National audits and the challenge of improving the patients' consultation experience

by Dr Richard GeneverAudit does little to improve quality standards and national audit does this on a grand scale. This doesn’t mean that audit is pointless but it does mean that we need to be absolutely clear on why we do audit and, above all, not allow it to detract from the essence of a good service.I found myself musing on this subject as I submitted my data to the 2017 UK National Parkinson’s Audit. I knew in my heart that these results would be very similar to my previous submission. In two years, according to the data it will appear that I have not improved my service in any way. It would be true to say that my ability to record answers to the 40-something questions has not changed a great deal in that time. But I would argue that the service has improved in many ways. We now have a Parkinson’s nurse specialist at the main movement disorder clinic. We have successfully recruited a consultant colleague and, most importantly of all, I have a new ‘opening question’ for patients – but more of that later.I do want to do better in the audit. There is a part of me that would take great pride at being the right hand-most column. I have no doubt that there is great value in identifying which patients are too sleepy in the daytime, whether bone health has been considered and having opportunities for advance care planning. What I do doubt is whether anyone has devised a way to address each of these (and every other issue) in a way that is practicable, affordable and does not turn the consultation into the proverbial tick box exercise.Ars Longa Vita Brevis. According to the Hippocratic aphorism, art is long, life is short. This was the motto of Sheffield Medical School and 25 years after first passing the stone plaque bearing these words on my way to lectures I am starting to get an understanding of their meaning. A quarter of a century on, I am better, but, as my audit results will soon confirm, I am a long way from perfect. One thing I have learned is that the consultation is part of the treatment. That can mean simply sharing information or correcting a harmful misconception to helping patients to set goals or helping them to change their mindset when contemplating future treatment (by the way one personal rule is that a patient has to want to start medication for it to be the right time).The easiest way to improve one’s results in the national audit would be to devise a clinic proforma. It would have a space for the patient’s details and a number of prompts to ensure that every question was asked. There might even be space for free text that would allow any positive responses to be expanded upon. At the end of it there would be comprehensive information about a wide range of issues relating to Parkinson’s. But would it be better? The truth is that we don’t know. This approach might be fabulous but it could also be disastrous. This is why audit doesn’t really add much to the improvement of quality. It is cumbersome and labour intensive. The results take a great deal of time to produce, analyse and digest. When the results come back it is difficult to know where to start and it will be two years before we know if your changes have produced results.The challenge is to improve the consultation experience for people with Parkinson’s disease. It is to find ways to learn and record large amounts of information without detracting from the therapeutic value of the clinic visit. The answers are probably found in repeated cycles of trial, measurement and revision over short timescales, looking at small numbers in real time. The other key message is that if you crack the problem you must tell the world, which brings me back to my new opening question. After years of asking people how they are I now start consultations by asking’ “Is there anything that you would like to discuss today?” Try it; it won’t improve your audit scores but it really helps to ensure that you are exploring the patient’s priorities.