comment: Star-system replacement must provide a true reflection of performance

It is ironic that on the day health secretary Alan Milburn revealed that the starrating system will apply to social services departments as well as NHS trusts, there was confirmation from the health service of just how flawed that system is.

The publication of the report of the Commission for Health Improvement’s clinical governance review on Ashford and St Peter’s Hospital trust has discredited the star system before it is even a month old.

Like those at the other 11 trusts awarded no stars, staff at Ashford and St Peter’s were upset, demoralised and angry at being branded as failing.

Until now it could have been argued that their protests that they were as good as - if not better than - other trusts was simply a case of sour grapes. What CHI has done is confirm not only that Ashford and St Peter’s is in no way a ‘failing’ trust, but that staff are doing their utmost to deliver high-quality care in extremely difficult circumstances which are, to a substantial degree, outside their control.

It is now abundantly clear in areas afflicted by staff shortages - nursing vacancies are running at 20 per cent at Ashford and St Peter’s - that star ratings, far from being useful, have the potential to do serious damage. A nurse faced with a variety of job opportunities will, understandably, choose the two or three-star trust above the one with no stars, no matter what the complexity of the story that lies behind those ratings.

In the case of Ashford and St Peter’s, many of the areas identified for improvement by CHI pose enormous difficulties for the entire health economy, not just in west Surrey.

Delayed discharge because of a lack of nursing and residential home beds and staff shortages are problems endemic to trusts. Many have been struggling to address them with a variety of initiatives - hardly reasons to brand them inadequate.

The Modernisation Agency is doing everything it can to support the 12 no-star trusts.

But there is a limit to the help it can offer - short of conjuring up more nurses and beds.

And in the case of trusts like United Bristol Healthcare, as well as Ashford and St Peter’s, there is only a limited amount of ‘good practice’ that hasn’t been applied already.

Mr Milburn has already confirmed that the rating system has, thankfully, only a limited lifetime. CHI’s work is to be amalgamated with the ‘balanced scorecard’ to produce a single system to measure performance.

The system that emerges must be transparent and comprehensive and have the support and confidence of NHS staff and managers. It must fairly and accurately reflect a trust’s level of performance, and leave no doubts about extrinsic factors or quality of data. It must be flexible and inclusive and avoid the ‘blame culture’ of which the service is supposedly trying to rid itself.

Must important, the service needs to know that the additional responsibilities and freedoms promised for the best performers are given to those who deserve them and can use them effectively, just as it needs to be confident that when a trust is told it is performing badly it is not on the basis of shallow and flawed information.