NHS trusts — star ratings < Influencers contents | Print this page A new organisation The Healthcare Commission was launched on 1 April 2004 and almost immediately asked for views on its corporate plan for 2004-08, Informing, inspecting, improving. See www.healthcarecommission.org.uk. Public statements from both the chair, Professor Sir Ian Kennedy, and chief executive, Anna Walker, seem to suggest that the commission has already begun to flex its muscles. Both have said that it would not hesitate in recommending the closure of a trust if it believed that patients were at serious risk. The HSJ has suggested that the arrival of both the commission and foundation trusts ushers in a new era: ‘The NHS will not feel much different today, but in three year’s time it will be clear that 1 April 2004 was a watershed in the development of English healthcare’. We shall see… 2003/04 star ratings The Healthcare Commission published the latest NHS trust star ratings for 2003/04. Although there are more three star organisations than ever before, the ratings appear to show that NHS performance varies widely across the country. In the north of England, 86 per cent of PCTs have two or three stars, but in London, no PCT has three stars. The three star trusts include 74 acute hospitals, 10 ambulance trusts, 15 mental healthcare providers and 44 PCTs. However, 35 organisations received zero stars. These include 10 acute hospitals, four ambulance trusts, seven mental health providers and 14 PCTs. The commission said that overall the health service in England was improving but that it was concerned that more than one in three mental health trusts had just one star or less and had a particular go at the quality of information which these trusts were able to provide. Also interestingly, four of the new foundation trusts (Addenbrooke’s, Moorfields, Papworth and Peterborough) lost their three star statuses in the 2004 ratings (but remain as foundation hospitals), as did another 10 wannabe hospitals, which were expected to join them as foundation hospitals in October 2004 but now won’t. Some 12 trusts have actually appealed to the Healthcare Commission challenging their star ratings — six PCTs, four acute trusts and 2 mental health trusts. These yearly ups and downs could well destabilise the whole foundation trust philosophy. See the 2004 performance ratings. NHS influencers should note that there is an excellent resource on the star ratings, which provides a map of England with each PCT boundary. Clicking on the map brings up the star rating for either 2003 or 2004 and also the detailed Healthcare Commission report for that PCT. This should be an invaluable aid to PCT business planning. See Primary care trust ratings 2003 and 2004. Local teams should know about the current star rating system and the implications for trusts as well as the actual stars given. NHS influencers should definitely know which of their local trusts are either zero-rated or three star-rated. Local hospital sales teams also need to know where their own hospitals rank in terms of local business planning. The commission website holds all these performance ratings and is divided into trust type (ie, acute, ambulance, mental health and primary care). The ratings can be searched by trust name, SHA, or browsed by trust-type. Dr Foster Hospital Guide The Sunday Times Good Hospital Guide was published again in 2004 in conjunction with Dr Foster. This is a must-read for hospital sales forces. Apart from ratings by mortality for all English hospitals and useful comment on each hospital, there is content about the postcode lottery in health and that star ratings do not gel at all with clinical outcomes. Nigel Edwards, NHS Confederation policy director, said in an accompanying Sunday Times article (16/05/04): ‘We now need to start looking at whether the way we treat people actually makes them better.’ Any move away from process (waiting times) to outcomes (death!) would of course be good news for companies. Credibility of the star ratings system The star-rating system has moved from the DH, to CHI and now to the Healthcare Commission, but still faces major criticism from a number of quarters. For instance, the credibility of the star ratings system was called into question by an Audit Commission analysis which found several ‘highly starred trusts’ had weak management and financial arrangements, while some zero-star trusts performed better. The commission compared assessments by local auditors in September 2002 on trusts’ management ability and their likelihood of achieving year-end targets with the star ratings they had been awarded two months earlier. Achieving the NHS Plan suggests that the DH star ratings are only ‘weakly related’ to performance or management ability. Also see the BMJ article, ‘Star rating system fails to reduce variation’, for comment linking star ratings to health outcome measurement. Shadow Health Secretary Andrew Lansley has said: ‘This has got to stop. Star ratings do not give an accurate reflection of a hospital's performance. They are extremely misleading for patients’. Liberal Democrat health spokesman Paul Burstow has said: ‘Hardworking NHS staff are being forced to run around chasing government targets instead of getting on with the job of treating patients’. The NHS Alliance has said: ‘The system is widely regarded as flawed… What is needed is greater collaboration between the Healthcare Commission and PCTs in setting meaningful performance measures’. NHS Alliance Chairman Dr Michael Dixon added: ‘We agree with many other experts that awarding stars — rather like a restaurant guide — is too simplistic and too crude to provide meaningful information about how primary care trusts are really performing. The system is in danger of becoming of interest only to Healthcare Commission insiders, politicians and journalists, but irrelevant to frontline professionals, patients and the public’. And King’s Fund chief economist Professor John Appleby has commented on the apparent ‘volatility’ of the star ratings system: ‘It is well known that in composite performance measures that if there is too much movement there is something wrong. In general too much volatility from year to year indicates the system is overly sensitive’. Healthcare report 2004 The Healthcare Commission has published its first overall report on healthcare in England and Wales. State of healthcare report 2004 examines various aspects of the NHS provision of healthcare, including care in hospitals and in the community, public health, mental health, care of children and of the elderly. The report says that although there are many signs that NHS healthcare is improving, the improvements are not happening quickly enough. The report is also highly critical of the amount of good information available and that too many measures are about sickness rather than health. The commission found wide variations in healthcare between different parts of the country and different groups of the population saying, ‘Britain is still plagued by health inequalities more than half a century after the creation of the NHS’. The document reports that many deprived communities, with the greatest health needs, are not getting their fair share of NHS resources while wealthy communities (eg, districts like Kensington and Chelsea) are receiving more than they need. The Healthcare Commission has pledged to put inequalities of healthcare at the top of its agenda and part of its future work will be to ensure that the NHS identifies the reasons for the variation in healthcare and what it intends to do to address the inconsistencies. The report also
says that in its first year of operation the commission will conduct
a national review of A&E services as well as a joint review
(with the Audit Commission and the Commission for Social Care Inspection)
of the older people’s national service framework. New healthcare standards: Standards for better health The Health and Social Care Act (2003) placed a ‘duty of quality' on each NHS body and the government moved to provide direction by consulting on a set of new healthcare standards for the NHS in Standards for better health. The NHS does not start with a blank piece of paper so this will mean major changes to the targets and performance system that has been operating since 1997. New Labour has repeatedly been condemned for introducing numerous central targets and there is a lot of spin with John Reid saying that targets for waiting lists have done their job and that it is time to be a bit more sophisticated. Others are saying that the government has done a complete U-turn. New healthcare standards: National standards, local action 2004 has seen the planning and priorities framework for the next three years published — National standards, local action: health and social care standards and planning framework 2005/06-2007/08. The normally half a dozen or so pages is now up to 50 pages as the document now includes the new healthcare standards that the Healthcare Commission consulted on in Standards for better health. The document follows on from the NHS improvement plan and they are very much a pair. So this is a standards-based planning framework for health and social care, with standards for planning, commissioning and delivering NHS services. The new standards are supposed to join up with the new system of chronic disease management and the new focus on public health. Certainly the formal targets/priorities do (see appendix B). The number of national targets NHS providers must comply with has been reduced and existing national targets (that will have been met by April 2005) will become core standards (which must be maintained), and NHS providers will be able to set more locally agreed targets. But be careful with this bonfire of targets spin. The new ones are broader based than many of the ones disappearing and if one carefully reads the document one will see that the targets come with many supporting paragraphs with almost hidden mini-targets. The document lays out two sets of standards — 24 'core' and 10 'developmental' — in seven key ‘domains’:
The areas of clinical and cost effectiveness and public health are the most interesting. The following is a core standard in this domain: 'Healthcare
organisations have systems in place to ensure that treatment and
care are based upon nationally agreed best practice or nationally
agreed guidance, including NICE technology appraisals.' Also note: '…ensuring
that the local director of public health's annual report informs
their policies and practices.' 'Healthcare
organisations will have disease prevention and health promotion
programmes which meet the requirements of the NSFs and national
plans'. Commission for Health Improvement This body has now been wound up. Amongst the last things to do before the lights were switched off was to publish a report on a number of service failures which strongly suggested that the national focus on access targets for acute trusts could be a key factor behind many failures as it probably has led to other services receiving less attention. Risk factors for serious failure identified by the commission at service operational level included:
Manchester University’s centre for healthcare management published an analysis of the Commission for Health Improvement’s work and what lessons the Healthcare Commission can learn. Learning from CHI: the impact of healthcare regulation Bottom line Learning from CHI: the impact of healthcare regulation looks at the principles of effective regulation.
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