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Fright night

The CQC report shows minimal improvement despite good funding, raising fears of what's to come

Illustration of frightened man hiding behind sheetDo you sleep OK? I read a press report that estate agents sleep less well than nurses. I'm not surprised.

There is one group of workers in the NHS that has not been sleeping well. It is the chief executives of NHS Trusts. They have been tossing and turning, wondering how they have been rated in the annual Care Quality Commission's (CQC) report on the health of the NHS (Published October 15, 2009).

Apparently, on service quality, the CQC rated 15 per cent of organisations excellent, 47 per cent good, 33 per cent fair and 5 per cent weak.

For financial management, the scores were 26 per cent excellent, 45 per cent good, 26 per cent fair and 3 per cent weak.

Well, that's OK then.

No, not exactly. The report, an annual assessment of quality of care and financial management of NHS organisations, concludes that while there have been significant improvements in waiting times, tackling superbugs and controlling budgets, many Trusts are still failing the basic requirements of good care, ie the number of patients having operations cancelled, heart disease care, record keeping, infection control and child protection.

On the bright side, more than 98 per cent of the 19 million patients attending A&E waited less than four hours; between January and March, three million patients waited 18 weeks or less from referral to treatment; 16 per cent of people aged 15 to 24 were screened for Chlamydia – up from 5 per cent the previous year; ambulances responded within eight minutes to more than 1.4 million calls over life-threatening emergencies; and there were 19,400 fewer cases of Clostridium difficile and 1,500 fewer cases of MRSA in 2008-09 compared with 2007-08, both down a third.

But let's not forget: there has been a drop in compliance with the core standard on child safeguarding, down from 96 per cent last year to 91 per cent this year; while MRSA and C. difficile rates are falling, Acute Trusts still need to do more on infection control because 48 Acute Trusts did not meet at least one of the three relevant standards, compared with 44 last year.

Only 37 per cent of Acute Trusts meet the required level of performance on specialist stroke care; there were considerable variations in quality of basic maternity and mental health data, vital for monitoring care quality, and the proportion of operations cancelled for non-clinical reasons rose for the second year in a row to almost 63,000.

What are we to make of this? Talking to The Times, Niall Dickson, chief executive of the King's Fund, said: "The minority of Trusts that repeatedly failed to sort out basic issues such as hygiene, patient safety and staff training were a cause for concern."

Too right! And let's not forget that all this was in a period of unprecedented funding. What happens in 2011 when the money dries up?

This was a theme picked up by Andrew Lansley, the Conservative health spokesman, who said: "The regulator's report showed that the level of improvement was not as it should be, given the increases in taxpayers' money spent on the NHS. Patients rightly expect that basic standards will be consistently met and will actually improve year-on-year."

Well it hasn't happened. Why? The NHS is very busy? The NHS is badly run? None of this welter of data explains it to us. I want to know why!

Mike O'Brien, the Health Minister, said that the "tough assessment" showed improving standards across the NHS. He said that the government expected "immediate action" to prepare Trusts rated as "weak" for the new standards next year. I have no idea what 'immediate action' means. Sack someone, I guess?

It struck me as odd when I looked at the standards with the lowest compliance: ensuring staff participate in mandatory training programmes; records management; decontaminating reusable medical devices. Do I have to say anything? I mean, if you can't train your staff, keep decent records and clean up, what can you do?

Here are the highest complied-with standards: supporting staff by having processes for them to raise, in confidence, concerns over services; ensuring staff abide by relevant published codes of professional practice. This is rubbish! We know it is almost impossible for members of NHS staff to blow the whistle and not get into all kinds of grief with colleagues, managers and the authorities. This compliance is meaningless.

At this point, it is worth remembering that the assessments, in the first instance, are made by the Trusts themselves – self declaration. The CQC then carries out a number of follow-up inspections to check that Trusts have performed at the level they have declared. The inspectors carried out 84 follow-up inspections.

A full 47 of the 84 inspections (57 per cent) led to a 'qualification' in relation to at least one of the four standards inspected. In other words, the Trusts got caught telling porkies about their performance.

The Patients Association regularly reports examples of appalling care across the health service. It admits that the proportion of patients affected is small, but it still amounts to thousands of people. The Association's vice chairman, Michael Summers, wants to see much tighter scrutiny by the regulator, based on more inspections. "We have to get away from reliance upon self-assessment," he said. "That is often misleading. We really want to have on-site inspections, seeing hospitals in the raw as they operate on a daily basis."

From next April, Trusts will have to register with the CQC and obtain a licence to operate. The CQC will have the power to close down a recalcitrant, recidivist Trust. They won't. It is politically too difficult and, anyway, where would the patients go for treatment?

If it looks a muddle then it probably is a muddle. I don't trust self assessment, I don't trust the regulator and I don't trust the politicians. This is a mess and it keeps me awake at night.

The Author
Roy Lilley is a (sometimes controversial) healthcare author and broadcaster.

30th November 2009

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