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Healthcare Commission declares NHS performance is improving

Healthcare Commission : 18 October, 2007  (New Product)
The Healthcare Commission has published performance ratings for all NHS trusts in England, showing overall improvement in quality of services and use of resources.
The independent watchdog has released the results of the 2006/07 annual health check of NHS trusts, the most comprehensive assessment of NHS performance.

In its second year, the annual health check for the first time now gives people the chance to compare performance.

People can see if trusts are improving in meeting the Government’s standards and targets in areas of real importance to them, like quality of care, safety and waiting times.

All 394 trusts get an overall rating - on a four-point scale ranging from ‘excellent’ to ‘weak’ – on both quality of services and use of resources (financial management).

The results show clear improvement overall, with more trusts scoring ‘excellent’, as well as fewer scoring ‘fair’ and ‘weak’. In all, one in three trusts improved on quality of services and a similar number did so on use of resources.

In particular, the Commission noted that 19 NHS trusts scored ‘excellent’ on both parts of the rating, up from just two last year.

Areas of significant improvement include:

- every trust achieved the target for cancer patients waiting no more than a month from diagnosis to treatment, except for good clinical reasons
- despite increases in attendance, A&E waiting time targets were met nationally with 98 percent of 18 million patients in A&E receiving care within four hours
- more trusts met the target of reducing the number of cancelled operations, with the proportion of cancellations falling for a third consecutive year.

Quality of services:

-16 percent of trusts were ‘excellent’ and 30 percent were ‘good’ (46 percent compared with last year’s 41 percent in these two categories)

- 45 percent were ‘fair’ and eight percent were ‘weak’ (53 percent compared with last year’s 59 percent of trusts in these two categories).

Use of resources:

- 14 percent of trusts were ‘excellent’ and 23 percent were ‘good’ (last year 16 percent were in these two categories)

- 36 percent were ‘fair’ and 26 percent were ‘weak’ (62 percent compared with last year 84 percent in these two categories).

The Commission noted concern that 33 trusts (eight percent) were rated ‘weak’ on quality of services. Of these, 20 (five percent) were ‘weak’ on both parts of the rating. Four of these trust have received the ‘weak’ rating for two years running.

The watchdog was also concerned that the largest group of trusts fell into the category of ‘fair’ on quality of services, meaning that their performance is adequate but there is room for improvement – 50 percent were ‘fair’ last year and 45percent ‘fair’ this year. The Commission is disappointed that more trusts did not move out of the ‘fair’ category this year.

On use of resources, the Commission recognises improvement overall, but said more was needed with one in four trusts (104) still ‘weak’ in this area. The Commission acknowledged that some trusts have historical deficits, but in many poor financial management remains a problem.

Anna Walker, the Commission’s Chief Executive, said: “This has been a tough year for the NHS, with significant reorganisation taking place, and tougher standards on infection control. Many trusts have stepped up to the challenge. They have delivered improvements in areas that really matter to patients, such as waiting times.

“I want to applaud those organisations that have done well. NHS staff don’t always get the opportunities they deserve to celebrate successes. It is hugely important that we recognise them.”

She added: “The next challenge is to narrow the gap in performance by getting the ‘fair’ and ‘weak’ up to the standards of the best.

“It is clear that a handful of ‘weak’ trusts need significant improvement and that too many organisations were ‘fair’. We need to see improvement in the performance of all these trusts on behalf of patients.”

Walker emphasised that the assessment highlighted that trusts had more to do on hygiene standards. 44 hospital trusts were non compliant with at least one standard.

“Healthcare associated infection really matters to patients,” said Walker. “Trusts have got to meet the hygiene standards.”

“We believe that the introduction of the Government’s hygiene code in October 2006, has helped organisations to focus on where they are still not doing everything that they should. The standards are much tougher in this area this year. This is how it should be for patients.”

Depending on the services provided at each trust, the Commission’s rating on quality of services is based on:

- 24 core standards (with 44 components) in areas like safety, standards of care and how responsive a trust is to patients
- up to 19 existing national targets designed to ensure that trusts are meeting basic levels of service in areas such as waiting times
- up to 14 new national targets designed to promote improvement in broader areas of public health and healthcare such as smoking cessation and reducing health inequalities.

Overall, performance in meeting the core standards improved, with 55 percent of trusts judged to have ‘fully met’ the standards, up from 49 percent last year. However, the Commission recognised there is still considerable room for improvement as all trusts should have been complying with these standards.

Core standards with the highest rates of compliance related to topics such as:

- protecting patients by acting on safety alerts in a timely manner (C1b)
- enabling staff to raise concerns about services (C8a)
- cooperating with other health and social care organizations (C6).
- requiring all employees to abide by professional codes of practice(C5Cc)
- having systems in place to ensure consistent application of research governance frameworks(C7)
- ensuring clinical care and treatment are carried out under supervision and leadership(C5b).

Core standards with the lowest rates of compliance related to:

- management of patient records (C9)
- participation of staff in mandatory training programmes (C11b)
- protection from healthcare associated infections (C4a)
- Decontamination of medical devices (C4c)
- discrimination, equality and human rights (C7e)
- design, maintenance and cleanliness of environment (C21)

The Commission assessed the core standards after cross-checking public declarations made by trust boards. It inspected 87 trusts, the majority of which were identified using information from patients, and ‘qualified’ the declarations of 45, based on that further information.

A central feature of the process of assessment is the submission of comments from patients and the public on trusts’ performance in meeting the core standards. In all, 8,000 comments were received from people across the country. The key areas of concern for patients were:

- equal access to services (C18)
- having accessible information (C16)
- healthcare environment and hygiene (C21)

Overall performance improved with 55 percent of trusts judged ‘fully met’ on existing national targets, an increase of 18 percentage points compared to last year. This is largely because of the significant improvements in the range of waiting time targets.

But 70 percent of PCTs failed the target relating to ‘convenience and choice’, which says that patients should be able to choose from at least four providers paid for by the NHS.

This was the worst area of performance in any of the existing national targets. The reasons for this include the fact that GPs are not contractually obliged to offer ‘choose and book’, and the intermittent technical problems with the necessary computer systems.

Performance on new national targets was broadly similar to last year with 25 percent of trusts scoring ‘excellent’, up from 24 percent last year. But this year a higher proportion of trusts scored ‘weak’, up to 24 percent from 17 percent last year.

The Commission said that trusts had made good progress nationally towards meeting the target whereby no patients referred to a consultant should wait more than 18 weeks for treatment. This target is due to be met in December 2008.

In 2003/04, trusts were set a challenging target to halve rates of MRSA by 2008. Despite a steady decline in rates of MRSA, this remains a challenging target.

Looking across the types of trust, acute hospital trusts and mental health trusts performed the best.

Acute trusts were found to have performed ‘extremely well’ in delivering existing national targets. In addition,19 percent of acute and specialist trusts scored ‘excellent’ on quality of services, up from seven percent last year.

Mental health trusts were the highest performing type of trust, with more than half scoring ‘excellent’ for quality of services. Mental health trusts performed well on meeting important targets, such as the implementation of crisis resolution teams and the core standards. However, they are currently assessed against fewer targets and, therefore, not challenged to the same extent as other trusts. The Commission is consulting with the sector on strengthening the assessment for future years.

Against a background of tough targets, 62 percent of PCTs were ‘fair’ and 12 percent were ‘weak’for quality of services. The picture was similar for use of resources. Areas of weak performance included ‘choose and book’ and updating practice-based registers, issues of significance to patients. The 72 PCTs reorganised in October 2006 performed the least well.

Foundation trusts performed better than non-foundation trusts across both parts of the rating, notably on use of resources. There were ‘excellent’ scores for 86 percent of the 59 trusts that had become foundation trusts prior to April 1 2007. All 19 trusts scoring ‘excellent’ for quality of services and use of resources were foundation trusts.

Looking across the ten strategic health authorities (SHA), areas with highest performing trusts on quality of services were the East Midlands, which had the highest proportion of ‘excellent’ trusts (26 percent), and the North East, which had by far the highest combination of ‘excellent’ (13 percent) and “good” trusts (61 percent).

The South West SHA had the highest proportion of ‘weak’ (20 percent) trusts. The South East Coast SHA had the lowest proportion of ‘excellent’ trusts and the highest combination of ‘fair’ (58 percent) and ‘weak’ (19 percent).

The Commission has announced that it will work closely with the Department of Health and the strategic health authorities to ensure that action plans are in place for trusts rated ‘fair’ and ‘weak’. The strategic health authorities have indicated that they would actively follow up these plans. The Commission will regularly monitor progress.

In addition, the Commission will:

- send a team of inspectors into the Royal Cornwall Hospitals NHS Trust. This trust told the Commission that in 2006/7 it did not meet almost three quarters of standards, the second year of poor performance. In a six-month review, the Commission will assess efforts to improve the situation and recommend action.

- inspect the other 32 trusts that were ‘weak’ in the quality of services including the nine that have been ‘weak’ for two years in a row. It will assess the nature of the problems and make recommendations for action, reporting back nationally on any common traits in ‘weak’ organisations

- follow up trusts that have declared non-compliance with standards, checking that they have plans to correct the situation

- write to the NHS leadership team in the Department of Health and NHS Confederation urging them to help to drive improvement on meeting the standards where compliance is lowest, as these standards really matter to patients

- continue to inspect two thirds of acute trusts on hygiene standards this year and prepare to inspect all acute trusts every year on infection control.

As part of its processes, Monitor has already identified areas of non-compliance with core standards. Monitor requires the boards of foundation trusts to ensure all core standards are met as a requirement of their authorisation and that boards will take action where they are non compliant with core standards. Where appropriate, Monitor requires foundation trusts to put in place action plans to ensure compliance. This is backed by Monitor's powers of intervention.

In the few foundation trusts, which were non-compliant with core standards in 2006-7 almost all have now implemented action plans to ensure compliance with core standards.

The Healthcare Commission will continue to work closely with Monitor to ensure that any problems around core standards are identified at the earliest opportunity.

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