The College The College Research Unit and its clinical audit programme

The College Research Unit was established initially with donations from College members. After a year of pilot work and fund-raising a programme of work began in October 1990 supported by a three-year grant from the Department of Health. The main theme of the programme isclinical audit. This report outlines the nature and role of audit in psychiatry, describes the structure of the Unit, and presents a brief summary of the Unit's work.

Medical audit involves the review of purely medical procedures in psychiatry, e.g. the use of medication, the value of laboratory investigations.
Clinical audit acknowledges that much psychiatric care is delivered by multi-professional teams and that adequate assessment of the effectiveness of that care can only occur if the team together reviews its practices (e.g. the quality of discharge or planning or evaluation of case management systems).
Needs-based audit assesses the extent to which a service meets the needs of its users or what impact different groups of service users have on available resources. Such audit may be based on the measured need of those currently in contact with the service or epidemiologically-based, i.e. based on the needs of the whole catchment population.
Service planningaudit is the systematic review of the current usage of the components of a service, such as out-patient non-attenders or liaison referrals. When combined with knowledge derived from needs-based audit these findings have implications for future service planning and development.
Ideally an audit programme should contain elements from each of these levels of audit activity and a balance between top-down and bottom-up approaches. A top-down approach takes an "expert" perspective, e.g. measures practice against some pre-determined standard or changes some aspect of service delivery and then measures its impact on patient well-being. A bottom-up approach monitors clinical practice or the needs of the user population, draws conclusions and alters practice accordingly. When the two approaches combine as part of the same process, the classical audit loop is conducted more efficiently.
Audit should drive management decisions. That this rarely occurs was confirmed by the interim report on progress in the six acute Resource Management Initiative pilot sites (Health Economics Research Group, 1989)which stated that: "The pro cess of reviewing service provision and relating it to measures of outcome or success in meeting objectives is perhaps the one [step] that is least well integrated into the emerging resource management process. This is not because of any apparent doubt about the importance of this element, allied as it is to medical audit".

The structure of the Unit
The Research Unit is based in the Royal College of Psychiatrists and has close links with the various College committees and working parties, in particu lar the Research Committee and the Medical Audit Working party. It does, however, reserve the right to function independently of the College structures, enabling it to provide impartial and sometimes critical advice.
The staffing of the Unit acknowledges the skills required to implement a comprehensive audit strat egy. The Unit Director (John Wing) is supported by a consultant psychiatrist (Paul Lelliott), and a senior registrar in psychiatry (Claire Flannigan). A special ist in community medicine (Gyles Glover) provides computing skills and expertise in epidemiology and health service provision and a health economist con sultant (Ken Wright) advises on the usefulness of including cost-benefit analyses in the various audit projects. The Unit also commissions others to under take specific projects on a time-limited basis, the first of these has been John Pippard. Paul Clifford, Director of the FACE Project, has recently joined the Unit as a consultant with two of his colleagues.

The audit programme
The College Research Unit has two main aims in the field of audit: firstly to initiate and participate in specific projects on topics considered priorities (either because of public concern or due to limi tations of resources) and secondly to support and encourage the development of audit in psychiatric services nationally.
The Unit is well placed to serve both the College and its members, the former acting as a source of intelligence (for example, by providing draft guide lines on priority topics for discussion and possible adoption) and the latter by providing an information and coordination service for audit activity.

Specific projects
The College recommendations on the administration of ECT were partly based on a national survey published just over ten years ago (Pippard & Ellam, 1981).One of the original authors of the survey (John Pippard) was invited to continue this audit by moni toring the effect these guidelines have had on practice in two regions; the finding (Pippard, 1992)that some aspects of ECT administration still did not meet the criteria set confirmed the importance of closing the audit loop. Furthermore, Pippard's review of ad vances in ECT practice over the past decade high lighted the need not only for practice to be regularly compared with agreed guidelines but also for those guidelines themselves to be the subject of regular scrutiny and update.
With the move into the community, hospital care in psychiatry has increasingly become limited to crisis control and stabilisation of patients with acute psychotic episodes. Beds are a scarce resource and ensuring their efficient use is prudent both economi cally and clinically. An audit of consecutive series of admissions in two London districts is well under way (Claire Flannigan and ShÃ²nLewis in Riverside and Sean Feeny and Paul Bebbington in Camberwell).

The College
This audit focuses on the reasons for admission and includes assessment of what alternative provision might have prevented admission had it been avail able. This project will also review the discharge plans formulated for these patients by their carers (based on College guidelines) and monitor the patients' interactions with services during the years following discharge.
This admissions and discharges audit will be allied with a comprehensive review of the activity of other facilities (health authority, local authority and voluntary sector) offering care to the same group of patients, and an epidemiolÃ³gica! estimate of the needs of the mentally ill population of the two districts. A picture will thus emerge of the extent to which existing service provision in these two districts meets the actual need.
The findings of this study are likely to be of some relevance to every psychiatric service, at least for purposes of comparison. The methodology however will be directly applicable in any unit that wishes to audit its use of beds and how this relates to total need.

Multi-centre audit
A survey of districts and health boards throughout Great Britain and Northern Ireland (Lelliott, 1991unpublished) has demonstrated consensus between College members. College committees and the Research Unit as to which topics are priorities; these include audit of acute admissions, discharge procedures, the Mental Health Act and ECT.
The national register of lead clinicians in audit, derived from the national survey, will facilitate multi-centre audit. This would be relevant for issues or events that occur too infrequently to be usefully audited in a single district. The first such project will be a review of the "new long-stay" patients currently occupying acute psychiatric beds. Other proposals include the use of emergency sections of the Mental Health Act, suicides of patients in contact with psychiatric services, and the extent and impact of bed-closures.

National issues
Working links have been formed with the Resource Management Unit, the Centre for Coding and Classification ("Read Codes") and the National Casemix Office. The Unit will produce a series of reports, describing the activities of these projects in psychiatry, for publication in the Psychiatric Bulletin. These links have also resulted in the setting up of collaborative studies. The FACE project (which is facilitating the development of resource management systems in mental health services) is now based in the Unit (Paul Clifford and Yvonne Webb)and a full-time Development Officer (Simon Shanks) and secretary have recently been appointed to review current coding and classification issues in psychiatry (under the joint direction of the Unit and Paul Clifford).
To ensure that the results of these collaborations are rapidly and efficiently brought to the attention of the College, a sub-committee of the College Research Committee, with representation from the Audit Working Party, is being set up to consider the findings and recommend appropriate actions.

Audit information service
The Unit is beginning to establish an audit infor mation service in collaboration with the College Library and the King's Fund Centre. In addition to compiling a psychiatric audit bibliography, the Unit is involved in a review of existing computer-based 315 information and clinical support systems; to comp lement this a "Bulletin Board" for computer users is being developed.