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Melvina Woode Owusu

Over the past year Melvina Woode Owusu has been the Study Manager for the National Clinical Audit of STIs and HIV Feasibility Study. This one-year project was commissioned by the Healthcare Quality Improvement Partnership (HQIP) and managed by MEDFASH in collaboration with Public Health England (PHE), the British Association for Sexual Health & HIV (BASHH) and the British HIV Association (BHIVA). In this eFeature Melvina looks at the value of reflective practice and clinical audit in sexual health as a means of reviewing practice against set standards and ultimately improving quality for the benefit of patients. With the rich sources of data available to the sexual health field she is confident that the process of clinical audit has the potential to make a real difference and to bring an active focus to using data more effectively to support quality improvement.


Holistic nature of sexual health

Over the past eight years I have worked in several roles across the sexual health field and have gained a valuable insight into the various stages of the patient journey through sexual health services provided in England. In this time, I have not only developed a holistic view on sexual health (and sexual ill health) but have also gained an appreciation of the importance of high quality performance - at every stage of the pathway. This is in addition to developing a better understanding of how each professional’s contribution can effect real change for patients. While high quality research, surveillance and evaluation can inform the design of targeted and cost-effective interventions, high quality and well-informed commissioning and strategic decision-making also supports and optimises the delivery of high quality care.

Whether the public health service that we offer is in the form of frontline care, policy, research, surveillance or evaluation, it is important that we all take an interest in reflective practice and improving quality, and embrace the various mechanisms (such as clinical audit) which enable us, as health professionals, to do so. It is also really important that this is done throughout the country, as patients deserve the highest level of service, regardless of where they live.

So, what does ‘clinical audit’ mean?
Often, the word ‘audit’ conjures visions of workplace appraisals, revalidation, and personal development reviews. Sometimes, the fear of judgement, exposure and even blame can cast shadows over the clinical audit process. In reality, clinical audit does not have to be any of these things and it certainly is not intended to be. The Healthcare Quality Improvement Partnership (HQIP) states that audit should focus on quality improvement and, the more I learn about clinical audit, the more I am convinced that the mechanism of ‘audit’ actually just gives services a formal opportunity to reflect on their own areas of progress and achievement, relative to the established standards of care. In sexual health, we are fortunate to have established standards of care and recommendations for the management of sexually transmitted infections (STIs) and HIV, which have been developed and published by MEDFASH, BASHH, BHIVA, PHE and NICE.

Clinical audit is a valuable mechanism for reflection. It is designed to systematically review current practice against set standards and identify the gaps between what is currently happening and what ought to be happening, all with the expectation that action plans will be created to address those gaps and raise standards for the benefit of patients. For example, following recent outbreaks of high-level azithromycin resistant gonorrhoea, PHE and the Chief Medical Officer, Dame Sally Davies, have highlighted the importance of following the national guidance when prescribing treatment for gonorrhoea. A clinical audit of the management of gonorrhoea could provide an opportunity for clinicians to review their current prescribing behaviour and put in place processes to raise compliance with BASHH’s guidance, thereby helping to curb antimicrobial resistance and protect the future treatability of gonorrhoea.

Clinical audit data can also support clinicians in making a business case for increased resources to address the areas of challenge identified. It’s a process that has the potential to make a real difference.

Clinical audit and engagement
Some might say ‘the idea of clinical audit is theoretically a nice idea, but in practice, who has time for that?’ I would ask ‘who doesn’t have time to engage in an activity that is designed to make things better and lead to improvement for patients?’ In the face of recent budget cuts and more to follow, we are all being asked to do more with less and to do it all more quickly. In honesty, it’s easy to see why some clinicians might be disengaged with the idea of audit.

In 2013, HQIP commissioned Improvement Science London to explore, analyse and report on the factors which influence clinicians’ engagement in quality improvement through national clinical audit. Their report made a number of very helpful and actionable recommendations, which can be transferred to the field of sexual health. It flagged the need to clarify the content and purpose of national clinical audits and to support clinics in how to analyse and interpret audit data. Most significantly (in my view) it highlighted the impact of organisational culture on the take-up of clinical audit. This all makes real sense. We need to explain the relevance of audit, support one another in interpreting the audit data and work with various stakeholders to ensure that they are well-equipped to support their workforce in making improvements.

The HQIP feasibility study
Over the past year, MEDFASH, together with PHE, BASHH and BHIVA, has managed a project commissioned by HQIP to explore the feasibility of a national clinical audit of STIs and HIV in England and Wales. I was fortunate enough to work as the Study Manager alongside an experienced and dedicated team. This study involved: determining national key priority areas for improvement and developing suitable clinical audit questions to address these priority areas; assessing the availability of national data to answer the proposed audit questions; and exploring how a national clinical audit could be implemented and how it could complement the audit work conducted by BASHH and BHIVA. We consulted a wide range of stakeholders to determine how a national clinical audit could be designed to have the largest impact on patient outcomes. We also spoke with lead clinicians from other national clinical audits, such as the stroke and lung cancer audits. The sexual health field is very rich in data, which is regularly collected at local authority and national level through key performance indicators and also PHE’s GUMCAD and HARS surveillance systems. These datasets provide a unique platform for launching a national clinical audit of STIs and HIV, which would minimise the burden of data collection on front-line services and make effective use of what we already have. A cultural shift is perhaps needed so that we, as a field, move from a culture of data collection to one where the primary focus is on actively using data for quality improvement.

Why is full participation in reflective practice important for sexual health?
Sexual health is a special area in many ways because the quality of care offered to one person can have an immediate and long-term impact on the health and wellbeing not only of the individual receiving care, but also of their sexual contacts now and in the future. We have the ability to really make a difference to people’s experiences and lives – on an individual and population level. For every individual offered the appropriate and recommended advice, tests and treatment, we can potentially protect an entire network of sexual contacts from avoidable STIs and a myriad other physical and emotional health conditions. It’s my firm belief that we should not simply pay lip service to activities such as clinical audit. Instead, we can view such activities as valuable opportunities to enhance our own practice, and maximise our personal and collective impact.

Only in doing so can we strengthen sexual health provision for the benefit of our clients and patients, which, for all of us, is a big part of why we entered this area of work.

For more information on the Feasibility Study please visit medfash.org.uk/national-clinical-audit-of-hiv--sti-feasibility-study


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