Medical audit: threat or opportunity for the medical profession. A comparative study of medical audit among medical specialists in general hospitals in the Netherlands and England, 1970-1999

Medical audit has been introduced among hospital specialists in both the Ne therlands and England. In the Netherlands following some local experiments, medical audit was promoted nationally as early as 1976 by the medical prof ession itself and became a mandatory activity under the Hospital Licensing Act of 1984. In England it was the government who promoted medical audit as a compulsory activity for medical specialists, in particular since 1989. I n this article the development and introduction of medical audit in the two health care systems is described and its impact on the clinical autonomy o f medical specialists gauged. It is concluded that in both countries extern al pressures seem to have been crucial in the 'compulsory' introduction of medical audit. Although there are differences in the organisation and cultu re of the medical profession in the two countries, in both countries medica l audit turned out to be an instrument 'controlled' by the profession itsel f. The question whether medical audit is instrumental in preserving clinica l autonomy has also been addressed. Our conclusion is that in its present f orm medical audit in the two countries has not been a threat to the clinica l autonomy of the medical profession. At the same time it is clear that the study of one quality instrument is insufficient to draw conclusions about the development of clinical autonomy, let alone autonomy in general. Moreov er, it remains to be seen how medical audit can survive alongside quality i mprovement mechanisms such as accreditation. certification, performance ind icators and formal quality systems (ISO, EFQM) where hospital management ex ecutes more control. The history of medical audit in the Netherlands and En gland over the past 30 years does illustrate, however, the capability of th e profession to maintain autonomy through re-negotiated mechanisms for self -control. (C) 2001 Elsevier Science Ltd. All rights reserved.