What is the secret of healthcheck ratings success? Loyal staff and paying close attention to what the public expects are key ingredients, hears Lynne Greenwood, as she talks to the two acute trusts with gold-standard ratings

Only two NHS organisations - both foundation trusts - received top marks in the Healthcare Commission's annual healthcheck. The Royal Marsden, a specialist cancer hospital in London, and Harrogate and District, which serves a catchment population of 183,000 in North and West Yorkshire, shared ratings of 'excellent' both on quality of care and use of resources.

Key to their success, say the pair, is the pride staff take in working for them, but what does more detailed analysis of what lies behind these highest possible scores reveal?

Certainly, neither is resting on its laurels. The assessment, which replaces the old star-ratings system, was based on 2005-06 data, and since then initiatives to tackle areas where there was still room for improvement have been introduced in London and Harrogate.

Harrogate: a stable workforce

At Harrogate and District foundation trust, chief executive John Lawlor, who took up the post in January, claims that the 2,000 staff are not only happy to be part of their particular ward or department, but also proud to belong to the wider organisation.

That there are few recruitment and retention problems backs up the claim to some degree, although there is no doubt that Harrogate is an attractive place to live and work.

Mr Lawlor has a firm belief in the model of a stable workforce, retaining staff for as long as possible with a small number of new faces arriving occasionally with fresh ideas ? and that it is a particularly effective strategy for the trust's local area.

'Having a population with high expectations of the NHS also helps the organisation raise its game,' he says. 'Since becoming a foundation trust, the membership and members of the public meet with frontline staff to tell us what it's like to receive treatment.' He says public and patient involvement has raised staff awareness of expectations.

There is no shortage of interested members of the public. Board chair Albert Day says: 'We have massive public support. We have attracted 13,000 members since becoming a foundation trust and an active board which plays a full part in the life of the trust. The governors' elections have been contested in every constituency, with the public competitively standing for elections.'

The Healthcare Commission complimented the close involvement of clinicians in many aspects of the trust. For example, complaints and risk-management meetings to review clinical incidents are held weekly, led by deputy chief executive Richard Ord and a senior consultant. As well as instigating any necessary investigations, they also decide whether clinical learning is indicated.

'If that is the case, the details are disseminated across the organisation quickly,' says Mr Lawlor. 'This weekly review is an important way of trying to minimise the risk of anything going wrong in future.'

Weekly meetings are also important in maintaining the trust's grip on performance. They aim to identify hotspots and deviance from expected local performance targets, including patient flows, waiting times, and other national targets. They are supported and informed by strong governance arrangements, particularly data management and verification.

'We have a very good multidisciplinary group of people attending performance meetings, including matrons, general managers, directors of pharmacy, radiology services - all the different bits of the organisation that need to understand where there may be barriers and blockages,' says Mr Lawlor.

Clinicians are also aware of financial constraints. 'When I came for interview, I was impressed by the number of clinicians who said they recognised that as a foundation trust and in the world of payment by results we have to succeed as a business to succeed as a trust,' he says. 'They appreciate money has to be used wisely, not just by managers but by everyone.'

Financial director Jonathan Coulter, like his counterparts in other foundation trusts, acknowledges that the status has brought more rigour and ownership of resource management to the organisation, helping to improve financial control. He says the strong board, which challenges the organisation, has also tightened discipline.

'We turn around information very quickly so we can report our financial position within four or five days of the end of each month,' he says. 'It is very powerful in enabling us to see quickly whether we are on track and, if not, to take action.'

Each report also integrates human resources information - one criticism of failing trusts is that finance and HR data remain separate - including staff turnover. At Harrogate, for example, an increase in day cases and a sound recruitment have helped keep agency rates low.

To help to improve the related areas of bed management and reduce emergency admissions, the trust has set up a clinical assessment team (CAT), which went live in June as a pilot. Faced with pressure to reduce costs by around£5m when the local primary care trust revealed a financial deficit, the trust chose to close one ward and find 'better ways of managing the needs of those patients', says Mr Lawlor.

Headed by a senior consultant supported by three lead nursing staff, the CAT has access to dedicated diagnostic slots to enable patients to have X-rays or scans the same or the next day. Patients are assessed through a series of tests and either admitted, given urgent outpatient appointments or discharged back to their GP.

The team has reduced emergency admissions by two-thirds, from the 90-95 per cent of patients referred by GPs or admitted via accident and emergency, down to 30-35 per cent. A snapshot of one weekday in October showed that, unlike the traditional pattern of medical and elderly admissions vastly outnumbering surgical admissions, there were seven medical/elderly patients admitted and 10 orthopaedic admissions.

As well as freeing beds - the trust's bed status is e-mailed throughout the organisation every day - reducing occupancy and infection rates, there are further benefits, says Mr Lawlor.

'This was not a case of introducing a new model because we merely thought it was a better one, because the model has to generate "levy" for the trust. It helps to ensure a high quality of service but at the same time helps the PCT retrieve its financial balance,' he explains.

One of the biggest challenges for the future, and for the entire NHS, he believes, is the 18-week target from GP referral to hospital treatment. 'It will make the four-hour A&E waiting target seem, well, simple.'

For his trust, Mr Lawlor wants to ensure even greater clarity on responsibility for resources, further improving transparency around 'where the money sits'. And he wants to devolve some power and responsibility to newly-formed clinical business units, multidisciplinary teams led by clinicians who can make independent decisions.

'We do not want them to run as mini-trusts but to feel they are not constrained by having to refer everything to the top,' he says.

'Our overall philosophy should be to get it right for the patient first time. If that is not always possible, it's important to learn from it rather than start a witch-hunt.'

Royal Marsden's history of excellence