the real impetus to complete an effective audit, one that will maintain relevant clinical standards or effect real change in order to do so.
