Health check improvements mask decline in acute trust performance

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The performance of acute trusts in the annual health check has dropped for the first time despite overall improvements in service quality across the NHS.

More NHS organisations than ever before have had the quality of their services rated as good or excellent by the Care Quality Commission in 2008-09.

In Numbers:
37 - Organisations receiving a double excellent score
43 - Organisations that have performed strongly over two years. They will receive a letter of congratulation
100 - Percentage of trusts that supported staff to raise concerns about services
0 - PCTs rated double excellent
1 - Organisations rated double weak - down from six last year

But nearly half have more to do to ensure they are ready to meet their legal duty to register with the CQC by next April.

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

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

CQC chief executive Cynthia Bower said: “The NHS has done very well against a very tough assessment on quality.”

She highlighted improvements on the 18 week referral target, accident and emergency waits and infection rates, saying these were “big things that matter”.

But while there were improvements among primary care trusts, acute trusts’ performance dropped. Only 37 were deemed “excellent”, compared with 52 last year, and 59 per cent were fully compliant with core standards, down from 69 per cent in 2007-08.

Last year, there were only two core standards where 10 or more acute and specialist trusts were not compliant by the end of the assessment year.

This year, this is true of five standards, concerning safe use of medical devices, mandatory training, safeguarding children, decontamination and clean, well designed environments.

Acutes also struggled on stroke care, cancelled operations, the quality of maternity data, heart disease audits, smoking during pregnancy and total time spent in A&E.

A CQC analysis document says the fall in ratings is “harder to diagnose” for acutes than in other sectors: mental health and ambulance trusts have been through tougher assessments this year.

The regulator partly attributes the decline to more realistic self-assessments following national reviews of child safeguarding and hygiene measures.

But Ms Bower said these factors “don’t explain the whole picture by any stretch of the imagination”.

NHS Confederation chief executive Steve Barnett said the pattern may reflect a “more self-critical approach” following last year’s scandal at Mid Staffordshire Foundation Trust.

Mr Barnett praised “notable successes” such as performance against targets and the achievements of PCTs but said it was “concerning” that not more organisations were compliant with registration standards.

Cynthia Bower warned the 20 organisations scoring weak on quality and the 32 that have never scored higher than fair that they must demonstrate they can improve. They will be told to publish an action plan on their websites.

However, Ms Bower was confident all organisations will register in April.

She said: “Patients and the public want us working together to ensure services are safe and of a high quality. They don’t want us saying ‘These organisations aren’t good enough.’”

The regulator will be “raising the bar”, she said, meaning organisations may in future be viewed as inadequate even if they are assessed as fair.

Organisations in “all sorts of circumstances” are performing well, she added, meaning there was no excuse to fail.

The CQC also plans to write to the top performers congratulating them on their achievements.

Next year’s health check could be the last - after 2009-10, the regulator does not expect its budget will stretch to running the registration system in addition to an annual stock-take of performance.

It is likely to move to a more ongoing process with a greater emphasis on measuring outcomes.

Breakdown: performance on core standards

Core standards with lowest compliance rates

Ensuring staff participate in mandatory training programmes
Records management
Decontaminating reusable medical devices

Core standards with highest compliance rates

Supporting staff by having processes for them to raise, in confidence, concerns over services
Ensuring staff abide by relevant published codes of professional practice
Having systems in place to ensure patients, their relatives and carers have suitable and accessible information about making complaints or giving feedback

Core standards with acute trust compliance rates below 90 per cent

Decontamination
Safeguarding children
Clean, well designed environments
Safe use of medical devices
Mandatory training

National performance indicators that acute trusts found particularly challenging

Stroke care
Offering a new date for cancelled operations within one month
Maternity data quality
Participation in heart disease audits
Smoking during pregnancy and breastfeeding initiation rates
Total time in A&E

Royal Marsden: four out of four

Managerial stability and an emphasis on efficiencies for the sake of quality rather than cash have helped the Royal Marsden Foundation Trust’s success in the annual health check.

The London trust is the only one to achieve a double “excellent” for four years running.

Chief executive Cally Palmer said the trust’s specialist focus on cancer care and research helped it foster a patient centred approach, focused on innovation and quality. Its specialist nature also created a sense of “community” between different groups of staff.

“There are no discernible barriers between clinicians and management,” she said. That was helped by the continuity in the management team - Ms Palmer herself has been chief executive at the trust for 11 years.

Ms Palmer emphasised that quality and risk rather than finance are the board’s primary concerns.

“When we are talking to staff about being more efficient it’s about doing that so we can treat patients better, rather than save money,” she said.

Foundation trust freedoms had also helped improve patient quality. Surpluses have been reinvested in a staff of “patient navigators” working to ensure patients did not fall between any gaps in a pathway or subject to delays in their treatment.