Recommendation 248

Auditing of quality accounts

Healthcare providers should be required to have their quality accounts independently audited. Auditors should be given a wider remit enabling them to use their professional judgement in examining the reliability of all statements in the accounts.

Quality accounts are independently audited by external auditors of foundation and non-foundation trusts.

For NHS trusts, directors of the trust should take steps to assure themselves that their quality accounts comply with the requirements set out in the legislation governing Quality Accounts: Part 1 chapter 2 of the Health Act 2009 and the National Health Service (Quality Accounts Regulations) 2010 and the National Health Service (Quality Accounts) Amendment Regulations 2012.  A statement of directors’ responsibilities confirming that these steps have been taken must be included in the trust’s published quality account.  Monitor requires foundation trusts to obtain an audit opinion on their quality accounts, this includes an opinion that the contents of the quality accounts comply with regulations and also an opinion on selected indicators included in the accounts.

Auditors also  provide a signed limited assurance on a small number of  indicators and provide assurance on the number of patient safety incidents that occurred within the foundation trust.

The trust must produce an annual governance statement, the content of which is determined by the trust, which refers to the steps taken to assure themselves that their quality account is reliable and accurate.

In 2012/13 external assurance requires foundation trust auditors to:

  • review the content of the quality report against the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2012/13
  • review the content of the quality report for consistency against the other information sources detailed in section 2.1 of this guidance
  • provide a signed limited assurance report in the quality report on whether anything has come to the attention of the auditor that leads them to believe that the Quality Report has not been prepared in line with the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2012/13 and is not consistent with the other information sources detailed in section 2.1 of this guidance
  • undertake substantive sample testing on two mandated performance indicators, and the newly mandated safety incidents indicator, (to include, but not necessarily be limited to, an evaluation of the key processes and controls for managing and reporting the indicators and sample testing of the data used to calculate the indicator back to supporting documentation)
  • provide a signed limited assurance report in the quality report on whether there is evidence to suggest that the two mandated indicators subject to a limited assurance report have not been reasonably stated in all material respects in accordance with the  NHS Foundation Trust Annual Reporting Manual 2012/13, and
  • provide a report (the Governors’ Report) to the NHS Foundation Trust’s Council of Governors and Board of Directors of their findings and recommendations for improvements concerning the content of the Quality Report, the two mandated indicators, subject to a limited assurance report, the additional mandated indicator and any locally selected indicator(s), if applicable.

However, in addition to the information audited outlined above, quality accounts also include local information that is specific to the services, priorities and needs of patients locally.  While this is useful information to report on within quality accounts it cannot be audited externally without considerable local knowledge.  Instead, quality accounts are verified locally for their accuracy and a declaration is signed by order of the Board by the Chairman and the Chief Executive (see recommendation 249).

We will review quality accounts before the 2014/15 cycle to ensure that they give patients appropriate information regarding the services they use, and that they add value to the quality assurance infrastructure used by trusts, local and national organisations.  The review will consider whether the remit of the audit process could be extended further and will report in early 2014.


The Quality Accounts review gave further consideration to the audit approach and how its remit might be extended. The skill set of the organisations and people currently auditing Quality Accounts is, in the main, financial.

One area the evaluation was particularly keen to explore was how the role of audit could be expanded beyond the review of source documents into a more outcomes orientated process. National Clinical Audit was seen as a key enabler for this. Participation in National Clinical Audit is mandated through the NHS Standard contract, supports local quality improvement and enables individual clinicians or teams to benchmark themselves against accepted clinical guidelines and standards.  Such an Audit also enables patients to question the quality of their care and exercise choice. National Clinical Audits are all supported by specialist methodological frameworks, are case mix risk adjusted where appropriate and will be reviewed through a Quality Assessment Framework.

Consideration will be given to how the current outputs of National Clinical Audit could be included within the Quality Account to provide an audited view of clinical data sitting alongside the current mandated audit arrangement for 2014/15.