Clinical Audit and Healthcare should be natural partners: audit identifies variation, highlights risk and helps teams improve patient care. But as Professor Scarlett McNally, Consultant Orthopaedic Surgeon at East Sussex Healthcare NHS Trust, argued in her session at the Clinical Audit – Elevating Patient Care Standards Conference, audit can also make healthcare worse when it creates bureaucracy, fear, and passive care rather than meaningful improvement.
The session, now available to watch on demand through the Clinical Audit – Elevating Patient Care Standards Conference, offers a timely reflection on what clinical audit is for, where it has succeeded, and how healthcare teams can avoid turning good intentions into yet another box to tick.
The discussion also prompted Professor McNally to develop her thoughts further for a wider audience. In July 2026, she published Clinical audit needs a shake-up in The BMJ, expanding on several of the themes raised during her conference session and examining how clinical governance can create an appearance of safety without always improving care.
When Clinical Audit Improves Patient Care
Professor McNally began by acknowledging the real value of clinical audit. She reflected on the early days of clinical audit around the time she became a consultant in 2002, when teams met during lunch breaks to review practice and improve services.
Some audit-driven changes were, in her words, “amazingly powerful” for patient care. One example was the use of funnel plots and related work showing that surgeons performing low volumes of certain procedures, such as hip replacements, had higher complication rates. This evidence helped shift practice away from occasional surgery and towards safer, more consistent care.
Another example was the best practice tariff for hip fractures, linked to the National Hip Fracture Database. By focusing on a small number of important standards, such as timely access to theatre, care for hip fracture patients improved significantly. The lesson is clear: audit works best when it identifies a meaningful problem, supports better decisions, and improves outcomes without overwhelming staff.
How Clinical Audit and Healthcare Can Go Wrong
The problem, Professor McNally argued, is that healthcare has changed. Services are busier, the population has grown, more people are living with multiple conditions, and staff are under intense time pressure. In that context, audit can become less about learning and more about generating administrative churn.
Her concerns are supported by research cited in her BMJ article. The 2025 Time Allocation in Clinical Training study, which observed 137 UK resident doctors across secondary NHS centres, found that doctors spent 73% of their observed time on non-patient-facing activities and 17.9% on patient-facing activities. Sixty-two per cent reported dissatisfaction with the administrative burden.
For resident doctors, audit and quality improvement can also become career currency. To compete for training posts, doctors may feel pressure to complete projects, present them, win prizes, and “close the loop” themselves. While this can build useful skills, it can also incentivise volume over value: more projects, more prompts, more forms, and more measurement. Professor McNally raises the same concern in her BMJ article, noting that requirements around audit projects can risk placing greater emphasis on career development than on improving care.
The Rise of the Tick Box
One of the strongest themes in the session was the danger of prompts and mandatory fields being added after something goes wrong. A single missed X-ray, for example, can lead to a new discharge box that every clinician must click forever, even when it is irrelevant to the patient in front of them.
Professor McNally develops this point in Clinical audit needs a shake-up, describing how each new audit project can generate action points, reminders and additional requirements that then become part of routine documentation. She argues that the cumulative effect can create an appearance of order and safety while adding to the administrative burden on clinicians.
Professor McNally described discharge summaries, VTE forms, and repeated checks as examples of well-intentioned safety processes that can consume precious clinical time. The concern is not that safety checks are unnecessary, but that systems often respond to failure by adding more friction rather than asking whether the process itself is sensible, proportionate, or useful.
When Measurement Makes Patients Passive
Audit can also change behaviour in unintended ways. If teams are judged heavily on slips, trips, and falls, staff may become reluctant to encourage patients to mobilise independently. That can keep patients in bed, increase muscle wasting, reduce confidence, and delay recovery.
This is one of the most important challenges raised in the session: reducing one measured risk may increase another unmeasured risk. A patient who never falls because they are never encouraged to move may not be receiving better care. They may simply be receiving safer-looking care on paper.
Why Perfect Healthcare Is Not Possible
Professor McNally also challenged the idea that every adverse outcome means someone failed. Healthcare is complex, and patients do not move through neat, linear pathways. People bring frailty, inactivity, social circumstances, multiple conditions, and different levels of support into every clinical decision.
She argued that healthcare professionals are not making mistakes because they are careless or unintelligent. Often, they are short of time, working within imperfect systems, and judged with hindsight. When audit creates shame or fear, it can make teams defensive rather than curious.
Her BMJ article reinforces this point by highlighting teamwork and communication failures, cultural and hierarchical barriers, and fear of embarrassment, mistakes or retribution as important contributors to safety problems that clinical governance processes alone do not address.
What to Do Instead of More Audit
The answer is not to abandon audit. It is to make audit more human, more focused, and more connected to real improvement. Professor McNally’s session highlighted several better approaches.
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Focus on Systems, Not Just Individuals
Instead of assuming that a new prompt will fix a problem, teams should ask where the real pressure points are. Are staff interrupted during safety-critical moments? Are forms duplicating information already collected elsewhere? Are doctors spending time on tasks that trained support staff could do?
Professor McNally gave the example of doctors’ assistants in her own trust, trained to help with tasks such as drafting discharge letters, preparing blood results, and supporting ward rounds. This kind of redesign frees clinicians to focus on the work that requires clinical judgement.
Professor McNally has also written about this model in her 2024 BMJ article, My trust has shown how doctors’ assistants can help support clinicians, setting out how changes to the distribution of work can support clinicians and help address administrative pressures.
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Create Time for Cross-Team Conversations
Clinical governance meetings can become number-heavy and passive. Professor McNally suggested using that time differently: bring departments together, remove unnecessary tick boxes, understand the pressures facing other teams, and redesign pathways collaboratively.
Real improvement often comes from seeing how work actually happens: what receptionists do, how information is stored, where delays occur, and what patients are told. Visiting other sites and learning from services that work well can be more powerful than simply hearing about them at conferences.
This is also central to Professor McNally’s July 2026 BMJ article, where she suggests using governance meetings to bring together staff from different departments and professional groups, identify requirements that could be removed, and learn from other NHS sites where more streamlined ways of working have been embedded.
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Support Shared Decision-Making and Shared Risk
Healthcare involves risk, and pretending otherwise can lead to over-control. Patients need honest conversations about risk, including the role they can play in improving outcomes. This includes encouraging activity, preparation before surgery, and better understanding of what recovery realistically involves.
Professor McNally emphasised that many patients can benefit from becoming fitter before interventions. Rather than only measuring whether standards were met, services should use clinical moments to help people reduce their own risk where possible.
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Use Simple Interventions That Change Culture
Not every improvement needs a large audit project. Posters, patient information leaflets, team conversations, and clear behavioural expectations can all help. In operating theatres, for example, simple rules such as maintaining silence during critical counting processes can address real human factors more directly than another dashboard.
She also drew parallels with work on bullying, poor behaviour, and sexual safety: culture changes through clarity, conversation, and early intervention, not only through formal processes after harm has occurred.
Rebalancing Clinical Audit and Healthcare
Clinical Audit and Healthcare can still drive better care, but only when audit remains connected to patients, staff, systems, and meaningful change. The warning from Professor Scarlett McNally’s session is not that measurement is bad. It is that measurement without judgement can crowd out the very care it is meant to improve.
Her subsequent BMJ article, Clinical audit needs a shake-up, makes the same case from another perspective, questioning whether the accumulation of audit projects, reminders and mandatory requirements is always producing the improvements they are intended to deliver. It also draws attention to the wider evidence around administrative workload, including the Time Allocation in Clinical Training study, and to alternatives such as changing how clinical and administrative work is distributed.
The better path is to audit what matters, remove what does not, listen across teams, accept that some risk is unavoidable, and give clinicians time to support shared decision-making. For healthcare leaders, audit teams, and clinical governance professionals, the challenge is simple but demanding: stop adding boxes by default, and start designing systems that help people do the right thing.
