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Survival tactics

NHS chiefs should pay particular attention to HC ratings in order to avoid the chop

In October, the Healthcare Commission (HC) published its first ever ratings for the health service in England.

While the Department of Health issued star ratings as a guide to performance, yet which were always seen as unreliable, the HC, as independent of the department and its judgements, may be better trusted.

The HC is looking at systems in place across the health service to show how an NHS Trust is performing in delivering clinical quality, the environment in which care is provided and, crucially, how well it manages its finances.

The commission asks all Trusts to fill in an annual check on how they think they are doing in managing financial and other resources and in delivering quality care. It also looks at other data from its own reviews and uses some lie detector techniques to check that Trusts are being honest in their submissions.

In addition, the HC receives information from organisations, staff, patients and carers, so if a Trust blatantly lies about its performance, staff and others can, and do, tip the commission off.

Ratings scale
The HC can give a Trust one of four bandings: excellent, good, fair and weak. Notably, only two NHS Trusts in the whole of England, the Royal Marsden Hospital in London and Harrogate Hospitals Trust (both Foundation Trusts), were found to be excellent in all respects.

Some 570 Trusts across England were surveyed and 37 per cent were found to be weak in managing resources - a higher figure than many expected, with just 9 per cent found to be weak in the quality of clinical services. What does this tell us?

In the first year of this new system, the answer is probably not a lot. We know that many Trusts are struggling with financial challenges this year, and most of those deemed to be weak fall into this category.

What is more interesting is information relating to the quality of patient services and clinical governance. It seems that a significant number of Trusts have chosen to share openly with the HC that they are struggling with particular issues.

This is a healthy development and demonstrates greater transparency, which has been welcomed by the commission, which takes the view that if a health provider recognises that it has problems then it is more likely to work with the HC to seek sensible remedies.

On the face of it, the public might be horrified that so many NHS outfits seem to be failing, but behind the tabloid headlines lies a more positive story.

The survey also shows some interesting regional variations. Trusts in central England have the best results across quality of services. Trusts in the South-West of England show the poorest results.

The acute and specialist acute providers are showing the best spread of results, but there are serious concerns regarding PCTs and ambulance services.

Of the 24 weakest Trusts, 11 were PCTs, four were ambulance services, eight were acute Trusts and one provides mental health services. This suggests that primary care and ambulance services need to do a lot to improve their game. In fairness, PCTs are in the middle of a major restructuring programme and ambulance Trusts have gone through a merger process, all of which might explain why players in these organisations may have taken their eye of the ball.

The HC survey shows that quality of care in the NHS is getting better when measured against government targets and HC reviews. Some 4 per cent of Trusts were deemed excellent, 36 per cent good and 51 per cent were found to be fair.

This suggests that despite a tough financial climate, the majority of NHS providers see the quality agenda as important, and this is certainly the set of issues that patients and the public will care about most.

What next?
The HC has asked the 24 weakest Trusts to develop a detailed action plan to share with their Strategic Health Authority (SHA). The plans will need to satisfy the HC that serious steps will be taken to improve both service quality and financial management.

Once the plan is signed off - this must happen by the middle of November - the SHA will monitor performance against the plan. In addition, the Trusts deemed to be weak will have their services reviewed by the HC over the next 12 months. The role of an HC review is not to punish these Trusts but to explore where it can support them in improving their performance.

The HC will then pick a sample of Trusts that fall into the fair category and these too will be subject to a review by the commission.

The HC is certainly not going to use its limited resources to visit Trusts deemed excellent or good. This set of visits should enable Trusts that have shared issues openly with the HC to have support in focusing on key areas that can help them shift from being fair to being good
or excellent.

Sir Ian Kennedy, the chair of the HC was adamant that by next year he expected all NHS Trusts to demonstrate improvement and assure the public that the extra money that has gone into the NHS is delivering improvements for patients.

What is of greater value is the longer term use of the data. The HC process is tougher and more comprehensive than the old star rating system. In the first year, the HC and NHS providers will have had to test a new system. Next year, all parties will be more familiar with the framework.

These results provide a sound baseline for the NHS in England and, over the next two years, we should be in a stronger position to actually determine how the NHS is performing. This will be valuable to the NHS, patients, the public and politicians.

The Blair government has poured record amounts of cash into the NHS and will continue to do so until 2008. Headlines earlier this year about the NHS being in financial meltdown must have confused the public. The HC report provides a more sober and balanced snapshot.

Right to know
It is absolutely right that the public has some idea of how the NHS is performing and the HC report shows clearly that a minority of Trusts are weak and that many do actually recognise that there is room for improvement. The results of the HC check next year should tell us a lot more.

The government is about to undertake a comprehensive spending review of all public services, including the NHS, for the period of 2008 to 2011. Many observers suggest that the NHS will not get as much growth money as it received in the last review. If the HC can demonstrate that the NHS takes the improvement agenda seriously and that investment leads to better care and use of resources, then our political masters and mistresses are in a better position to defend NHS spending.

In the run up to an election, the HC annual review will be centre stage in decisions about the funding of healthcare.

The HC report also allows the public to interrogate data about their local services through their website.

Commercial websites, such as Dr Foster, have done a brilliant job of helping the public know more about NHS performance, but the HC report will be viewed as authoritative and comprehensive.

Critics suggest that members of the public do not know how to use this type of data. The public are not stupid. They will recognise that this is the first year of a new system and will be able to look at the results in a balanced way.

What will be more fascinating is how this information builds in the next few years and how well the NHS responds.

Pharma firms can look at the full report at, where it should be possible to see how a company might work with local NHS providers to help them bring about improvements in quality and resource management.

The HC report will certainly be read by every board and CEO. If a service deemed to be weak remains in that category in year two, it is likely to be career-limiting for the CEO. Companies need to see what support they might be able to offer such CEOs on a partnership basis.

The author
Ray Rowden is an associate with the Healthcare Commission, but the views expressed here are personal

2nd September 2008


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