Published: 28/07/2005, Volume II5, No. 5966 Page 14 15

In two months' time, trusts will have to state publicly whether they have complied with 24 standards underpinning the new NHS ratings. Ian Lloyd asks how the system will work

The clock is ticking and time is running out. Fast.

Mountains of documents have been pored over, action plans put into place, countless conferences attended and more roadshows organised than by Radio 1.

And in just two months' time all NHS trust boards in England will be expected to sign a public declaration proclaiming whether or not they have complied with 24 core standards that will form the bedrock of the new health service ratings.

It has been a long and bumpy road, and there are still twists and turns to negotiate before October.

How exactly will a trust's performance against the standards be translated into an overall rating?

Are patient forums and local authority overview and scrutiny committees competent to comment on a trust's performance? Is the new system, with its emphasis on selfassessment, too subjective?

Trusts are not the only organisations trying to navigate their way through the process. The Healthcare Commission, which devised the system, is still grappling with how it will work on paper.

The commission has embarked on a tour of the country, giving presentations to trusts and patient forums about what they need to do in the declaration process.

It was clear from one such event in London earlier this month that the learning process is very much a two-way street.

'It is a very new process - It is new for all of us - we are all learning in this and it is important to stress that, ' John Billings, the commission's regional head for London and the South East, told delegates. 'We are not necessarily coming to this with all the answers.' Consequently the declaration trusts will have to sign in October will be a draft, ahead of a final declaration in April next year on performance for 2005-06.

'This is a massive challenge within the system and the service, and indeed the commission needs time to build up to it, to learn and to get shared knowledge about how the system is going to work. [The draft declaration] enables trusts to see for themselves how they are doing against the standards and, where necessary, put measures in place where gaps or problems are identified, ' said Mr Billings.

But the draft process is not a 'get out of jail free' card. Trusts will still have to refer to any significant lapses, and the way in which they responded, when they put together their final declaration in April.

This has come as a surprise to some. Hull and East Yorkshire Hospitals trust deputy director of service delivery Barbara Cummings says: 'It is a tight timescale. We are still going to get new information and still learning - with two months to go - to do a draft declaration that counts towards your final one. We have known It is going to come but we are well into the year and we are just getting the detail of what is needed.' Milton Keynes primary care trust chief executive Barbara Kennedy says there will be no time for trusts to turn around their performance on the standards from October to April.

'All that will happen is that there will be feedback from the Healthcare Commission to organisations, based on their draft declaration, in order that they can clarify any points before making their final one, ' says Ms Kennedy.

'That will catch out some organisations who may not be aware this is the case, particularly if consultation on the standards meant people haven't had the final version [of the assessment guidance] for very long. I think it is even more challenging than people perhaps thought, although I do believe it is a much better process.' Once trusts have made their declarations, the Healthcare Commission's cross-checking process kicks in between November and January.

Some 2,000 data items, including the commission's own surveys and information from other regulators, will feed into a traffic-light system which either confirms or contradicts a trust's statement of compliance.

Ten per cent of trusts for whom cross-checking identifies a high risk of an undeclared lapse in core standards will then receive an inspection by the commission.

But the commission is at pains to point out that a red light will not mean the trust is automatically judged to be failing in a particular area. Trusts will be given the opportunity to reassure the commission they have used different data to ensure compliance.

An additional 10 per cent of trusts will be subjected to random visits by the commission. Where a trust is discovered not to have declared a significant lapse in a standard, this will be reflected in its rating.

The smooth running of the selfassessment will hinge on one thing: trust. 'We have tried to come up with a system where people take responsibility for how they are performing locally and declare publicly how they are doing against the standards, ' says Mr Billings.

'Balancing that with checks and balances assures us and the public that when people say they are meeting the standard it is a true reflection. It is based on trust, that is absolutely clear, ' says Mr Billings.

'Our assumption is that the vast majority of boards will want to participate in this process in the spirit in which it was intended, ' he adds.

It appears most trusts are responding positively to the challenge.

'We feel that the declaration is our declaration, ' explains South West Kent PCT clinical governance and risk manager Anne Carroll.

'It is quite a mature approach to say : 'You do your self-assessment as an organisation'. It is the organisation itself rather than an outside agency coming in and ticking the box for you.

'You would be taking quite a big risk if you knowingly decided you were not going to declare something you knew about. There is a chance you might be caught out, and how much worse does that look when the Healthcare Commission qualifies your statement? My feeling is that trusts will be harder on themselves than an external agency.' Worcestershire Acute Hospitals trust chief executive John Rostill agrees: 'The system is too sophisticated for people to get away with things. There is the strategic health authority and PCT monitoring, there are neighbouring organisations, there are various other peer groups.

'I do not get the impression people are trying to fudge things these days - there is much more integrity.' Another method of crosschecking - the use of patient forums and local authority overview and scrutiny committees - has proved more controversial.

Although there is no obligation, both will be invited to comment on how they perceive trusts to be performing against the majority of standards.

Healthcare Commission head of engaging patients and the public Anna Coote says it is well known that the capacity of forums to contribute effectively to the declaration is 'patchy', but that does not mean their view should be discounted. 'Talking down the forums at this stage of the game could just be a way of preparing the ground for discounting their comments, and we would not accept that, ' she says.

Another sticking point for trusts is that self-assessment creates a more subjective system. Trusts are required to form their own opinions on what constitutes the 'significant lapse' of a core standard.

'The problem might be that with self-assessment without any predetermined criteria you might get different perceptions, ' says North East London Mental Health trust associate director for service improvement Susan AylenPeacock.

'You will have one healthcare organisation saying it is almost meeting a standard and another may have the same information and be saying we are meeting this standard.

'That is a potential problem because ultimately this will result in a performance rating.' These are questions to which the Healthcare Commission admits it has no answers. Although standards carry the same weighting, no benchmark has been set on how performance against the standards falls into one of the four categories of 'fully met', 'almost met', 'partly met' or 'not met'.

Nor is there any information on how many standards, if any, trusts will be allowed to fall short on.

Most crucially, the commission has yet to decide on how trusts will be rated as either 'excellent', 'good', 'fair' or 'weak'.

Neil Walters, the commission's testing manager for the new system of assessment, told delegates at the London conference: 'The declaration is not intended to pick up the trivial lapses or the purely technical lapses.

We need to make sure that when Healthcare Commission staff come in they make a consistent judgement about whether it is significant or not. Over the next three months we will be working on inspection guides and they will help ensure we have consistency across these judgements.' This final rating will be based not only on performance against core standards, but also against existing targets and use of resources. The commission has suggested these areas could be weighted.

Barts and The London trust head of planning, commissioning and information Lee Outhwaite said: 'What would be useful for healthcare organisations is to have a very transparent process for how the attainment of these standards will translate into the performance assessment ratings.

'Without that it will be relatively difficult for boards to fully appreciate whether or not they have got reasonable assurance around some of these elements.' .


The assessment system for 2006-07 will incorporate improvement reviews designed to gauge performance against the developmental standards.

By the Healthcare Commission's own admission they are 'not something we are grappling with this year'.

Commission regional head for London and the South East John Billings said: 'Developmental standards by definition are longer term, and we need to introduce them in a measured way that doesn't over-stress the system and creates the improvement we are aiming for.

'In some places they will be a big challenge.

Other places will be up for it and will already be thinking about it.' Milton Keynes primary care trust chief executive Barbara Kennedy said trusts that had yet to get to grips with the core standards would struggle with the 13 developmental standards.

'What's good about the Healthcare Commission system is that you cannot rush to complete a project.

'You have got to be systematic - it doesn't lend itself to last minute work.

'An organisation that hasn't put the work plan in place well in advance will really, really struggle.'