There are two distinct views about the purpose of quality assurance by means of medical audit. The first is that it is a job requirement, to be backed by sanctions where necessary. The second is that it is a desirable attribute of professional practice, backed only by exhortation and opportunities for further training. This difference of view lies at the heart of much of the dispute as to how medical audit should be pursued in the UK at present. It explains why the medical profession insists that such audit should be conducted by peers, for peers, and accountable only to peers, whereas managers want some say in what is audited, how it is audited, and also want the reports of such audit made available to them, so that they can act upon the findings in their role as employers (e.g. in organising workloads, contracts, etc.). In this chapter the ‘job requirement’ view is supported, and its implications explored. It is argued that unless this route is chosen, it is unlikely that medical audit will deliver improvements in the health of the population that are commensurate with its costs.