'Audit Society' in action: a study of audit and performance management in the National Health Service in Scotland
Cumming, Alison Jane
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This thesis seeks to understand the role of audit in managing the performance of the NHS in Scotland and the impact which the relationship between performance and audit has upon key actors, including NHS organisations and national audit bodies. It is informed by Michael Power’s Audit Society (1999) and associated works, which present audit as a collection of ideas which shape how society defines control, accountability and transparency. The premise of this doctoral research is that the age of performance assessment in the NHS is evidence of Power’s Audit Society in action. A longitudinal analysis of annual Overview Reports produced by Audit Scotland, which symbolise the national audit body’s identity relative to the NHS, explores the impact which the performance assessment regime had upon the evolution of the national audit body and demonstrates the capacity of a national audit body to forge its own role in performance assessment and in doing so shift its identity from traditional external auditor to authoritative commentator on performance. A recent performance crisis in a Scottish NHS board is the subject of a case study which explores the role of audit when significant gaming is uncovered in a previously high-trust system. This case demonstrates how the ritual appeal of audit can be mobilised by the government to restore public confidence in reported improvements in performance across the whole NHS. The organisational impact of audit on performance management is explored through an observation-based case study set in a Scottish NHS board, which traces interactions between the main actors in audit and performance networks. These analyses show how audit can permeate the performance assessment of NHS bodies, at both the national and organisational level, even where it is not given a formal role in the assessment framework.