title: Holding services to account.
abstract: BACKGROUND
  Recently, the frequency of audit inspections of health services for people with intellectual disability (ID) in the UK has increased, from occasional inquiries to a systematic audit of all services. From 2008, a process of continuous audit 'surveillance' of specialist health services is to be introduced. Similar regimes of inspection are in place for social care services.
  
  
  OBJECTIVE
  To explore the conceptual positions which inform audit, through detailed examination of the investigation into the learning disability service at Sutton and Merton.
  
  
  RESULTS
  Audit is distinct from evaluation because it neither provides opportunities for service staff to give an account of their work nor represents a search for knowledge. Audit investigates adherence to government policy. In ID, audits measure aspirations derived from normalisation, despite research showing that some of these aspirations have not been achieved by any service. As audit consumes significant public resource, it is questionable whether the dominant finding of the Healthcare Commission's investigation into Sutton and Merton, that the ID service was chronically under-funded, represents value for money.
  
  
  CONCLUSIONS
  While basic checks on minimum standards will always be necessary, service excellence requires not audit but research-driven evaluation. Audits inhibit rather than open-up debate about improving support to people with ID. They impose an ideology, squander resource, and demoralise carers and staff. Evaluations challenge the implicit management-versus-professional binary enacted by audit, and can inform new care systems which make effective use of all those engaged with people with ID.
authors.affiliation: School of Community Health Sciences, University Hospital, Nottingham, UK. Jennifer.clegg@nottingham.ac.uk
authors.forename: J
authors.initials: J
authors.lastname: Clegg
mesh_terms: D000203:Activities of Daily Living; D003695:Delivery of Health Care / Q000941:ethics; D004995:Ethics, Professional; D006295:Health Resources / Q000941:ethics; D006801:Humans; D008607:Intellectual Disability / Q000534:rehabilitation*; D033183:Interdisciplinary Communication; D008329:Managed Care Programs / Q000941:ethics*; D008330:Management Audit / Q000941:ethics*; D020380:Needs Assessment / Q000941:ethics; D009937:Organizational Objectives; D011785:Quality Assurance, Health Care / Q000941:ethics; D012947:Social Work / Q000941:ethics*; D013222:State Medicine / Q000941:ethics*; D006113:United Kingdom