Former NHS England deputy Medical Director, Dame Celia Ingham Clark, explains why clinical audit must play a key role in designing an NHS that is “Fit for the Future”
The challenges that the NHS faces are not new. With an ageing population and staff shortages, we are faced with daily news headlines about soaring costs and long waiting lists. The 10 Year Plan Fit for the Future describes the pressing need to ensure a sustainable, financially-viable future for our NHS, focussing on community care, digital technologies, and prevention. For local and national clinical leaders the real challenge comes in how to achieve this. These three ‘shifts’ need to be delivered alongside improving care quality and reducing costs. For me, the key lies in using the rich data source that is clinical audit. By measuring the quality of care, it enables us to see what is working well, and what is not, against recognised standards. It identifies where change would have the greatest impact, driving the targeted use of resources. As such, clinical audit is a critical tool in delivering efficiencies that will lead to the most important measures, improving and saving lives.
National clinical audit – the primary example of which is the National Clinical Audit and Patient Outcomes Programme (NCAPOP) – goes from strength to strength. Commissioned by the Healthcare Quality Improvement Partnership (HQIP), on behalf of NHS England and others, the NCAPOP comprises circa 40 audits and outcome reviews. These cover a wide range of services including cancer, mental health, and maternity care. NCAPOP has been running for decades, and measures care in line with standards set by NICE. Its programmes are trusted by clinicians and patients alike, not least because they are co-developed with both clinicians and patients. The NCAPOP has developed a robust and reliable approach to data collection, analysis and reporting, with many delivering quarterly data online updates and annual ‘State of the Nation’ reports. These reports provide readily accessible summary infographics and a focussed number of recommendations for improvement that are developed with clinical, patient and commissioner input.
There are many examples of excellent audits out there; as a former colorectal surgeon I have a particular interest in the National Bowel Cancer Audit (NBOCA). Initially established by the Association of Coloproctology of Great Britain and Ireland (ACPGBI), this audit has a long-standing history of clinical engagement. It is now part of the National Cancer Audit Collaborating Centre (NATCAN) – a collaboration between the Royal College of Surgeons of England and the London School of Hygiene and Tropical Medicine – that covers ten different types of cancer, and is commissioned through the NCAPOP. The NBOCA focuses on surgical outcomes, non-surgical treatments, and new approaches to care such as genetic testing. The latter is significant as it aims to identify which patients are most likely to benefit from chemotherapy, and avoids the futile use of potentially toxic and costly treatment for patients with particular genetic profiles.
The NBOCA has reported improvements across a range of care and outcome measures over time, for example, 90-day postoperative mortality has almost halved over the past decade. There has also been a significant improvement in the two-year postoperative survival rate, resulting in approximately 1,150 additional people surviving two years after surgery1 (2021/22 saw a 5-percentage-point increase compared with 2012/13). These statistics highlight advancements in treatment pathways and multidisciplinary patient care across the sector. They also reflect another important aspect of clinical audits. By making data publicly available, and actively working with the healthcare community to support peer review, they identify areas for improvement. Audits operate an ‘outlier process’ which identifies where indicators at a Trust level fall significantly outside the expected range2. NHS England and the Care Quality Commission are notified of confirmed outliers, so that remedial actions can be taken. This is an extremely valuable process for Trusts, who often welcome the opportunity to understand where changes would have the greatest impact. One recent example is an NHS Trust that increased patient telephone follow-up on discharge to reduce unplanned emergency department attendances, following such a notification.
Clinical audits also support initiatives to improve care pathways directly. For example, patients who have had rectal cancer surgery are recommended to have their ileostomy closed within 18 months of first surgery, and this is currently the case for only 62% of patients1. As such, Close it Quick (a collaboration between NBOCA, the Royal College of Surgeons of England and the Association of Coloproctology) was launched to promote timely stoma closure, improve quality of life, and reduce the risk complications.
Another aspect of care where clinical audits are invaluable, is in shining a light on inequity. There are many examples where the data helps us to understand what is happening, so we have an opportunity to improve care for everyone. A highly reported example in recent years is maternity care. When looking at 2014-16 data, the MBRRACE-UK programme (part of the NCAPOP) found that women from Black ethnic backgrounds had five times the risk of maternal mortality, compared to white women. This finding emphasised the need for a continued focus on actions to address this disparity. By 2021-23, this statistic had reduced to around double. There’s still much work to be done, but, using data in this way provides clarity and shines a light on issues, leading to improvements like this.
So, what does all this mean for healthcare leaders, both providers and commissioners? Having been in a leadership role in the NHS for many years, I’m fully aware of the constant pressures to maintain and enhance quality of care while reducing avoidable costs. On a daily basis, you are having to ask ‘where should I allocate my resources to deliver maximum benefit to patients and the Trust?’. Clinical audits also provide assurance regarding clinical services through Quality Accounts, and in terms of performance against process and outcome metrics. Furthermore, they offer robust data that clinicians can include and reflect on in their annual appraisal.
If Wes Streeting called me tomorrow and asked my view on how to drive quality improvement when designing an NHS that is “Fit for the Future”, I would say ‘start with national clinical audits’. But, I would quickly follow that up with ‘don’t take my word for it, ask our patients’. Katrina Attwood, Chair of the NBOCA Patient and Public Involvement Forum, sums it perfectly, when she says: “I know first-hand how useful it is to have data. Audit is not a tick-box exercise – it’s driving real improvements for patients, and demystifying care, as well as shining a light on places where we need to do better.”
1) Source: NBOCA State of the Nation report, published 9th Oct 2025
2) To 3 standard deviations
Author
Dame Celia Ingham Clark
Celia Ingham Clark is Chairman of the Healthcare Quality Improvement Partnership and Chairman at the Faculty of Medical Leadership and Management. She trained in Cambridge and London and worked as a general and colorectal surgeon for ten years. After roles in medical education she was Medical Director at the Whittington Hospital Trust for eight years, then joined the National Medical Director’s team, initially as Director for Reducing Premature Mortality, then as Medical Director for Clinical Effectiveness and latterly as Medical Director for Professional Leadership and Professional Standards. She stood down from NHS England in 2024 and took up her roles at HQIP and FMLM later that year. In 2025 Celia was awarded a Damehood in the King’s Birthday Honours.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: I am the chairman of HQIP and the Chairman of FMLM.