How are we doing?

Gary Needle, head of NHS assessment at the Healthcare Commission, gives an insight into this year’s annual health check results

Regulation does not tend to set many people’s pulses racing. However, its importance in healthcare has certainly come under the spotlight of late.

But here at the government’s healthcare regulator, we are not surprised. After all, the issues we deal with are the same as those that regularly occupy the front pages of our newspapers.

This has been particularly evident in the past few weeks.

There was our dignity in care report, which suggested that many trusts were getting the right systems in place, but that there was some way to go before we could be confident that the NHS was offering dignity in care to all of their patients, all of the time.

Our national complaints audit followed swiftly. This was the first report of its kind, and we found there to be considerable variation in the way the NHS handles complaints.

Indeed, the NHS provides 380 million treatments a year so, at 140,000, the number of complaints is small in comparison. But when someone does complain, trusts need to respond well. After all, the very best organisations value feedback from the people they serve, and this should be no different in the National Health Service.

And before the dust had time to settle from the political party conferences, our investigation into two outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust was published.

What happened to the patients there was a tragedy. Our report into the events was shocking. But as a regulator with teeth, we wanted to fully expose the reasons for that tragedy so that the same mistakes are never made again.

As a regulator, it is our role to identify areas for concern and ensure lessons are learnt. But it is as important for us to highlight good practice, so those organisations that are not doing so well can learn, and catch up with the best.

This type of fearless regulation is what earns the public’s trust. It is perhaps the reason why, when we published the results of our annual health check the week later, everyone stood up and listened.

Our health check provides the most comprehensive assessment ever of the NHS. It covers the issues that matter to patients: How long will I have to wait for my treatment? Will I be treated with dignity and respect? Will the hospital be clean? Are my taxes being used to fund an efficient service?

But in the way it is carried out, it also gives trusts the chance to consider whether they are reaching the right quality of care. What is more, it distracts them as little as possible from doing their jobs; our pioneering system is a far cry from the ‘clipboard brigade’ images that many have of regulation.

How does the annual health check work?

The health check looks at two areas: quality of services and use of resources. For each of these, every one of England’s 394 trusts receives a score on a four-point scale: “excellent”, “good”, “fair” or “weak”.

Our assessments on use of resources – that is, how well trusts are managing their finances – draw on the work of other regulators. Foundation and non-foundation trusts are assessed differently to reflect the different governance arrangements they are under.

For all NHS trusts, other than foundation trusts, the Audit Commission provides the assessments based on the local evaluations made during the statutory external audits. This covers areas such as the organisation’s financial accounting and reporting arrangements, its planning and management of finances, how it is improving value for money and whether it breaks even for the year.

To assess how well NHS foundation trusts are doing, we use the quarter four annual financial risk ratings compiled by Monitor, the independent regulator of foundation trusts. This looks at underlying financial performance, achievement against plan, financial efficiency and liquidity.

The score for quality of services, on the other hand, is based on three components, namely:

· core standards in areas which really matter to patients such as

safety, quality of care and how responsive a trust is to patients;

· existing national targets, designed to ensure basic levels of service

are being met in areas such as waiting times;

· new national targets, designed to promote improvement in broader

areas of public health and healthcare such as smoking, sexual health, health inequalities and mortality rates.

The process starts when we ask trust boards to self-declare their performance against 44 requirements set out in the core standards. It is the trusts themselves who deliver improvements in their services, not us, as the regulator. Self-declaration therefore gives them the opportunity to consider whether they are reaching the right quality of care.

Those trusts that have put their hands up and declared non-compliance in some areas are to be applauded – this shows boards really examining their own performance. Though, of course, they then need to put matters right.

The next step is to ask local patient groups and local people how they think the trusts are doing. This is real customer feedback.

We also pull together all the other information we have on the trusts, then we add it to the patient views and declarations. The results provide us with an indication of which trusts we need to visit.

This approach lets us target visits only to those organisations and services we think are at most risk of breaching standards of care and putting the health and safety of patients at risk. It also picks up the views of patients and tells them what they want to know about their healthcare organisations.

Naturally, there is a lot of information for us to present. Therefore, we put a lot of effort into ensuring the data we publish on our website answer the questions people want answering and is as user-friendly as possible.

This year, we hope the results are easier than ever to navigate.

So, what were the results?

Overall, the National Health Service has improved in the past year. There are more trusts in the top band of “excellent” for both parts of the rating – quality of services and use of resources. Fewer trusts scored “fair” and “weak”. And, of particular note, 19 NHS trusts scored “excellent” on both parts of the rating, compared to just two in 2005/06.

Performance for use of resources has improved, both in terms of more trusts scoring “excellent” and fewer scoring “weak”. Fourteen per cent of trusts scored “excellent”, up from just 3% last year, while the proportion of trusts scoring “weak” has fallen from 37% last year to 26% this year.

In terms of quality of services, good performance was achieved in relation to cancer waiting times, and inpatient and outpatient waiting times, with improvements evident regarding cancelled operations. Sixteen per cent of trusts were rated “excellent” and 30% “good” – last year only 41% of trusts fell into these categories.

But, performance in relation to convenience and choice, which requires a choice of hospital appointments to be offered to patients and for these appointments to be at patients’ convenience, is more concerning. Current performance levels suggest that significant challenges, concerning both system implementation and behavioural change, will need to be addressed if improvements are to be achieved in 2007/2008.

Overall, 33 trusts were rated “weak” for their quality of services, 20 of which also scored “weak” on use of resources.

We would also have liked to have seen more trusts move out of the “fair” category and into “good”. This did not happen, with the largest group of trusts scoring a rating of “fair” on quality of services. The performance of these trusts is adequate, but there is certainly room for improvement.

Hence, we will be working very closely with the Department of Health and the strategic health authorities to ensure that action plans are in place, and then followed up, for trusts rated in the lower two categories. We will also be inspecting the trusts which were “weak” on quality of services to assess the nature of the problems and make recommendations for action.

But our work will not stop there. On publishing the results for the annual health check we also committed to take tough action in NHS trusts that are failing to put adequate systems in place to tackle healthcare-associated infections.

In October last year, the government introduced the Hygiene Code – this raised the bar in relation to infection control. But, 44 out of 172 acute and specialist trusts (hospital trusts) did not comply with at least one of the standards relating to infection control. These trusts need to do more on controlling infection to ensure that the safety of patients is not put at unnecessary risk.

We recognise the concerns patients raise about poor practices in the control of infection. We will therefore continue with a programme of wide-ranging inspections that will help to drive improvement in infection control.

We are already in the process of carrying out our biggest programme of inspections of infection control. This is aimed at driving improvement in the control of infections such as C. difficile and MRSA.

So far, 87 inspections have taken place, either as part of the annual health check or as an unannounced visit to check on measures required by the Hygiene Code.

A further 33 inspections will take place by the end of this financial year. Trusts with high rates of MRSA and C. difficile will be inspected as part of this programme.

And, from April next year, in line with the government’s recent announcement, we will be inspecting every hospital trust in England, every year, to assess how they are preventing and managing healthcare-associated infections.

This has certainly been a tough year for the NHS, with significant re-organisation taking place and tougher standards on infection control.

Many trusts have stepped up to the challenge – this should be recognised and applauded.

We now want to see more trusts follow this lead, with more moving away from the “weak” and “fair” performance ratings. The target is to get the core standards in place across the NHS for the first time. This would give all patients a minimum guarantee on issues such as safety, cleanliness, waiting times and quality of care, regardless of where they lived. It would be an historic achievement.

Last year, the annual health check gave us the benchmark for NHS performance. This year there has been improvement. Next year we hope to see trusts push on and publish even better results.

Effective and less bureaucratic regulation will certainly play a part in this. Regulation that the public need, the government demand and the frontline staff respect. And who said the future of regulation was not exciting?