INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL. 7: 1-3 (1992)

EDITORIAL

Medical Audit in Geriatric Psychiatry- More Questions than Answers?

Achieving the highest possible standard of patient care is every doctor’s duty. Critical examination of one’s performance is an essential tool. But, whilst self scrutiny is important, most would agree that review by peers is necessary to safeguard generally acceptable standards. This is the heart of medical audit and is no less important for old age psy- chiatry.

By April 1991 the UK government had intro- duced major changes (Department of Health, 1989a) to the health service-mainly an attempt to introduce an internal market in health care-and it had become a requirement for doctors to practise medical audit (Department of Health, 1989b). Audit seemed to be the government’s hope for assuring standards of care within a maelstrom of change. It is a good time, therefore, to consider audit in relation to old age psychiatry both in the UK and in the international scene.

In general psychiatry audit has developed most in North America and Australasia. North America has shown the more sanction-driven face of audit (Van’t Hoff, 1985; Hoffenberg, 1987). Quality assurance, which includes audit but which is a broader concept encompassing the ‘corporate face’ which a hospital presents to the world-including, for example, the dust in the waiting room-has been the dominant theme in the USA for decades. Hospitals require accreditation and this requires a demonstrably effective internal peer review system. Quite separately the Medicare system randomly samples 15-25% of its funded patients, to ensure quality of care, with an independent nurse (and if necessary an independent psychiatrist) screening case notes (Psychiatric News, 1990). The emphasis is on justifying procedures and keeping down costs.

Discharge of patients ‘quicker and sicker’, with a heavy cost accountancy approach to medicine, is a fear expressed about this system. An overwean-

ing burden of accreditation-Johns Hopkins, for instance, having to satisfy 100 funding bodies-is another fear. Fear of excessive dominance of psy- chiatric care by ‘managed’ costs has led Sharfstein (1990) to raise the spectre of ‘mangled psychiatric care’. Some have advocated abandonment of this inspectorial spot check approach and use instead of the Japanese industrial model of continuous quality improvement (Berwick, 1989). The cost- effectiveness of the whole expensive system has been seriously doubted (Garden et al., 1989; Rivett and Fawcett-Henesy, 1990). And, amidst this pleth- ora of monitoring and regulation, the profile of psychiatrists in leading-as opposed to participat- ing in-audit of their own professional area is not always high. By contrast in Australasia, the Royal Australian and New Zealand College of Psychia- trists has impressively taken a strong lead role by defining treatment protocols for various con- ditions, which may be used in peer review (Quality Assurance Project, 1982).

But what of old age psychiatry? A recent review revealed very few reports and very little activity specifically in old age psychiatry and led by old age psychiatrists, based on an informal 1990-91 international survey (Jones).

What are the problems for audit in old age psy- chiatry? Firstly, old age psychiatry is often not securely identified as a special area. Secondly, there are problems with the established categories for audit-structure, process and outcome-with out- come, which is very hard to define in psychiatry generally, especially complex here (Royal College of Psychiatrists, 1989).

The structure of a service should be easy to define. In reality services are crucially dependent on effective collaboration with other agencies- such as social services, voluntary services or the family practitioner team-much less tangible and generally unrecorded data. Activity measures

0 1992 by John Wiley & Sons, Ltd.

2 EDITORIAL

(included within process) may similarly fail to reflect the major work of services in community settings. In the UK there is barely any data collec- tion on this aspect. In fact effective data collection for audit seems likely to require psychiatrists them- selves to record much of the data.

Clearly, in modern old age psychiatry the ‘pro- cess’ is highly dependent on a multidisciplinary team effort with patient and carer, which should be audited. But how happily would different pro- fessionals take to the judgements of others? One approach could be for one team to audit another, discipline by discipline, periodically-the physio- therapist audits the physiotherapist, though in a team context, and so on. But teams vary in their make-up and approach, and this could be very time consuming.

The most major problem is outcome. How, for instance, do we balance outcome with the patient against outcome with the carer? With many demented patients managing a ‘good death’ is sur- ely the aim. But how is this measured? At what point should outcome be assessed? And we lack clear agreement always on what is a good outcome -let alone agreed simple, easy, valid and reliable measures for the frequently complex, multifaceted, physical and psychosocial matrix which we call out- come. The important work of Rosser and others in this broad area, QALY’s and concepts from cost benefit analysis are important as research tools but seem unready for general application (Donaldson et al., 1988; Rosser, 1988; Wilkinson, 1990). And, may summarising and condensing information about patients in this way risk missing individual fine grain details of outcome which could be important determinants of quality of life? Certainly discrimination, focusing on practical details of out- come seems more appropriate for audit. The tech- nique of needs assessment (Brewin, 1987) shows promise but has been little applied to the elderly psychiatric patient as yet.

Could we use ‘proxy’ measures of outcome, by picking on particular service activities which seem likely to be associated with ‘good outcome’? At this stage these would be picked on a face validity basis but then studies should establish their actual association with outcome. Examples might be the responsiveness of a service-how soon after refer- ral the patient is seen-or the community orien- tation of a service-how many referrals are seen by the psychiatrist at home. Both would be expected to promote a better initial assessment at least and thereby perhaps a better outcome-but

we need to study this. A more detailed approach could involve, like the Royal Australian and New Zealand College of Psychiatrists, devising consen- sus protocols of management of specific conditions. These would be expected to produce the best out- come. Simple sets of clinical standards (process) could be derived from these protocols and audit would check how fully they were met. Again, studies should assess how such protocol clinical standards really relate to good outcome. And, per- haps, we should think in terms of detailed particu- lar outcomes with specific conditions rather than blanket ‘good outcomes’.

One measure of outcome, certainly, is death. This has been the focus in the IJK for the successful system of confidential data gathering from clini- cians, the Confidential Enquiry into Peri-Operative Deaths (CEPOD) (Buck et a/., 1987), itself a devel- opment of the Confidential Enquiry into Maternal Deaths. There is a place for a similar operation in old age psychiatry, though perhaps it would need also to span general psychiatry. Confidential reporting-run by the national professional orga- nisation, probably with support from public fund- ing-of the circumstances surrounding death of elderly patients in psychiatric care (or soon after discharge) should yield much to help improve the practise and reality of services.

There is a strong role here for the national pro- fessional organisations-Associations or, in some parts of the world, Royal Colleges. The UK Government began by strongly asserting that audit should be medical and led by the medical profession (Department of Health, 1990). In reality other changes in the health service seem to be shifting the focus for audit to local hospital units and their managers. Some American experience suggests that audit and quality assurance do not work unless built into the management system (Rivett and Fawcett-Henesy, 1990). Certainly effective audit activity needs the support of managers and admin- istrators for funding, data and personnel. But there is a clear conflict between the efficiency and cost cutting focus of managers and the medical pro- fession’s desire to assure and improve high stan- dards of clinical care (Glover, 1990). To ensure appropriate professional audit it is important that old age psychiatrists establish leadership in this area. That doctors should regularly spend some time effectively in peer groups in ‘systematic, criti- cal analysis of the quality of (their) medical care’ should and has become widely accepted (Holman, 1989; Shaw, 1989; Shaw, 1990).

EDITORIAL 3

So what should old age psychiatrists do? We are still learning the answer but certainly they should do it to themselves before it is done to them!

Old age psychiatrists should form local groups (or exploit those already in existence) to conduct independent peer review on each other’s services. At the simplest level review of a few randomly plucked cases is easy to do and repays rich divi- dends in highlighting what actually happens. How- ever sophisticated audit becomes, this simple basic examination of what happens with individual patients should remain at the heart of the activity. Such peer review should be frank but realistic and focus on a supportive, and constructive approach. A broad perspective is necessary, addressing the needs of carers as well as those of patients, and, if possible, including contact with other ‘con- sumers’ such as family practitioners. All doctors in the service should be involved and attempts should be made to explore multidisciplinary audit. Certainly, geriatrician physicians and general psy- chiatrists should be involved in this audit from time to time. It is important to try to produce agreed specific outlines of good clinical practice for use in audit activity. These should be simple enough to allow of relatively easy checking against what case records show. Actual practice is thus estab- lished and goals for improvement set for later review (Shaw, 1990).

Old age psychiatry is particularly vulnerable to fragmentation of care and to underfunding. Audit can very helpfully highlight such problems and pro- vide an effective argument for improvement. Let audit demonstrate to your funding authority the strengths and weaknesses of your service, and use it then to achieve greater funding both for better audit and for better services.

ROB JONES University of Nottingham Medical School

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