Commissioners are not short of data. Activity reports, tariff analysis, benchmarking
packs and performance dashboards arrive constantly. What they are frequently short of is
evidence: the kind that can be put on a table in a contract meeting and holds up when a
provider disputes it.
That distinction matters more than it sounds. A dashboard shows a variance. It does
not explain the variance, and an unexplained variance is very difficult to negotiate
about. Both parties can look at the same number and hold entirely different views on
what caused it.
What an audit adds
A clinical audit goes to the case notes. It asks, for a defined sample, what actually
happened to these patients and whether it should have happened. That produces something
a dashboard structurally cannot: a defensible clinical judgement about appropriateness,
attached to a countable number of cases.
Three examples from audits we have run for CCGs.
Emergency and ambulatory care pathway
The audit identified around forty thousand pounds of avoidable non-elective admissions
in the nought to one hour band, and set out the specific reasons for the blockages in
patient flow through A and E. It also established baseline metrics for the ambulatory
care unit for the first time, which then became the basis for revising the local tariff.
The commissioner went into negotiation with a case rather than a concern.
First to follow-up ratios
Ratios that look high on a dashboard are easy to explain away as case mix. The audit
produced the evidence to renegotiate the ratios and the avoidable readmission rate, and
to reduce payment in the specialties where the pattern could not be clinically
justified.
Short stay admissions
This one was the most uncomfortable for the provider and the most useful for the
commissioner. The audit supported non-payment for thirty five per cent of very short stay
admissions, on the basis that they were largely serving the four hour target rather than
the patient. It also found that around eighteen per cent of paediatric non-elective
admissions were avoidable, which became the basis for standing up a paediatric short stay
assessment unit. That second finding was worth more than the first, and it was not what
the audit set out to look for.
Why the evidence survives challenge
Because it is clinical rather than statistical. When a provider disputes an activity
based claim, the argument is about methodology and both sides can sustain it
indefinitely. When the finding is that a named cohort of patients did not clinically
require admission, and clinicians have reviewed the notes and agree, there is much less
room to move.
This is also why audits work better when the provider’s clinicians are involved in
scoping them. An audit done to a provider produces a fight. An audit done with a provider
produces a shared conclusion, and usually a service change rather than just a payment
adjustment.
Where audit earns its keep
Clinical audit is worth the effort where you need to drive improvement in clinical
effectiveness and outcomes, test whether spend is buying value, understand patient
experience beyond the survey score, redesign a pathway, or build a contract position that
will hold.
It is not the right tool for everything. It is slow, it needs clinical time, and a
poorly scoped audit produces a lot of work and no decision. The ones that pay for
themselves start from a specific commissioning question rather than a general wish to
look at a service.
A practical starting point
Pick the service where you most distrust the activity data, and where you would
struggle to say precisely why. That discomfort is usually a reliable signal that the
number is hiding something a dashboard is not built to show you.