PERFORMANCE MEASURES Anna Walker's vision, and below, the new ratings explained

Published: 02/12/2004, Volume II4, No. 5934 Page 6

Trust chief executives will not be able to treat the new 'health check' as a project while ignoring the rest of their responsibilities - as some did with the star-ratings - the chief executive of the Healthcare Commission has warned.

A combination of targets plus core standards, along with spot checks and unannounced visits, will make it more difficult for managers to plough all their resources into hitting targets, Anna Walker told HSJ.

Under the proposed replacement for the star-ratings, currently under consultation, trusts will have responsibility for regulating themselves against the commission's standards, and local partners like councils, strategic health authorities and patient forums will help monitor their performance.

'When I first started this job a trust chief executive said to me that the thing about the previous starratings was that you could achieve them as a project and the rest of the organisation could go by the way and you could just concentrate on targets, ' said Ms Walker.

'But this combination of targets and standards are much more broadly based, particularly against the backdrop of standards - not just core standards but developmental standards with the concept that you need to improve over a period of time.' Ms Walker said there would be some healthcare managers who wanted the system to stay the same, 'for us to tell them at the beginning of the year exactly what we are going to measure and how we are going to measure it, because it is easier for them to assess how they are doing'.

But she said there would now be more emphasis on issues that affected patients like cleanliness and safety, as well as clinical outcomes.

'Gone are the inspections where you require huge amounts of information in advance and then we send a team, five or six strong for five days to the organisation.

'What we are planning is that the trusts' boards will have to take the first responsibility for saying whether or not they think they meet the standards, ' she explained.

In an effort to make local healthcare organisations more responsive to the needs of their communities, local targets will play a part in the health checks.

However they will only be piloted in the first year of the system because of the complexities of measuring them and are expected to be introduced across the NHS in 2006-07.

Interwoven with this will be the emphasis the checks put on public health.

'One of the areas [in which] public health features significantly will be in the local targets and they have to be agreed with the local authority, ' said Ms Walker.

'To me it is very striking how the public health needs of different populations are very different, so local public health targets help you pick that up.' But Ms Walker said the commission faced one of its biggest tests in using its judgement to measure core standards.

'The commission is going to have to make some judgements about whether standards are being met, ' she said.

'Healthcare managers will rightly want to ensure that the right procedures are in place. Are we using the right evidence? Are we talking to them about our findings? Are we giving them a chance to discuss our findings with them?

'A very big challenge for the Healthcare Commission is to get fair and open processes in place for the handling of this - and we will meet that challenge.'

The 2005-06 ratings

Performance will be assessed in two areas Getting the basics right In this area performance will be measured against:

24 core standards (see standards box);

20 existing targets;

trusts' financial position and management, plus the value for money use of resources. Assessments will be based on information collected by the Audit Commission and foundation trust regulator Monitor;

findings from over 20 regulatory bodies.

Making and sustaining progress In this area performance will be measured against:

the four national priorities set out in the Department of Health's public service agreements;

some 'improvement reviews' examining services by patient experience are likely to contribute towards the 2005-06 ratings.

Pilot studies have been conducted in substance misuse, public health and children's hospital services.

Producing an overall rating

Trusts will be given one of five performance grades: very good, good, satisfactory, unsatisfactory or serious concerns. The commission is considering two methods of deciding how to award grades.

First, scoring a trust out of four on each aspect of 'getting the basics right' and out of five on each category within 'making and sustaining progress'. The percentage of the maximum possible total score would be used to calculate the performance grade: ie 67 per cent = 'good performance'.

However, some 'simple rules' might be used to 'override' a rating - for example, failure to achieve two or more existing targets would automatically mean a trust was rated within the 'serious concerns' category.

The second method is basing the rating on a set of rules. For example, an 'unsatisfactory' score on one of the core standards, existing targets, use of resources, other regulatory findings and new national targets would automatically mean the trust was rated 'unsatisfactory'.

The 2006-07 ratings

Future reviews will also take into account:

performance against local targets;

improvement reviews gauging performance against more ambitious 'developmental standards' (see box) starting with safety, access and public health. They will be piloted in 2005-06 but are not expected to feed into ratings until at least 2006-07;

improvement reviews in further service areas;

assessments of leadership and organisational capacity.

Organisations could be given a separate rating on this, or become part of the aggregate score.

The standards

There are 24 core and 13 developmental standards within seven domains:

safety, clinical and cost effectiveness, governance, patient focus, accessible and responsive care, care environment and amenities and public health.

Core standards set out a minimum level of performance. The consultation sets out 472 'prompts' which boards should 'take into account hsj. co. uk in satisfying themselves they are meeting the relevant standard.

Developmental standards indicate the improvements the government expects all trusts to make.