Quality Assurance Auditing as a managerial technology: Clinical Governance and the managerial regulation of NHS medical practice

Bruce G Charlton
In press as: Charlton BG. 2001. Clinical Governance: a Quality Assurance audit system for regulating clinical practice. In: Clinical Governance: encouraging excellence or imposing control? Edited by Andrew Miles et al. Aesculaepius Medical Press, London

Prof. Bruce G Charlton MD
UEL Centre for Health Services Research,
St Bartholomew’s Hospital,
Reader in Evolutionary Psychiatry
Department of Psychology
University of Newcastle upon Tyne

Editor-in-Chief, Medical Hypotheses

Tel: 0191 222 6247
Fax: 0191 222 5622
e-mail: bruce.charlton@newcastle.ac.uk

Clinical Governance is - at root - a very simple proposition. Clinical Governance is reorganization of the NHS such that the it will embody an auditable 'Quality Assurance' system for the monitoring and controlling of clinical practice. When stripped of ideology, rhetoric and propaganda, Clinical Governance is a managerial system for regulating clinical activity.

Clinical Governance as a 'Quality Assurance' system

The introduction of Clinical Governance has been marked by confusion over what kind of a thing it is. There appears very little substance behind the swirling declarations of high minded intentions (Goodman, 1998).

But we have been looking for Clinical Governance in the wrong place: it is not a thing of substance, but a thing of style. Clinical Governance is not a pre-specified blueprint for change; rather CG is an aspiration. And that aspiration is that NHS managers (and via NHS managers, the government and their executive arm in the Department of Health) should substantially control clinical practice of the NHS.

And by 'clinical practice' is meant, for example, the specific details of what doctors do in the consultation - history taking, examination, investigation, treatment, prescription, referral and everything else that constitutes the activities of a doctor. For the first time, all this is to be brought within the control ('or 'responsibility') of the NHS general management hierarchy. This is the aspiration of Clinical Governance.

And there is a further expectation that control over clinical practice will be achieved by some version of 'Quality Assurance' (QA) auditing, where 'Quality Assurance' is defined in a technical managerial sense, as discussed below.

Clinical Governance is not, therefore, an answer to the question of how to improve the 'quality' of clinical services. Nor is it a method for reducing malpractice or incompetence. Nor is it a means of ensuring that the NHS is of equal excellence throughout the United Kingdom, nor anything of this kind of thing. These may be hoped-for outcomes, or they may just be semi-plausible excuses for implementing the system, but the essence of Clinical Governance is that it is a system. Clinical Governance intends that clinical medicine should be built-around a Quality Assurance system. It is - of course - suggested when clinical practice is done according to a QA system, this will inevitably and continuously generate improvements in the quality and reliability of clinical practice. But there is not a shred of evidence to support this idea, so it is hard to take seriously. There is no historical or international precedent for running an excellent health service in this fashion. Indeed, the proposition that a Quality Assurance system applied to clinical medicine will improve medical practice is not explicitly asserted, nor argued, nor defended - it is just assumed.

The exact nature of a Clinical Governance QA system in the NHS is not predetermined. But the outline shape of the CG system is intended to be one based-upon audit technologies (ie. managerial methods derived from accountancy practice). Given past experience of public sector audit, it seems probable that CG will be dominated by audit of systems and processes, rather than audit of outcomes - this makes it an example of Quality auditing (Feigenbaum, 1983; Power, 1997).

Corporate Governance - the roots of clinical governance

The term Clinical Governance is derived from Corporate Governance (Scally & Donaldson, 1998). Corporate Governance became talked about in 1992 following the Cadbury Report which was commissioned following several major contemporary financial scandals in which audit mechanisms had failed and the regulatory methods of corporations were judged to have been deficient (Cadbury Report, 1992; Power, 1997).

Although the Cadbury Report concluded that the main cause of vulnerability to financial mismanagement was inadequate auditing, it recommended that the best way of preventing such scandals was to have more auditing. But a new kind of auditing. The concept of Corporate Governance was launched, in which governance was 'the system by which companies are directed and controlled', and it was recommended that the focus of external auditing should be to ensure that an appropriate 'governance structure' was in place in an organization (Nexia, 1996). External auditors should concentrate on 'assuring' that an adequate internal auditing system was up-and-running. Clinical Governance is exactly this kind of 'governance structure' - but applied to clinical activity instead of financial management.

This was a critical shift in auditing (Power, 1997), away from traditional year-end auditing of outcomes designed to check that the books balanced - and towards ensuring that each organization possessed an explicit 'governance structure' defining the flow of information within that organization, and auditing the processes which constitute that system. This was the shift from outcome to process that enabled the massive expansion of auditing which we see today in what has been termed the 'audit society' (Power, 1997; Charlton, 1998). As Feigenbaum (1983) puts it: 'The quality-style audit assesses the effectiveness of implementation of the quality system and determines the degree to which systems objectives are being achieved. The audit is system - rather than product - oriented'.

Interestingly, the original thrust of the Cadbury Report was a concern with the transparency' and 'accountability' of senior executive managers to supervisory figures such as the Chairmen and non-executive directors of an organization - and the opening up of senior managers to regulation. This was a response to the financial scandals of the early 1990s which stemmed mainly from corruption and incompetence among upper managerial staff. However, the concepts of transparency and accountability have been hijacked, and the apparatus captured by senior executives - and turned against lower-level employees including profession practitioners. Senior managers never did become the subject of audit, and instead became the controllers of audit (Power, 1997).

Quality Assurance

Quality Assurance (QA) does not have anything directly to do with assuring 'quality' in the real-world sense synonymous with 'excellence' - rather QA is a technical managerial term for auditing concentrated upon systems and processes rather than outcomes. Clinical Governance adopts the Cadbury Report-derived idea that a properly-constituted organization should be based around a system of auditing systems and processes.

Quality Assurance auditing has become closely identified with older managerial approaches including the word 'Quality' - such as Total Quality Management (TQM) and the awarding of quality assurance systems of organizations with British Standards and International Standards (Feigenbaum, 1983; Perigord, 1990; TQM International, 1992). Quality Assurance auditing therefore has close evolutionary links to 'quality enhancement' strategies, based upon based upon creating a 'culture' centred on 'quality' which usually means reorganizing production around reliable processes and systems of checking and feedback. These were in contrast to traditional assembly line 'quality control' inspections which focus upon testing the completed product and rejecting faulty items. These ideas are usually credited to the late W. Edward Deming, and also credited with generating the Japanese economic miracle of the post-1945 era - but they enjoyed a belated revival among late twentieth century UK public sector where they are still regarded as excitingly radical and promoted with Messianic zeal.

When 'quality' has been re-defined in terms of proper systems and processes, rather than proper outcomes, this has the effect of liberating 'quality enhancement' initiatives from the need to define desirable outcomes and best practice. This is of particular relevance to the NHS, since valid and reliable definitions of the real-world 'quality' (ie. excellence) of clinical practices have proved impossible to agree-upon in medicine. However, with the advent of QA, managers have no need to worry about whether they are measuring real-world quality. Debate has been shifted away from the contested territory of outcome measures, towards obtaining agreement to a standard system of practice - to make a fully explicit system of clinical Quality Assurance in which all essential elements can be planned, documented and monitored. This has the effect of rendering clinical procedures at last amenable to external audit - hence external managerial control.

Transparent and accountable

In other words, with the introduction of Clinical Governance as a QA system applied to clinical practice, proper clinical systems and procedures are conceptualized only as those which are transparent to auditing. To be 'transparent' to auditing is termed being 'accountable', and used as a praiseworthy attribute (Charlton, 1999). Indeed, with the rise of the 'Audit Society' (Power, 1997) to be 'opaque' to auditing is regarded as intrinsically suspicious, and 'unacceptable'. Yet, although transparency and accountability have become terms of approbation, strictly speaking they refer merely to audit-ability - and audit-ability does not legitimately carry any necessary implications of responsibility to the public, especially since auditing is implemented, performed and evaluated largely by managers and other bureaucrats.

The conflation of 'accountability with 'responsibility', and of 'transparency' with probity has arisen because, taking a lead from the Cadbury Report, modern managers equate a proper organization with an auditable organization. Organizations must be made auditable - at any price. Traditional 'collegial' organizations of professionals - such as schools, universities, or hospitals - are regarded as intrinsically flawed - since managers do know and cannot control what is going on in them. But by its concentrations upon systems and procedures, QA provides a mechanism for quantifying almost any aspect of organizational performance that can be given a name - 'quality', 'equity', 'access' or whatever the current buzz word happens to be. Aspects of measured organizational performance that are attached to these terms can then 'objectively' be compared with pre-established criteria. What was un-measurable has been rendered measurable - as if by magic - so long as one does not inquire too carefully into what words like 'quality' actually mean in operational terms...

So - QA auditing has profoundly re-shaped the perception of what constitutes a proper governance structure for an organization. Proper practice has been re-defined as auditable practice; and organizations (such as medical clinical practice in the NHS) whose procedures are insusceptible to audit are regarded as unacceptable. Such organizations are stigmatized as unaccountable - implying irresponsible - and lacking in transparency - implying deliberately secretive. The present climate of uncritical advocacy misses the obvious point that audit of processes is merely a crude managerial technique, and far from being a panacea, Quality Assurance has a very poor track record within the UK public sector.

Why anyone should imagine that Quality Assurance methods are suitable for controlling all forms of human activity is an interesting question. Yet this wildly improbable belief is the norm among UK public sector managers, and forms the basis for implementing Clinical Governance. Apparently, the UK government and their civil servants and administrators are in the grip of some form of mass psychopathology. However, there is more to it than that.

The meaning of 'quality' - the example of university teaching

Since, under QA, organizations are no longer seen in terms of outcomes, but in terms of systems and procedures, it follows that proper organizational structure is seen to be fully systematized, fully documented, fully auditable - hence fully controllable by those who can set the agenda for auditing. And a Quality Assurance system has no obvious limit to its range. Criteria for measuring quality, excellence, equity - or any other desired attribute - can usually be defined in terms of 'proper' systems and procedures on the basis of no mare than superficial face-plausibility. It comes down to a question of names.

For example, criteria to measure the real-world quality of university teaching proved impossible to agree upon. Instead, the 'quality' of teaching was re-defined by the QAA (Quality Assurance Agency for Higher Education) in terms of compliance with the Quality Assurance system (Charlton, 1999a; 2000). Teaching characterized by flow-charts, planning, documentation and internal audit was defined as 'high quality'. Only that which is 'on paper', hence auditable, is deemed to count as legitimate teaching activity. No attempt was made to prove that this method of organizing and evaluating teaching inevitably lead to 'high quality', nor that this method of teaching-by-numbers was superior to previously practiced methods of teaching. The QA-approved system was high quality by definition.

All existing evidence is that QA-driven teaching is vastly inferior to traditional methods: there has never been a university of acknowledged excellence in teaching run in this fashion. Excellent universities in the world and throughout history have taught their in totally many many different ways - but never in a fashion which would meet with QAA approval. Indeed, because of its high transaction costs, teachers spend more time on documentation and less on teaching. QA also causes a shift in resources away from teaching and towards auditing, and a shift in power away from academics and towards managers, auditors and the politicians who set the audit agenda. And since managers, auditors and the politicians are more remote and more difficult to influence than academics, there is also a reduction in the power of students. What goes on in universities - from admission, to what is taught, how it is taught, how it is examined and the degrees awarded - are all coming increasingly under centralized control.

Debate on the subject of quality of university teaching was swamped by the QAA-generated mass of pseudo-objective cross-referenced explicit documentation concerning 'standards' and 'performance'. All competent authorities agreed that there has been a decline in the real-world quality of university teaching (with many more students and much less in the way of teachers and teaching resources, this decline is a near-certainty as a general observation). But QAA inspections do not measure real-world teaching quality - indeed they make no attempt to measure real world quality. Instead 'teaching quality' is re-defined as that which is measured by the QAA audit.

Quality Assurance as a managerial technology

Freeman Dyson (1997) has described how societal change can be driven by ideas; but more often it is driven by technologies - with the ideas left trying to keep-up. Quality Assurance auditing can be seen as a technology - a technology for management.

Physics has been driven by ideas such as those of Newton and Einstein - but also by technologies such as the telescope and the particle accelerator. Technologies enhance the situation of some social groups and damage the position of others: breakthroughs in spinning and weaving cloth during the 18th century destroyed the livelihoods of independent male craftsmen and led to the growth of mill factories employing women and children - the factory owners became rich and powerful, the displaced weavers starved to death (Bronowski, 1943).

Technologies are adopted because they serve the interests of social groups with power. The telescope made Galileio a rich man because he could provide a service for the dominant merchant class (Bronowski, 1973). Control of a large particle accelerator makes a scientist powerful and prestigious (Taubes, 1986). Only to the extent that career-enhancement coincides with good science does new technology enhance science (Hull, 1988). Much the same applies to medicine. In the past technologies were adopted that served the interests of the power groups of the time: doctors, patient groups, industrial corporations and mass public opinion (Le Fanu, 1999). Nowadays, medical technologies more closely support the interests of the ascendant class of managers.

Quality Assurance usually describes itself as an ideology, a set of aspirations harnessed to a transforming ethos. For example, it is often said that a QA system is one which puts 'quality' at the centre of an organization, or an ideology which subordinates an organization to 'the needs of the customer'. So QA is presented as a new ideology of management. But the implementation of QA systems very seldom attain the ideal of a quality-centred ethos permeating corporate life. In practice, QA is almost always something that managers do to employees. In practice, QA systems in schools, in universities, in local government, in the police - have been imposed upon the practitioners that actually do the work by a new class of managerial regulators. Indeed, the ideology of Clinical Governance is a very old one - essentially the ideal of 'rational' and 'efficient' administration that has driven many previous bureaucratic expansions as diverse as Bismarck's Germany, Taylorian 'scientific' management' in the USA, 'economic planning' in Britain, and the Command Economies of the USSR and Eastern bloc, China and India. So the ideals of QA are certainly not novel.

What is novel is the technology of Quality Assurance auditing. This really is a new technology - a new tool for the management of organizations. And, like other technologies, its use has spread primarily because it serves the interests of those with power.

What is new about QA is the technology of auditing applied to systems and processes. And it has spread because it is more effective than the previous system of managing organizations. In other words, QA has spread because it is good for managers.

Clinical Governance and Quality Assurance auditing

What will Clinical Governance be like ?- assuming that it is implemented in something like the form its advocates envisage. This is not a difficult question to answer, because general models of the effects of Quality Assurance auditing systems are readily available from other organizations in the UK public sector already - in local government functions, the police, schools, and further- and higher-education. For instance, OFSTED (Office For Standards in Education) is the enforcement arm of QA in schools, auditing teaching against nationally defined standard practices. The QAA (Quality Assurance Agency for Higher Education) does a similar job in universities.

It is known that OFSTED and QAA are both extremely bureaucratic, generate massive paperwork, and inflict heavy opportunity costs on auditees (Charlton, 2000). OFSTED is also notorious as a cause of psychopathology among teachers due to overwork, uncertainty, and fear of victimization in the event of failure. OFSTED inspections seem to be a significant factor leading to teachers retiring early and leaving the profession. Doctors can expect the same kind of pressure from a Clinical Governance system.

The QAA inspection of my own medium-sized university department (approximately 15 academic staff) generated considerably more than ten thousand pieces of paper housed in dozens of box-files that filled a room; and the inspection lasted four full days. The logistics of preparation took many months including full- and part-time secondment of several academic and secretarial staff, dozens of hours of meetings and 'away days' involving dozens of staff, and temporary employment of extra secretarial help.

While the QAA central bureaucracy is itself a relatively small organization, and relatively inexpensive for the government, the heavy cost of inspection is borne by the department being audited. Nationally, it has been estimated that the QAA Subject Review exercise has probably cost several hundred million pounds in opportunity costs. Similarly, the costs of Clinical Governance bureaucracy cannot be estimated from the central bureaucracy - the indirect costs to the clinical organizations operating under the system would account for the bulk of costs.

The nature of auditing: cross-checking for consistency

The bureaucratic and invasive nature of QA systems is "Quality Assurance" auditing derives from financial auditing, and the principal purpose of financial auditing is to detect and deter incompetence and dishonesty in the handling of money. Incompetence is relatively straightforward to discover - but it is the claim of audit to detect dishonest dealing which requires further examination (Charlton, 2000).

There is an apparent paradox involved in auditing. At first sight, it might seem that checking the books fails to solve the problem of dishonesty. After all, if a practitioner is not trusted to do their job honestly, then why should they keep the books honestly?

The answer is that audit detects fraud through cross-checking for inconsistencies. It could be said that the essence of audit is the search for discrepancies in documentation (Perigord, 1990). Fraud is detected when 'the books don't balance'. Cross-checking works when the accounts contain independent sources of evidence, making-up a web of money flows that constitute the operations of the organization. Each strand of the web should be consistent with each other strand when checked every-which-way. A large organization has so many strands that the number of potential cross-checks is almost infinite. Anyone wishing to 'cook the books' has a great deal to fake if they are to ensure that every possible inconsistency has been ironed-out.

Fraud is therefore apparent to an auditor - especially when the volume and inter-connectedness of organizational activity is unmanageably large, and when it involves many people. In effect the auditor is like a detective who takes a statement from each witness to a crime, then checks that each witnesses 'story' is consistent with all of the others. For example, in his 'how to do it' manual of quality auditing, Mills (1993) describes the ways in which an auditor can use cross-questioning and observation to catch the auditee in various types of discrepancy. It is a basic assumption that inconsistency is evidence either of incompetence or dishonesty. Discrepancies are assumed to constitute attempts to cover-up fraud.

Financial accounting (usually) works in its job of deterring and detecting fraud because it is (usually) easier, cheaper and more efficient to be honest than it is to prepare internally-consistent fake accounts which can stand up to skilled cross-checking. In other words, true accounts automatically balance when cross-checked because they are a reflection of reality, while it takes a great deal of work to create audit-proof false accounts.

Clinical Governance - checking for medical incompetence and dishonesty against guideline-based norms

QA auditing has many analogies with financial auditing. But instead of monitoring cash flows to detect financial fraud, a quality assurance system monitors compliance to a quality assurance system - it monitors that such a system is in place, and is functioning. But instead of money, the currency is information.

Clinical Governance will audit doctors on their compliance to a particular - guideline-based - norms of clinical practice. The specific content of guidelines does not much matter - what is vital is that there are guidelines, and that they are complied with. The approved CG system is one in which, ultimately, it is intended that every significant aspect of practice is formally and explicitly planned, documented and monitored. What is not documented does not count as significant, because it cannot be part of the QA system, hence cannot be audited. Good clinical practice is defined by Clinical Governance in terms of an explicit information flow system; and whatever is implicit, or outside of the system, does not count as good practice.

Making medicine auditable is therefore what guideline-based practice is all about - at least from a managerial perspective. This explains the vast amount of manpower and resources which NHS management has invested in guidelines over past few years - creating and funding an army of researchers (health economists, epidemiologists, biostatisticians, health service researchers, facilitators and administrators) in the process. Ultimately, Clinical Governance guidelines will be expressed in terms of flow diagrams ('care pathways') - as in managed health care systems or the treatment plans used in some Health Maintenance Organizations in the USA. The flow diagrams are necessary to Quality Assurance auditing because they define the relationship of information sources, and the legitimate range of cross-checking between information flows. Armed with these diagrams of what is supposed to happen, the Clinical Governance enforcers will behave very much like financial auditors in their search for inconsistencies. And inconsistency implies fraud.

A CG system would audit clinical practice documentation for its completeness (minimum data set) - and each item of documentation must be consistent with all other items of documentation when cross-checked. Undocumented practice is bad practice - and the nature and level of documentation will be defined by managerial demands - not by clinical need. Practice must also be consistent with the mission statements, and aims and objectives, of the organization; and documentation must be provided to demonstrate this consistency.

And as the CG system becomes more comprehensive, so the potential for cross-checking will increase. Each specific item of information must also be consistent with the documentation from other professionals in the organization, and with other disciplines. Internal information can be checked for its consistency with external policies, such as relevant government or NHS executive policies (such as Patients Charter, Waiting List initiatives, Ethnic monitoring or whatever the latest high profile project). All this cross-checking inevitably requires vast documentation, hence vast bureaucracy, hence substantial cost (Charlton, 2000). And this is the essential reason why QA systems have an irresistible tendency to become highly bureaucratic and expensive. Escalation of documentation is built-in - even when this is not the initial intention and when the early phases are relatively modest and sensible.

The fact that auditors could not conceivably read all the vast documentation, let alone perform the almost infinite number of potential cross-checks, does not matter. The point is that the auditors might want to know anything. And failure of either comprehensiveness of documentation or consistency in cross-checking in any one respect is taken as evidence of generalized fraud. If the auditee has failed to stick to recommended procedure (failure to 'stick to guidelines'), then the auditee is culpable.

In the end, for QA auditing to prevent 'fraud', it is driven into making the demands for documentation so comprehensive that fakery is easily established by cross checking, and so heavily labour intensive and multidisciplinary that fake accounting will not be an option. It must be made easier to comply with the letter of the audit than it is to cook the books. So, in practice, QA systems will always generate a demand for vast quantities of documentation - whatever the hopes or promises of its advocates.

Trust in process, distrust of people

Audit systems such as CG displaces trust onto the process of audit rather than the individual employee (Power, 1997). Instead of trusting employees to do their job properly, employees are made to comply with audit procedures and trusted only to prepare auditable documentation. The practitioner is not trusted to perform well, but the audit process is trusted to ensure good performance.

Audit systems such as Clinical Governance therefore mark a stark reversal of assumptions for the medical profession. In the past, doctors have been trusted except were there was reason to assume that trust was being abused. Doctors were assumed to be doing their job unless it could be shown otherwise. But under Clinical Governance these principles are inverted. Audit is based upon an assumption that doctors are incompetent frauds - except when documentation can prove that they are not; the assumption is that doctors are not doing their job properly, except where documentation demonstrates that they are. Failure to comply with procedure is sufficient evidence of incompetence or fraud.

For example, re-accreditation or re-validation are being absorbed into the Clinical Governance structure. In the past a medical qualification was a license to practice - and removal of that license required that the practitioner be proved unfit to practice. Now the principle is reversed - the medical qualification means very little. Practice is conditional upon compliance with re-validation or re-accreditation procedures, which are already being driven by managerial and political imperatives. The future seems clear enough. If a doctor does not jump through managerial hoops in a manner which satisfies managers then he or she will not be allowed to practice. The primary medical virtue will become obedience - not competence.

Managerial control by QA auditing

Corporate Governance put forward the idea that legitimate corporate functioning depends upon audit; that audit is primarily a matter of regulatory systems; and that the role of the auditor is to ensure that the appropriate governance structures are in place and operating properly.

Traditional outcomes auditing is retrospective and seeks to impose good practice only by its deterrent effect. If you commit fraud, the books will not balance, and the auditors will catch you. By contrast QA auditing is - in intention, if not always in practice - prospective. The name tells us that QA seeks to assure good practice - not to detect bad practice. And quality is operationalized by defining good practice as adherence to a specific set of systems and processes. In medicine, this translates into good clinical practice is defined-as clinical practice based-upon documented adherence to pre-planned guidelines, protocols, standards etc. As described above, the 'high quality' good doctor is defined by obedience to the QA system of conditional re-accreditation and continued documented compliance with guideline-based practice.

Politicians, managers or anyone else can come to control a 'quality assured' organization by 'capturing' and its audit system. Inspections and audit cycles are linked to incentives (such as differential funding, published league tables, withdrawal of funding, threat of closure, imposition of external management, scapegoating or naming-and-shaming). An organization that wishes to do well in a Quality Assurance inspection will need to provide evidence that there are procedures in place of the recommended kind, and that these procedures are operating. Documented compliance with procedure is taken to mean that the organization can 'assure' whatever is required by the controllers.

For example, if governments want to encourage an NHS Trust to work more closely with Local Authorities, it can do this by QA mechanisms. Government might set-up an external agency (OFLOC?) whose job is to audit NHS Trusts and relevant branches of Local Authority for compliance with a system of standard procedures that are assumed to represent cooperation (eg. monthly joint policy meetings, joint-appointment of liaison managers, two-way circulation of newsletters etc.). NHS Trusts and Local Authorities might then be inspected by OFLOC to ensure that these systems and procedures are in place and functioning. An NHS trust that wants to do well in the audit will need to set up formal structures for policy, liaison, feedback and so on - and provide documentation that these structures are operating. If the Trust 'failed' an OFLOC inspection by providing insufficient or inconsistent documentation it could experience a funding penalty with job losses and hostile media coverage.

Yet only insofar as it can reasonably be assumed the demands of auditors - and the politicians and managers who devise the standards which auditors enforce - are identical with excellence, can Quality Assurance be said to be genuinely about enhancing quality.

Advantages of audit-based management

In old fashioned 'command' systems of management, the managers must directly 'order' the workers to perform certain tasks. This raises the problem of enforcing obedience. Orders will either need to be face-to-face, via an intermediary (eg a foreman), or by written instructions 'memo'). But however it is done, this style of command management involves an element of direct confrontation, of one person asserting their will over another person, and achieving dominance.

When managers are more skilled, better educated, higher status and more confident than the workers attaining dominance is not usually a problem. Indeed, imposing dominance on others, bending them to your will, is enjoyable for some people. But when, as in the NHS, the workers include people such as doctors who are (or at least were) more skilled, better educated, higher status and more confident than the managers who were supposed to command them - this makes command style management difficult and unpleasant at best, and impossible at worst (Charlton, 2000a).

As audit technologies have evolved away from outcomes and towards systems and processes, difficult policy decisions and unpleasant personal confrontations have been exported outside the organization executive - away from the corporate management and onto third-party groups. Managerial consultants are used to generate standards, guidelines and protocols, and in the public sector enforcement has been devolved to external agency auditors such as OFSTED and QAA. For example, in the NHS it is envisaged the NICE will generate guidelines, and CHIMP will enforce them. Both NICE and CHIMP are third parties detached from executive control, but both are NHS managerial appointees and employees, ensuring that their actions will not be independent of the demands of politicians and NHS executives. By many such maneuvers, NHS managers have retained power but shifted responsibility, have retained control but shifted the locus of dissent and resistance onto third parties.

At least in the UK, Quality Assurance therefore appears to be a evolution of managerial technology, a style of management which - from the managers perspective - is superior to previous styles of management such as a direct command system. QA is superior not in the sense of improving the performance of the organization, but in the sense that QA works more effectively to promote the interests of managers. In particular, it enables managers of low-level expertise and modest individual dominance, to impose their will upon expert and personally forceful people - a description that would fit many doctors.

The 'success' of Quality Assurance auditing

There is no doubt that Quality Assurance is a success story. The big question concerns the nature of this success.

The managerial technology of auditing, especially of systems and processes, has swept the UK, especially the public sector. Accountancy firms have expanded enormously and come to dominate the vast and highly paid workforce of 'management consultants' - which in their turn attract many of the most highly motivated and best educated of the workforce. This has so affected the organization of large corporations that our world contemporary world has been characterized as 'The Audit Society' (Power, 1997).

Professionals seem powerless to resist. The idea that Quality Assurance auditing is able to assure quality seems to have been accepted without even asking for proof. There has been no debate over the principles of CG - just moaning about the details of implementation. It has not been noticed that doctors are being stripped of professional autonomy and reduced to the role of functionaries. So far, Clinical Governance has been a major success story for government and managers.

Yet when the specific individual areas in which Quality Assurance has been introduced are subjected to appraisal, it appears very obvious that the performance of core functions of organizations is usually severely damaged by these managerial systems. Of course there are almost certain to be some benefits when vast and expensive re-organizations are imposed. Nonetheless, it is clear that the real success story of QA is that it is extremely beneficial to the power, rewards and career prospects of managers.

Typically these gains in the career trajectory of managers are attained at the expense of practitioners. There is a power shift away from 'doing' and towards 'regulating' (Power, 1997; Charlton, 1998). Although managers put themselves forward as advocates of the consumer interest, and a QA-dominated organization typically makes use of customer surveys, focus groups, feedback from users etc. - but this evidence is collected at the behest of managers, and it is managers who are responsible for selection, analysis and interpretation of this information.

So, although QA has not been successful in improving services, it has been extremely successful in promoting the career trajectory of managers. That seems to be the key factor behind the widespread adoption of QA.

Quality Assurance auditing has spread through the public sector and has now reached the NHS in the guise of Clinical Governance. Clinical Governance is fundamentally parasitic, a system of regulation that will enhance the power and prospects of the managerial class at the expense of the clinical practitioners who actually do the work of the NHS. And like most parasites, Clinical Governance will tend to weaken, and may eventually kill, its host.

The fact that this lethal remedy is being applied with the excuse of 'improving quality' is merely one of the more ironic aspects of this tawdry tale.


Bronowski, J (1943) William Blake, 1757-1827; a man without a mask, Secker & Warburg: London.

Bronowski J (1973). The ascent of man. BBC: London.

Cadbury Report (1992), Report of the Committee on The Financial Aspects of Corporate Governance, Gee and Co. Ltd., London.

Charlton BG. (1998) Essay Review of The Audit Society by Michael Power. Journal of Evaluation in Clinical Practice 4: 249-53.

Charlton BG (1999) The ideology of 'accountability' Journal of the Royal College of Physicians of London 33: 33-5

Charlton B. (1999a) QAA: why we should not collaborate. Oxford Magazine 169: 8-10.

Charlton B. (2000). QAA: 'light touch' auditing is not an option. Oxford Magazine 176: 12-13

Charlton BG (2000a). The new management of scientific knowledge: a change of direction with profound implications. In: Miles A, Hampton JR, Hurwitz B (Eds.) NICE, CHI and the NHS reforms: Enabling excellence or imposing control? Aesculapius Press: London

Dyson, Freeman J. (1997) Imagined Worlds Harvard: Cambridge, MA, USA.

Feigenbaum AV. (1983). Total quality control: 3rd edition. McGraw Hill: NY, USA.

Goodman NW (1998) Clinical governance. BMJ 317:1725-7

Hull DL. (1988) Science as a process. Chicago University Press: Chicago, USA.

Le Fanu J. (1999) The rise and fall of Western medicine. Little, Brown and co.: London.

Mills D. (1993). Quality auditing. Chapman and Hall: London.

Nexia International (1996). International handbook of corporate governance. International Thomson Business Press: London.

Perigord M. (1990). Achieving total quality management. Productivity Press: Cambridge, MA, USA.

Power M. (1997) The audit society; Rituals of Verification. Oxford University Press: Oxford, UK.

TQM International (1992). BS 5750/ IOS 9000 Handbook. TQM International: Frodsham, UK

Scally G, Donaldson LJ (1998). Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 317:61-5

Taubes, Gary (1986) Nobel Dreams: Power, Deceit and the Ultimate Experiment. Tempus Press: Redmond, WA.

Bruce G Charlton MD
Department of Psychology
University of Newcastle upon Tyne



also by Bruce Charlton
Cargo Cult Science
The Malaise Theory of Depression
Psychiatry and the Human Condition
Audit, Accountability, Quality and All That
Awareness, Consciousness and Language
Psychopharmacology and The Human Condition
Injustice, Inequality and Evolutionary Psychology