Safety outcry is ‘mandate’ for NHS quality

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Public outcry about apparently unsafe hospitals gives the health service a mandate to put quality ahead of finance in planning and providing services, the NHS medical director has said.

Sir Bruce Keogh said quality goals should determine financial strategies, rather than the other way around.

What better mandate could we have from the public and media to address the quality and productivity challenge?

Reacting to the anger provoked by poor standards at Basildon and Thurrock University Hospitals Foundation Trust and Dr Foster’s patient safety ratings, Sir Bruce said: “If we have learnt anything from the past few weeks it is that in the eyes of the public quality trumps money every single time.

“What better mandate could we have from the public and media to address the quality and productivity challenge?”

His comments came in the wake of a reputational battering of the NHS following the leak of a Care Quality Commission report on Basildon, and the Dr Foster Hospital Guide 2009.

The Sun, under the headline “National horror story”, claimed: “A staggering 3,145 patients died needlessly in a year at 26 NHS hospital trusts.” The Sunday Telegraph reported “a deepening crisis over the standard of care in the NHS”.

Widespread local newspaper coverage included the Sunderland Echo declaring: “Sunderland Royal Hospital has the country’s worst record for surgery on the wrong body parts, it was revealed today.”

Speaking at the HSJ Leadership Forum on Monday Sir Bruce said that as the NHS prepares for investment cuts, strong “clinical endeavour, financial endeavour and managerial endeavour” had to go together.

He later told HSJ: “Financial considerations are only one input into quality. Others include technical innovation, service redesign, and customer satisfaction and clinical outcomes.

“With imagination these inputs can extract a bigger bang for the taxpayer’s buck, elevating the quality bar higher than when pure finance is the dominant driver.”

But the medical director urged organisations to be positive in response to the patient safety outcry. The NHS should be “proud”, he said, and pointed out that, according to Dr Foster, hospital mortality rates reduced by 7 per cent last year.

Sir Bruce told the Leadership Forum: “Why is it we adopt the approach that we are frightened to shout from the rooftops the benefits of what we do? We don’t get that message across. This has to change as we move forward.”

Heart of England Foundation Trust chief executive Mark Goldman said it was difficult to put quality ahead of finance, but the two had to be brought together.

He said: “You have to deliver a quality strategy but you have to do so within the financial parameters - and they are an absolute.

“In any organisation if you undermine your own finances you undermine your ability to do other things. You have to bring the two together.”

Dr Goldman said the events surrounding the Dr Foster data presented difficult issues for trusts.

He said: “My question is, what exactly is quality? Is it as measured by the CQC, by [foundation regulator] Monitor or Dr Foster?

“Where was the voice last weekend that spoke up to even try to cast light on the confusion the public now has?”

The trust best rated by Dr Foster, with a patient safety score of 100, was University College London Hospitals Foundation Trust.

Chief executive Sir Robert Naylor said he had made patient safety, outcomes and experience its top three priorities.

Sir Robert said good quality went “in parallel” with good finance, and highlighted the importance of clinical leadership and management.

He said: “Many of the hospitals which don’t do well in the quality league tables are ones that haven’t invested in clinical leadership.”

Several of the trusts criticised by Dr Foster have strongly questioned its methodology, for both its hospital standardised mortality ratios and patient safety point scores.

Dr Foster’s patient safety scores

The Dr Foster patient safety scores have been contrasted with trusts’ performance as judged by the Care Quality Commission and others.

The scores are based on several indicators, including death rates, admission rates, safety error rates and staff-to-bed ratios. Also included are trusts’ responses to a Dr Foster questionnaire on items such as whether their board receives safety information.

Trusts are ranked, then the rank is “rescaled” to a score of zero to 100 - which explains why Basildon and Thurrock University Hospitals Foundation Trust scores zero and University College London Hospitals FT gets 100.

Dr Foster’s hospital standardised mortality ratios have been questioned by academics and trusts who argue that they do not accurately reflect safety or quality. Some trusts say they don’t understand the methodology, which is not published.

The 2009 guide states: “There is much debate over HSMRs and whether a single figure can give an accurate idea of hospital mortality. The debate is valuable as it encourages hospitals to dig below the numbers to understand what’s behind them.”

Annual health check quality scores, from the Healthcare Commission and now CQC, are based on performance against “existing commitments” such as number of delayed transfers of care, “national priorities” such as patient experience and staff satisfaction, and trusts’ declarations of whether they meet “core standards”.

The standards ask whether trusts, for example, “protect patients through systems that identify and learn from all patient safety incidents”. Some trusts’ self declarations are checked by the regulator.