The lack of integration of clinical audit and the maintenance of medical dominance within British hospital trusts

Concerns have been expressed repeatedly about the effectiveness of clinical audit. Some have argued that this is limited by the lack of integration wi thin day-to-day practice and with other NHS policy initiatives. We aimed to explore what mechanisms were being used to develop annual clinical audit p rogrammes within NHS Trusts, and to describe the influence of other initiat ives on this; to understand how such influences are exerted; and to underst and the role of key players, in order to inform future programme developmen t. Semi-structured face-to-face interviews were performed with Chairs of Cl inical Audit Committees, Clinical Audit Managers and Coordinators (N = 15) in the former Yorkshire Region of the NHS in England. Concerns about the de velopment, planning and integration of clinical audit focused upon an almos t exclusive medical dominance and upon how audit leadership could be delive red within the context of hospital management structures. The lack of an ov erall plan for the development of clinical audit in most sites was seen as enabling the doctors' agenda to dominate. Purchasing authorities were recog nized as being important, but often with limited influence. Other influence s on the audit agenda, such as research and development (R&D) and clinical risk management, were rarely well co-ordinated. These findings concur with previous studies in identifying a wide range of constraints on the progress of audit. Several of these constraints operate within the internal environ ment, for example the doctors' agenda, and concerns about management involv ement. Such constraints require resolution in order to facilitate the integ ration of audit with other initiatives and to achieve the goals of audit ef fectively. Clinical effectiveness and clinical governance may offer a means of facilitating this integration.