developingrole of medical audit advisory groupsquality in health care 1993;2:232-238 developingrole...

Quality in Health Care 1993;2:232-238

Developing role of medical audit advisory groups

Charlotte Humphrey, Diane Berrow

AbstractObjectives-To investigate the ap-proaches to audit of different medicalaudit advisory groups (MAAGs) and toconsider the implications for evaluationof their activities and their developingrole in the light of new priorities forclinical audit.Design-Qualitative study based on semi-structured interviews.Setting-I 5 family health servicesauthority (FHSA) districts in two Englishhealth regions.Subjects-MAAG chairpersons and sup-port staff and FHSA general managersand medical advisers in each district,totalling 68 subjects.Main measures-Structures and activi-ties of MAAGs; perceptions of theMAAG's role and its achievementscompared with the initial brief in a healthcircular in 1990.Results-The approaches of differentMAAGs varied considerably: someconcentrated on promoting audit andothers were involved in a wider range ofdevelopment activities. MAAGs assessedtheir progress in various different ways.The importance of collaborative workingwas recognised, but few interface auditprojects had been undertaken. MAAGshad little contact with other qualityassurance activities in the FHSA, andFHSA involvement in the MAAG strategywas variable, although MAAGs weretaking steps to improve communicationwith the FHSA.Conclusions-Major differences exist inthe approaches taken by MAAGs and theroles they fulfil, which will makeevaluation of their effectiveness acomplex task. Already MAAGs areresponding to changing expectationsabout audit and pressure for closer linkswith management.(Quality in Health Care 1993;2:232-238)

Department of PublicHealth and PrimaryCare, Royal FreeHospital School ofMedicine, LondonNW3 2PFCharlotte Humphrey,lecturer in medicalsociologyDiane Berrow, researchassistant

Correspondence to:Ms HumphreyAccepted for publication5 November 1993

IntroductionThe 1989 white paper Working for Patientsintroduced medical audit as a central featureof the NHS reforms.' In primary care,guidance was issued requiring each familyhealth services authority (FHSA) to set up amedical audit advisory group (MAAG), whosefunction would be to direct, coordinate, andmonitor medical audit activities in its area.2MAAGs were to be medically led, most oftheir members being local general practitioner(GP) principals, but they would beaccountable to the FHSA for carrying outtheir work (box).

Since 1989 thinking has changed about thenature and role of professional audit in theNHS. The Department of Health's recentpolicy statement on clinical audit3 exemplifiesthe new perspective. Medical audit is expectedto give way to clinical audit, with auditbecoming largely multiprofessional andspanning all aspects and sectors of care. Auditremains a professional activity, but there isincreased emphasis on the influence ofpurchasers of health care, health servicemanagers, and patients on the auditprogramme. In the light of the new prioritiesthe department has emphasised the need toreview the progress of the MAAG initiativealong with that of the other audit programmes.As FHSAs move more into the role ofpurchasers and have to make difficultdecisions about service priorities they are alsoincreasingly concerned to know whether theyare obtaining value for money from theirMAAGs.4 Thus there is a desire bothnationally and locally for an analysis of whatthe MAAGs have been doing.MAAGs are new bodies with a new task.

They have no precedent to work with, and noestablished historical relationship with, otheragencies in primary care. In these circum-stances it is hardly surprising that the varietyof approaches adopted by different MAAGshas been noted as one of their most strikingfeatures.5 We report a qualitative study whichset out to explore the nature and extent of thisvariation. The first aim was to find out whatMAAGs were doing and how those peoplemost directly involved perceived their tasksand achievements. By obtaining views of eachstudy MAAG from various professional andmanagerial perspectives we sought to explorethe degree of consensus about its role and toidentify areas of disagreement. Further aimswere to find out what mechanisms theMAAGs were using to measure their progressin promoting audit and to consider theimplications of our findings for evaluatingMAAGs themselves.

Accountabilities ofMAAGs to FHSAs2* Instituting regular and systematic medical

audit in which all practitioners take part* Establishing procedures to ensure

confidentiality for individual doctors andpatients

* Establishing appropriate mechanisms toensure that problems disclosed through auditare solved

* Providing a regular report on the generalresults of the audit programme

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Subjects and methodsSince our purpose was to explore varietyrather than to establish frequencies we were

more concerned to ensure coverage of a widerange of different approaches than to obtain a

statistically representative sample. On thesegrounds we chose to study all 15 MAAGs intwo English regions instead of samplingrandomly from the 90 MAAGs in England as

a whole. From preliminary discussions withstaff in the two regions selected we were ableto ascertain that the regions contained a range

of districts with a wide variety of contrastingcharacteristics which seemed likely toinfluence the work of the MAAG (box).Our initial intention was to seek interviews

with the MAAG chairperson, MAAG supportstaff (clinical or lay), FHSA general manager,

and FHSA medical adviser in each district.Names were obtained and responsibilitiesconfirmed by telephoning the FHSA. Inplaces where we learnt that the medical adviserhad no contact with the MAAG, where

Interview topics and examples of subsidiary items of inquiry

Topic

Setting up of MAAG

Membership of MAAG

Group functioning

Financing

Relationships with others

Aims and objectives

Activities and methods used

Measurement of practice auditactivity

MAAG self evaluation

FHSA's perceptions of MAAG

Future

Example of subsidiary item

Extent of FHSA involvement indeciding constitution

Roles and responsibilities ofdifferent members

Communication within group

Adequacy and conditions offunding

Nature of FHSA-MAAG contact

Extent to which measurableobjectives set

Most and least important activitiesof the MAAG

Nature of data collected

Perceived failures andachievements

Criteria for assessment

Likely lifespan of the MAAG

structures varied, or where responsibilities hadrecently changed hands we followed localadvice about whom to approach. We wrote to

all individual subjects thus identified, askingthem to agree to a confidential interview.When jobs were divided between a number ofpart time staff we asked to speak to one of thegroup or several together in the same

interview.We devised a semistructured interview

schedule which we piloted with FHSA andMAAG staff in a district outside the studyregions. The topics (box) were developed inconsultation with an advisory group whosemembership reflected the different interestgroups included in the study. We used thisinterview schedule with all participants. Whennecessary during the interviews respondentswere asked to clarify any differences betweentheir personal views, those of others involvedwith the MAAG, and agreed MAAGstrategies.The interviews, which took one to two

hours to complete, were recorded on audio-tape and subsequently transcribed. Interviewdata were supplemented with additionalinformation from all the MAAGs' annualreports and other relevant documents, wherethey were available. The data were analysedaccording to several themes selected on threedifferent grounds: some were identified withinthe original brief for MAAGs; some havebecome relevant in the light of the more recentfocus on clinical audit; and some emerged as

important to understanding the work of theMAAGs during the interviews.

In this paper we draw on our findings toshow how the MAAGs in our study haddeveloped in different ways and how theyviewed their progress in getting auditestablished. We consider how far they hadtaken on board changing views about theimportance of multidisciplinary and interfaceaudit, links with wider quality management,and management involvement in the auditagenda. Finally, we briefly discuss differentcriteria which might be used to evaluate thework of the MAAGs and consider theimplications of our findings for any suchassessments.

ResultsEveryone approached agreed to be inter-viewed. In total we interviewed 68 peopleduring the winter of 1992-3 (table 1). Two ofthe FHSA general managers and eight of themedical advisers interviewed were also MAAGmembers.The titles, grades, and responsibilities of

support staff varied considerably betweenMAAGs; here we refer to them generically as

MAAG staff. In areas where views variedsignificantly between different categories ofrespondents we make this clear; where a

reasonable consensus of opinion was found wehave not distinguished between opinions.Respondents frequently referred to the MAAGas a single entity possessed of its own attitudesand perceptions; where it seems appropriatewe have adopted this usage.

Variable characteristics

Geography/populationLarge/small districtRural/urban populationAffluent/deprived population

General practice characteristicsHigh/low proportions of singlehanded practices,training practices, and GP fundholdersPresence/absence of a local academicdepartment of general practiceHigh/low profile local medical committee

Health service characteristicsFinancially "losing"/"gaining" FHSAMerged/separate FHSA/DHAOverlapping/coterminous FHSA/DHAboundariesOne/several local hospitals



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Table 1 Subjects interviewed, by category, in 15 MAAGs in England

MAAG

A B C D E F G H I Jr K L M N 0

FHSA:General manager + + 2+ + + + + + + + + + + 14Chief executive - - + + - - - + - - + - - - 4Medical adviser + 1/3* 2+ + + t + -t + - + + 2/2* -1-13Other directorate f -tft t+ tt+ f + 3tt f3

MAAG:Chairperson + + + + + + + + + + + + + + + 15GP facilitator - - - 1/7* + + - - - 1/4* - 4Lay support staff + + + - - + + + + - 4/4* 2/2* + - + 15

Total 68

+ Postholder interviewed.2+ Two people interviewed (old and new incumbents).- Non-existent/not in post.*Number interviewed/total number for part time postholders.tNot involved with MAAG.

HOW MAAGS HAVE DEVELOPEDThe MAAG circular was primarily concernedwith the organizational structure within whichaudit should be undertaken, rather than thenature of the audit process.2 The originalguidelines deliberately left room for localinterpretation, on the assumption thatapproaches would differ from place to placeand evolve as experience was gained.The MAAGs in our study had conformed

fairly closely to the original recommendations,as far as they went. All were numericallydominated by GPs (table 2); however, 12 ofthe 15 had extended their membership toinclude at least one FHSA representative.They were all heavily involved in providingtraining, support, and facilitation for theirconstituent practices, with a variety ofdifferent approaches; all had some links withthe wider medical education system, all haddeveloped effective methods of protectingconfidentiality, and all reported regularly ontheir activities to the FHSA. But within thesecommonalities there were importantdifferences between styles and activitiesreflecting the substantial room for manoeuvrewithin the original guidelines and the impactof widely differing local circumstances on thenature of the task faced by the MAAGs andthe shape of the local response. For example,the MAAGs varied in how they perceived theirrole in relation to management, some seekingto provide a "buffer" between local generalpractice and the FHSA, others serving as a"bridge"; how they defined their function,some choosing a narrowly defined focus on

Table 2 Comparison of guidelines for membership and findings for 15 study MAAGsGuidelines Study MAAGs

Precise size to be determined locally. Normally Range 7-15 medically qualified members"No more than 12 members who are medicallyqualified"Majority of members to be local GP principals Range 6-12 GPsOne hospital consultant >-1 Consultant (14 MAAGs)One public health doctor --1 Public health doctor (13 MAAGs)Other health professionals might be co-opted Nurse member (1 MAAG)No mention of lay representation Lay member (1 MAAG)No mention of FHSA representation FHSA general manager* (2 MAAGs)

FHSA medical advisers (8 MAAGs)Other FHSA representation (2 MAAGs)

MAAG might employ GP facilitators GP facilitators (4 MAAGs)No mention of lay support staff Lay support staff (11 MAAGs)*In addition, two general managers attended MAAG meetings as observers.

audit, others assisting practices to meet a widerange of developmental needs; and howproactive they were in setting the local agendafor audit. The FHSA managers likewisediffered in their perceptions of the MAAG'srole, some regarding it as confined toproviding audit support to general practice,others as a potential source of professionaladvice to the health authority across a widerange of service issues. They varied in howmuch importance they attached to the MAAGand what they committed to it in officesupport or additional funds beyond the basicbudget allocation. Almost half the MAAGshad access to funding from other FHSAbudget areas to help support audit. As a resultof such differences the problems facing theMAAGs and their criteria for measuringsuccess were also very variable amongdistricts.From our findings we constructed three

models of MAAGs (box), whose character-istics were chosen, not for their particulardominance - no dominant combinations couldbe identified - but to illustrate the complexityof the variation. Our sample contained 15MAAGs, each of which was unique inimportant ways; presumably in England as awhole there are 90 different versions. Theextent of these differences limits theobservations that can be made about theMAAGs as a homogeneous group.

ESTABLISHING AUDITThe first and main task for which the MAAGswere accountable in the circular was "theinstitution of regular and systematic medicalaudit in which all practitioners take part."2

All the MAAGs in our study had madeefforts to evaluate their progress in audit andwere becoming more systematic and advancedin their methods of categorising practice auditactivity. Many had developed their ownsystems of assessment, others were usingadapted versions of a model developed by theOxford MAAG.6 However, many MAAGs stillhad incomplete information about the auditactivity in their practices, especially those thatwere unwilling to press their practices fordetails, those whose strategies did not entailregular or comprehensive practice visits, andthose that had adopted a decentralised modelof patch based working. MAAG staff alsocommented on the difficulty of keeping theirinformation up to date and ensuring thatpractice visitors filled out assessment formsconsistently. Therefore, most staff had doubtsabout the accuracy and validity of their owndata. These problems apart, no consistencyexisted among the MAAGs in the informationrecorded about practice activity. It would notbe possible, therefore, to produce an accurateaggregate measure of the degree of progresstowards the objectives.

Nevertheless, all the people we interviewedfrom MAAGs and most FHSA respondentsfelt that progress was being made: there wasgeneral confidence that more practices weredoing audit; the range of practice teammembers involved had widened; the topics



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Contrasting models ofMAAGs

MAAG ASetting: Large suburban district with a minority inner city population.Well established teaching practices in affluent areas and strugglingsinglehanded practices. Financially "losing" FHSA.

Membership: Based on shadow audit group set up by local medicalcommittee. Commitment to including "normal" GPs. No FHSA presence

on MAAG.Siting and support: Administrative assistant based in MAAG member'spractice.

Finance: £80 000 basic budget allocation from FHSA.

Philosophy: Non-directive, led by local GPs' interests. Willing to advisepractices on wide range of professional issues. Not keen to providepractical help in areas of FHSA responsibility.Strategy: Highly devolved patch based support led by GP facilitators.

Perceived success: Developing the trust and interest of previously scepticallocal general practice.Pressing issues for VLAAG: Responding to diverse needs of local practices;maintaining independence from FHSA.Pressing issues for FHSA: Improved communication with MAAG over itsstrategy; seeking evidence of value for money.

MAAG BSetting: Medium sized, city based district. Strong academic departmentof primary care. Single central hospital. Coterminous FHSA/DHAboundaries.Membership: Set up by general manager in consultation with academicGPs. High profile academic leadership with commitment to excellence.General manager is observer at MAAG meetings.Siting and support: Research coordinator based in academic departmentand several audit assistants.

Finance: £60 000 basic budget allocation from FHSA; £45 000 over two

years from externally funded projects.Philosophy: Strong commitment to educational leadership. Keen to helppractices with audit but not wider development issues.

Strategy: Organises districtwide projects on topics selected for their valuein teaching about audit. Lay support staff provide practices with technicalhelp and advice in writing proposals for funding.Perceived success: Obtaining substantial external funding for projects,several publications, and a national reputation for rigorous audit.

Pressing issues for MAAG: Maintaining project funding and coordinatingMAAG funding from multiple sources.

Pressing issues for FHSA: Keeping MAAG down to earth and focused on

practical local issues rather than research projects.

MAAG C

Setting: Small urban/rural district. FHSA/district health authority recentlymerged.Membership: Set up by FHSA medical adviser with public healthbackground. Members chosen for enthusiasm and technical expertise.Medical adviser sits on MAAG.

Siting and support: Audit facilitator based in FHSA.

Finance: £45 000 budget allocation from FHSA. Free accommodationand office support. Access to GMS and FHSA "slippage" monies forpractice support on an ad hoc basis.

Philosophy: Pragmatic commitment to improving services by whatevermeans available.Strategy: Mixture of MAAG initiated audit projects addressing local

priorities; computer based group audits and facilitation of local practicedevelopment (help with age-sex registers, teamworking, etc).Perceived success: Working with FHSA to develop practice information

systems and compatibility of computer systems for audit.

Pressing issues for MAAG: Fear of neglect of audit by the new joint health

authority with its wider agenda.Pressing issues for health authority: Developing multidisciplinarycollaboration over a wide range of quality issues; identifying opportunitiesfor transfer of resources to primary care.

audited were becoming more appropriate;audit skills had improved; and interest in audithad increased and fear had diminished. SomeMAAGs could document these changes ingreat detail with evidence from their records;in others the assessment depended on a widevariety of indicators such as comments frompractices, attendance at meetings, requests forMAAG help, etc. Several of the MAAG staffwe interviewed, however, questioned theextent to which the MAAG could take thecredit for these developments. Some felt that,in part at least, they were observing anddocumenting changes that would havehappened anyway.At the same time the MAAG respondents

clearly appreciated where the MAAG's limitslay. All knew of practices that were notauditing and seemed unlikely to start. Someacknowledged that they had given up on aminority of the most resistant practices (oftenwith the tacit agreement of the FHSA),believing their efforts were better placed wherethey were more likely to be successful. Amongthe practices that were doing audit, all theMAAGs were aware of instances in which onekeen partner or a member of the practice staffwas carrying the audit brief for the practice asa whole. The direct involvement of allpractitioners, as opposed to practices, wasseen by most respondents as a distant orunrealistic objective.

In the winter of 1992-3 most of the MAAGsin the study were still fully engaged in teachingabout audit and getting practices started.Encouraging practices to move beyond datacollection to complete the audit cycle wasrecognised to be the next major task and inmany ways the acid test of the MAAG's worth.One MAAG chairperson spoke for many whenhe acknowledged that much of the currentactivity was not useful as it stood. "If it stayslike this," he said, "we may well look back ina few years' time and say the whole thing wasa failure."The MAAG respondents also recognised

the difficulties of assessing and demonstratingeffective change, even supposing it could beachieved. One problem was that they did notnecessarily know where changes had occurredsince their commitment to confidentialityprecluded access to audit results unless thesewere volunteered by the practice. A furtherproblem was that, even where beneficialchange was known to have taken place, itcould not necessarily be acknowledgedpublicly without compromising the privacy ofthe practice. These constraints aside,beneficial effects on patient health arenotoriously difficult to identify in primarycare. Most MAAGs therefore relied on interimindicators of effectiveness such as changes inpractice behaviour. On this basis, and usingtheir informal knowledge of the practices,most MAAG staff we spoke to were able toproduce a list of examples of beneficialchange. However, there was an awareness thatthe changes were not always achieved in "theright way" - that is, through completing theaudit cycle.



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INTERFACE AUDIT AND MULTIDISCIPLINARYWORKING

The original circular required MAAGs toestablish links with public health medicine andconsultants associated with hospital medicalaudit with a view to auditing services bridginghospital and community health services andprimary care. Within primary care co-option ofother team members was suggested.Nevertheless, medical audit among GPs wasclearly predicted to be the major focus ofactivity.The study MAAGs had their prescribed

complement of hospital and public healthconsultants, but these members were ofvarying importance in the group. A fewmembers were strongly engaged with theMAAG, others had only peripheralinvolvement and rarely turned up to meetings.Relatively few interface audit projects hadbeen undertaken. Those that flourished wereusually large scale projects that had obtainedadditional separate funding. The initiative forsuch projects tended to come from either onecommitted individual member of the MAAGor a particular confluence of circumstances,such as local interest and skill in a particularsubject and opportunistic links betweenMAAG members and hospital staff. Suchprojects had clearly been easier to set up indistricts with fewer hospitals and simpler localreferral patterns.MAAG respondents were well aware that

success in implementing audit depended onthe involvement of the whole professionalteam. Practice staff were encouraged toparticipate in discussions about audit atpractice visits and in educational activitiesorganised by the MAAG. However,commitment to multidisciplinary working hadnot extended to having a multidisciplinaryMAAG. Many of the MAAGs had discussedco-opting other primary care staff as membersof the group, but with one exception they stillremained entirely medical in their professionalmembership.The MAAG respondents did view interface

audit and collaborative working as important,but generally they saw these as goals to pursueonce audit was going well among GPs. Manyregarded their present GP centred approach asthe obvious first step in a development modelwhich starts with the core professional group,progresses to include the practice team, andsubsequently expands to encompass the widerprimary health care team and community andhospital services. On the other hand, aminority of MAAGs were already taking amore eclectic approach, seeking to tap intoenthusiasm for audit wherever it was to befound. These MAAGs had learnt fromexperience that there was often morecommitment to audit among team membersother than the GPs. They were also findingthat GPs themselves were interested incarrying out audit at the interface withsecondary care. In part this reflected GPs'concerns about the services their patients werereceiving elsewhere; many were also keen todevelop new skills and extend the care they

provided - for example, in shared care forchronic diseases.

WIDER QUALITY MANAGEMENT

Initially, medical audit was seen as clearlyseparate from wider issues of quality, and itwas anticipated that the FHSAs woulddevelop independent mechanisms to considerquality. Since then they have become involvedwith various quality initiatives including thepatients' charter, total quality managementprojects, and British Standard 5750.Most MAAGs in our study had no links

with other quality initiatives in the FHSAs anddid not forsee any. In a few cases, where theMAAG office was based in the FHSA,informal contact between MAAG staff andmembers of the quality assurance directoratehad led to joint working on specific projects.Some of the MAAG staff involved in suchcollaborations, however, felt uneasy about thepropriety of this association.Formal quality assurance initiatives apart,

many MAAGs had expanded their own briefto encompass several wider quality issues. Forexample, they were using their growingexperience and knowledge about localresources to provide a significant amount ofinformal help to individual practices withvarious personal, clinical, or organisationalproblems often only indirectly to do withaudit. In this respect most of the MAAGrespondents acknowledged a support functionfar wider than their official role in promotingaudit. Some felt this was an undesirableexpansion which distracted energy andattention from the MAAG's proper purposeand led to a dangerous blurring ofresponsibilities between MAAG and FHSA.In some districts FHSA staff shared this viewand accepted the continuing need for alimited, professionally led focus exclusively onaudit and were successfully using other routesto involve professionals in their servicedevelopment activities. In others MAAGrespondents were interested in movingcautiously towards a role as a professional armof the FHSA, offering advice on a wide rangeof practice and service development issues.Several of the FHSA managers and medicaladvisers were keen to suggest possible areas ofcollaboration with the MAAG (box). There

Suggested service development rolesfor MAAGsProviding advice to FHSAs in:* Evaluating changes in service provision* Identifying opportunities for service

innovation* Identifying needs* Evaluating demands* Developing acceptable systems of assessment* Developing standards* Investigating local problems* Promoting local strategies* Developing other quality initiatives



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was no consistent relation within districtsbetween the views of the MAAG and FHSAon the role of the MAAG.

MANAGEMENT INVOLVEMENTThe original brief proposed joint discussionsbetween MAAG chairpersons and FHSAgeneral managers to agree the programme andscale of medical audit activity,2 though byimplication this was more concerned withsetting the budget than agreeing the content ofthe MAAG's work. There was no mention ofFHSA representation on the MAAG, althoughthe FHSA had the option of suggestingmembers.

In 13 of the 15 study MAAGs, FHSA staffregularly attended meetings, some only asobservers, but most with full membershipstatus. Despite this presence managementinvolvement in the MAAG's strategy was veryvariable. Several of the medical advisers wereinvolved with the MAAG in a personalcapacity rather than as representatives of theFHSA, and others chose to stand back fromthe decision making and take a more advisoryrole. Some general managers had played amajor part in establishing the MAAG andsubsequently stepped back; others had hadrelatively little involvement and were stillseeking to establish dialogue.There was a strong sense of growing interest

among the FHSAs in negotiating with theirMAAGs to ensure that national and localpriorities were taken into account in planningwork. The MAAGs were aware of thispressure and many had already taken steps toimprove communication with the FHSA toidentify common interests and increase theirunderstanding of each other's needs. Althoughnot prepared to be told what to do by theFHSA, they accepted the need to justify theirfunding not only in terms of effectiveness butalso relevance to the authority's concerns. Inmany cases the interests of the FHSAs,MAAGs, and their constituent practices hademerged as quite compatible, simply becauseall were preoccupied with the same currentissues, such as the health promotion bandingsystem and the Health of the Nation priorities.All the MAAGs were committed to respectingthe right of practices and individuals to choosetheir own audit topics, should they wish. A fewMAAGs were unwilling to offer any directiveleadership at all, and these were the districtsthat seemed to be having the greatest difficultyin reconciling the views of MAAG andFHSA.

DiscussionWe have explored the considerable varietybetween the approaches of different MAAGsand also identified some features they shareand discussed some of the common directionsthey seem to be developing. Finally we brieflyconsider some of the implications of ourfindings for assessment of the value ofMAAGs.

Nationally, concern might be expected toconcentrate on the MAAGs' demonstratedeffectiveness in promoting audit, inasmuch

as this was the purpose for which theywere created. However, the range of additionalfunctions that some of the MAAGs hadsuccessfully taken on means that an evaluationon the basis of the audit workalone would be incomplete. An importantstrength of the way the MAAG guidelineswere formulated was the opportunity forlocal innovation and the resulting explorationof previously unconsidered ways of working -

for example, in providing professional adviceon service issues. Such local developmentsmight be evaluated on their own account andtheir adaptability for use elsewhereconsidered.An evaluation of the MAAG initiative would

have to weigh the cumulative achievementsand shortcomings of all the different modelsrepresented. Earlier we commented on theproblems of aggregating evidence of theprogress of MAAGs and interpreting theirachievements in promoting audit. Insofar aseach of the MAAGs in our study was workingwith different priorities in different circum-stances it would be equally difficult, andarguably inappropriate, to compare theirapproaches with a view to saying which worksbest. This was certainly the view of ourrespondents. Although many were confidentof the advantages of their own approach overthose of other districts that they knew about,they all accepted that no single way of workingwould be applicable everywhere.

In contrast, local evaluation of anyindividual MAAG will inevitably be influencedby the impact and perceived appropriatenessof the particular approach that it has taken.Although acknowledging the audit brief of theMAAGs, some of the FHSA managers in ourstudy were equally (sometimes even more)interested in evidence of the MAAG's abilityto help them deal with other pressing issues ontheir own agendas. In those study districtswhere the views of the FHSA and MAAG ofthe MAAG's role differed, the perceptions ofits value tended to be equally at odds.

In conclusion, when the MAAGs were setup it was not known whether their structurewas appropriate to the task or how they wouldwork. Since then those involved with MAAGshave developed a wealth of skills andunderstanding about what is possible and howit can be done. The MAAGs in our study hadclearly provided a focus for sustained thinkingabout the value and limitations of audit and itslinks with wider service development activities.Without this focus it seemed unlikely that localunderstanding and discussion of these issueswould have progressed so far as it had.The past three years have seen great

changes in primary health care services and inpriorities for audit. Consequently, demandson the MAAGs have also changed. The newobjectives of collaboration between differentservices and closer links between professionsand management are arguably more difficultto meet and at least as controversial as theoriginal medical audit brief. Nevertheless, theMAAGs in our study had already begun torespond to these changing expectations and



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were making progress on both fronts. Despitethis evidence of flexibility most peopleinterviewed recognised that furtherdevelopment might entail more fundamentalmodifications to the MAAGs. Although theywere concerned not to leave the originalbusiness of the MAAGs unfinished, many ofthem were already thinking about new names

and structures for taking audit forward.

We thank the MAAG and FHSA staff who participated. Thestudy was supported by a grant from the Department ofHealth.

1 Secretaries of State for Health, Wales, Northern Ireland,and Scotland. Working for patients. London: HMSO,1989. (Cm 555.)

2 Department of Health. Health service developments - workingfor patients. Medical audit in the family practitioner services.London: HMSO, 1990. (HC(FP) (90)8.)

3 Department of Health. Clinical audit: meeting and improvingstandards in health care. London: NHS ManagementExecutive, 1993.

4 Wall C. Medical audit - value for money. Audit Trends1993;1(2):43-5.

5 Spencer J. Audit in general practice: where do we go fromhere? Quality in Health Care 1993;2:183-8.

6 Derry J, Lawrence M, Griew K, Anderson J, Humphreys J,Pandher KS. Auditing audits: the method of OxfordshireMedical Audit Advisory Group. BMJ7 1991;303:1247-9.



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