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A surgical team from Wilford Hall Medical Cent...

An Auditor of One checking on surgical performance

The UK’s coalition government’s reform agenda continues to unfold with the planned scrapping of the Audit Commission. While the Commission has good analytical capacity and did focus on issues of importance, the need to shift the audit function further into systems and out into the community was not one of its core objectives.

In healthcare, I have written and spoken of the patient as the “auditor of one”, as the patient is the only person who has a real experience of the continuum of care, and it is only through the patient that the integration or not of services is achieved. While bureaucratic processes may try to knit systems together at their edges, only users have that ‘joined up experience’, and it is by engaging with them more effectively that radical service improvement will come about (the use is really the most disruptive force for quality improvement we have).

The next test for audit in the UK will be ensuring that all these auditors of one can be effective; rather unfortunately, the government is referring to them as “armchair auditors” a term which tends to describe distant interest, rather than engaged in the critical appraisal of performance. But organised interest groups can emerge, or existing one expand their scope of interest to increase the salience of issues in the delivery of publicly funded services.

I think one auditor is really enough anyway, but the National Audit Office will need to expand its remit in at least two areas if it is to be really worthy of public expectations, to include:

  1. value-for-money retrospective audits (and not just of assessing implementation against legislative intent);
  2. prospective audits of planned legislation (similar to the US non-partisan Congressional Budget Office).

I might add a third, namely being advised by, and engaging with, the public, perhaps through regional citizen audit advisory groups who can act to bring local concerns together where national concerns, at least, are an issue. There are models for this sort of relationship which would enhance accountability, transparency and visibility with the public.