Summary of: Evaluation of the end user (dentist) experience of undertaking clinical audit in the post April 2001 general dental services (GDS) scheme

Key Points

• Provides an evaluation of the post 2001 GDS clinical audit scheme.

• Allows practitioners and policy makers to appreciate the potential barriers to effective clinical audit.

• Allows readers to consider catalysts that may help ensure effective outcomes from clinical audit projects.

• Provides an example of qualitative research undertaken in the primary dental care setting.

Abstract

Introduction A mandatory scheme for clinical audit in the general dental services (GDS) was launched in April 2001. No evaluation of this mandatory scheme exists in the literature. This study provides an evaluation of this scheme. More recently a new dental contract was introduced in the general dental services (GDS) in April 2006. Responsibility for clinical audit activities was devolved to primary care trusts (PCTs) as part of their clinical governance remit.

Methods All GDPs within Essex were contacted by letter and invited to participate in the research. A qualitative research method was selected for this evaluation, utilising audio-taped semi-structured research interviews with eight general dental practitioners (GDPs) who had taken part in the GDS clinical audit scheme and who fitted the sampling criteria and strategy. The evaluation focused on dentists' experiences of the scheme.

Results The main findings from the analysis of the GDS scheme data suggest that there is clear evidence of change following audit activities occurring within practices and for the benefit of patients. However, often it is the dentist only that undertakes a clinical audit project rather than the dental team, there is a lack of dissemination of project findings beyond the individual participating practices, very little useful feedback provided to participants who have completed a project and very limited use of formal re-auditing of a particular topic.

Conclusions This study provides evaluation of the GDS clinical audit scheme. Organisations who propose to undertake clinical audit activities in conjunction with dentistry in the future may benefit from incorporating and/or developing some findings from this evaluation into their project design and avoiding others.

Editor's summary

The stated aim of clinical audit for dentists is: 'to encourage individual GDPs to self-examine different aspects of their practice, to implement improvements where the need is identified and to re-examine, from time to time, those areas which have been audited to ensure that a high quality of service is being maintained or further improved.'¹

This aim is taken from the 2001 document¹Modernising NHS dentistry – clinical audit and peer review in the GDS, in which the current system of clinical audit in the GDS was made a requirement.

I find the 'self-examine' element of the clinical audit aim above particularly interesting. Though prompted by a government requirement, a clinical audit surely allows and encourages dentists, and the whole dental team, to look at their own practices and their peers' methods to identify areas in which quality improvements could be made. Yes it might be a pain in the neck, but at the end of the day it allows for a large element of the self-regulation that the profession so craves.

We see that dentists have been involved in clinical audit for over a decade but who has been auditing the audit? Is clinical audit of dentistry in the NHS actually effective in improving patient care and quality of service? Are individual GDPs learning from their self-examinations and cross-practice audits? This paper offers the first evaluation of the clinical audit scheme since it became mandatory in 2001, examining individual research interviews from a representative sample of GDPs in Essex.

The detailed responses from the participants show up some interesting outcomes of auditing and the processes by which it is currently undertaken, in relation to anonymity, collaborative outcomes, the audit's organisational framework, the involvement of the whole dental team and the sharing of findings. What is clear is that there was a feeling amongst the participating dentists that clinical audit is a good tool for quality improvement.

Of course this all begs the question: who audits the auditor of the audit? In this case it seems to be the journal's peer review process – which is a whole other discussion!

The full paper can be accessed from the BDJ website (www.bdj.co.uk), under 'Research' in the table of contents for Volume 213 issue 5.

Ruth Doherty

Managing Editor

Author questions and answers

1. Why did you undertake this research?

My interest in clinical audit commenced in 1996 when I was trained as a clinical audit facilitator, allowing me to work with practitioners in the development of peer review and clinical audit projects. Clinical audit provides an opportunity to use a quality improvement tool within healthcare for the benefit of the patient and dental practice. Although its use in GDS dentistry became a mandatory requirement in 2001, there has been little or no formal evaluation of clinical audit within dental practice since this time to determine its effectiveness or to aid its future development. This research seeks to address these questions and to provide some recommendations for the future.

2. What would you like to do next in this area to follow on from this work?

Within the wider healthcare community there is now a well developed system for undertaking local and national clinical audit which is supported by the Health Quality Improvement Partnership (HQIP) set up in 2008 to increase the impact that clinical audit has on healthcare quality in England and Wales. However, dental engagement within these processes is minimal at present. Future development of clinical audit in dentistry might involve the setting up of national audit, allowing those participating to compare their results with others both regionally and nationally, and facilitating, where applicable, the development of national standard setting.

Commentary

Clinical audit in the General Dental Services (GDS) in England has gone through three stages. The second stage ran from 2001 to 2006, when the 'new' dental contract was introduced. During this period, all GDPs working in the GDS were required to take part in a rolling programme of a minimum of 15 hours of clinical audit or peer review activity every three years. The audit/peer review projects concerned were assessed by local audit and peer review assessment panels (LAPRAPs) and nationally by a central audit and peer review assessment panel (CAPRAP). Since the introduction of the new contract, this system has stopped. Although participation in clinical audit remains a requirement for dentists working in the GDS, there has been no close monitoring. Primary Care Trusts (PCTs) have had a duty, as part of their clinical governance remit, to ensure that GDPs who contract with them take part in clinical audit. However, with the exception of a few PCTs, who have promoted large collaborative clinical audits, this topic has had a lower priority than between 2001 and 2006. The study by Cannell gives valuable insights into the experiences of a group of GDPs from Essex who took part in the GDS clinical audit scheme between 2001 and 2006 and the benefits to them and their patients. The author claims that no previous evaluation of the scheme has been reported. He sought to obtain an in-depth assessment by interviewing eight GDPs using a semi-structured format. Although an attempt was made to ensure that they were representative of all GDPs in Essex, there may be some doubts that the views the expressed reflect those of all their colleagues. That said, some interesting findings emerged. There was clear evidence of changes following audit which improved both patient care and practice efficiency. However, the GDPs reported little involvement of their teams or dissemination of the results of their audits or formal re-auditing of the topics they had audited.