Date Published: 16 October 2008

Healthcare Commission publishes NHS ratings showing major improvement in performance

NHS urged to root out pockets of remaining poor and mediocre performance and get all trusts up to the standards of the best

The Healthcare Commission today (Thursday) publishes the annual NHS performance ratings showing that trusts are improving the quality of services and managing money more effectively.

The independent watchdog has given all 391 NHS trusts in England a rating in its third annual health check, the most comprehensive assessment of the NHS ever undertaken.

The assessment incorporates thousands of items of data related to performance, information from patients and the public, and inspections targeted at one in five trusts.

Trusts must meet a broad range of measures in areas that matter to patients including safety, waiting times, infection control and health outcomes.

The Commission rates each trust - as "excellent", "good", "fair" or "weak" - on both its quality of services and use of resources.

For quality of services, 100 trusts (26%) were "excellent", 139 (36%) were "good", 132 (34%) were "fair" and 20 (5%) were "weak". Two years ago, only 41% were excellent or good, while 59% were fair or weak.

For use of resources, 94 trusts (24%) were "excellent", 145 (37%) were "good", 132 (34%) were "fair" and 20 (5%) were "weak". Two years ago, just 16% were excellent or good, while 84% were fair or weak.

Sir Ian Kennedy, the Commission's Chairman, said:

"Patients and the public should celebrate these results as they show a real shift in performance. Over the past two years, in almost every part of the country, we have seen the number of trusts rated ‘good' or ‘excellent' expanding and the number rated ‘fair' or ‘weak' shrinking.

This is a broad and demanding assessment so we pay tribute to those trusts that have done well. It is a team effort: the cleaner, the porter, the nurse, the doctor and the manager have all played their part. Patients have benefited. Waiting times for cancer treatments, once a significant problem for the NHS, have come right down and ambulances are responding faster than ever to calls in life-threatening situations.

Performance is not universally good, however. We are a lot closer to getting core standards in place across the NHS but there are still too many trusts that are not there. It's very satisfying to see MRSA rates falling overall but the challenge posed by these infections remains. Some trusts are still not doing all that's necessary to sustain the drop in rates of infection.

Three years into this assessment, the public are entitled to expect urgent action at trusts which are still performing poorly. The primary care sector has improved, but more is needed as this sector delivers 88% of healthcare. Primary care trusts must redouble their efforts in areas such as access to GPs and the provision of choice. Regionally, performance in most areas in England has improved but the NHS in London continues to face significant challenges."

Sir Ian concluded:

"The NHS has taken a significant step forward under the sustained pressure of our independent assessment. It must now address the remaining concerns, root out poor and mediocre performance and get all organisations up to the standards of the best."

This year, 42 trusts were "excellent" for both quality of services and use of resources. In the first annual health check in 2005/06, just two were "excellent-excellent". Over the same period, the number of trusts scoring "weak-weak" has fallen from 25 to six.

Looking only at quality of services, two years ago about 60% of NHS trusts were rated "fair" or "weak". This year, about 60% are rated "good" or "excellent". There are now 100 trusts - over one quarter of the NHS - rated "excellent" for quality of services when two years ago there were just 25.

Overall, 151 trusts - more than a third of the NHS - improved their rating for the quality of their services this year. Of these, 26 improved by two performance bands. Sixty-six trusts (17%) saw a decline in performance, of which nine fell back two performance bands.

On use of resources, the improvement is even more marked. In the first annual health check, results for use of resources were significantly worse than those for quality of services but now the picture is broadly similar.

In 2007/8, 61% of trusts were rated "good" or "excellent" for use of resources compared with just 16% in 2005/6. Overall, 205 trusts - more than half the NHS - improved their rating for use of resources this year, 14 of those by two performance bands. There was a decline in performance at nine trusts (2%).

Regionally, trusts in the north of England performed best - on both quality of services and use of resources - for the third year running. But it was trusts in the southwest that delivered most improvement.

London was the only area of the country in which performance for quality of services declined, with 48% scoring "excellent" or "good", compared to 55% last year.

For the first time, our assessment now shows a gap between London and the rest of the country. The areas of concern centre on access to services: A&E waiting times, access to GPs, the waiting time from referral to treatment, and screening for breast cancer.

The Commission said that action is needed to address the concerns in London. It should focus on encouraging PCTs to work together to commission services, improving access to GPs and reconfiguring hospital services where this would benefit patients.

The Commission also urged all trusts in the NHS to make a new effort to meet all the core standards, pointing out that one in three trusts were still not fully doing so.

Looking at specific standards and targets, positive trends included:

* Trusts performed well against the government's three targets relating to waiting times for cancer treatment. According to these targets, when a GP makes an urgent referral for suspected cancer, patients should wait no longer than two weeks for an appointment as an outpatient and should wait no longer than one month from diagnosis to treatment. In all, patients should wait no longer than two months from referral to treatment. In 2007/08, about 83,000 patients (97%) received treatment within two months of referral - approximately 28,000 more than in 2005/06. In addition, the number of people who waited more than two months fell from 10,800 to 2,560 over the same period. For more information on targets for cancer waiting times, see page 62 of the annual health check's overview document.
* Good progress is being made in meeting the government's demanding target to treat all patients within 18 weeks of referral. Although it is not due to be met until the end of 2008, 108 (64%) acute and specialist trusts are on track to meet the target, with 40 (24%) just falling short. However, there are 22 trusts (13%) that are well behind the milestones for achieving the target. See page 79 of the annual health check's overview document for more information.
* In 2007/08, ambulance trusts responded to 77% of category A calls within eight minutes, above the government's target of 75%. Ambulances responded to 1.27million calls about potentially life-threatening situations within eight minutes - 38,000 calls above the target. See page 58 of the annual health check's overview document for more information.
* Availability of crisis resolution home treatment teams meeting the implementation guide criteria has improved across the country. This is very important in terms of preventing unnecessary hospital admissions and providing good support in the community for people with mental health problems. See page 56 of the annual health check's overview document for more information.

The assessment also highlights the following issues:

* 114 trusts - a quarter of the NHS - failed to meet one or more of the three core standards relating to infection control, rising from 111 trusts last year. In addition, only 52% of acute trusts met the target to reduce rates of MRSA by at least 60% over three years (or a maximum of 12 cases of infection). See pages 5, 45 and 80 of the annual health check's overview document for more information.
* There was a dramatic decline in the number of PCTs meeting the target that every patient should be able to see a GP within two working days, down to 31% this year from 80% last year. The drop is the result of a significant change to the way the target was assessed with results from surveys of patients now included as well as information from GPs' surgeries. See page 65 of the annual health check's overview document for more information.
* Only 16% of PCTs achieved the target on provision of convenience and choice, which includes the use of the online choose-and-book system. But this is an improvement on last year when only 2% achieved the target. See page 63 of the annual health check's overview document for more information.
* In 2007/08, the national proportion of patients waiting less than four hours in A&E fell just below the 98% target for the first time in three years (to 97.9%). The slight drop coincides with a rise in numbers of patients attending A&E. In 2007/08, 18.55 million patients were treated within four hours, compared to 18.38 million in 2006/07. See page 59 of the annual health check's overview document for more information.

Results by type of trust

Acute and specialist trusts: The most dramatic improvement over time has been in the 169 acute and specialist trusts. This year, 29 acute and specialist trusts were rated "excellent-excellent", compared to just two in 2005/06. More than three quarters of acute and specialist trusts (77%), were "excellent" or "good" for quality of services, up from 54% two years ago. On use of resources, almost two thirds of acute and specialist trusts (64%) were rated "excellent" or "good", compared to less than a third (31%) in 2005/06.

Primary care trusts: The assessment is challenging for primary care trusts due to the large number of targets they must achieve, including a range of demanding measures of health outcomes. Even so, the performance of PCTs is disappointing overall with only 33% rated "excellent" or "good" on quality of services. This is, however, an improvement from last year when 26% were rated in the two highest categories. There was improvement in PCTs' ratings for use of resources, with 51% scoring "excellent" or "good" this year, up from 20% last year. This year also sees the first ever double-excellent PCT - Salford PCT.

Ambulance trusts: The assessment shows the sector starting to deliver against challenging targets for times of response. This year, two ambulance trusts achieved "excellent" for quality of services - the first time any ambulances trust have done this - five were "good", one was "fair" and three were "weak". For use of resources, four ambulance trusts scored "good", six "fair" and one "weak". No ambulance trust was rated "excellent" for use of resources. This is the first full-year assessment since reorganisation reduced numbers of ambulance trusts from 30 to 11.

Mental health trusts: Mental health trusts performed better than other types of trusts, although the assessment includes fewer targets and so is less demanding. In 2007/08, 12 out of 56 (21%) mental health trusts scored "excellent" for both quality of services and use of resources, compared to two last year and none the year before. On quality of services only, 37 (66%) mental health trusts scored "excellent", 14 (25%) scored "good", four (7%) scored "fair" and one (2%) scored "weak". For use of resources, 19 (34%) mental health trusts scored "excellent", 28 (50%) scored "good", eight (14%) scored "fair" and one (2%) scored "weak".

Foundation trusts: Foundation trusts continue to outperform non-foundation trusts. Thirty-eight out of the 42 trusts rated "excellent-excellent" have foundation trust status. Eight foundation trusts were "fair", while just one was "weak" for quality of services.

Core standards with highest rates of compliance

* C06 (100% compliance) - requires cooperation between health and social care organisations.
* C10b (99.7%) - requires organisations to ensure that employees abide by relevant codes of professional practice.
* C08a (99.5%) - relates to whistleblowing and raising concerns.
* C22a&c (99.5%) - requires organisations to cooperate and work in partnership to promote and improve the health of the local community.
* C22b (99.3%) - requires organisations to use annual public health reports to inform policies and practices.
* C15a (99.2%) - requires organisations to provide patients a choice of safely prepared, balanced food.

Core standards with lowest rates of compliance

* C04c (77.3%) - requires organisations to ensure that all reusable medical devises are properly decontaminated. This was also one of the standards with the greatest decline in compliance, down from 84.8% last year.
* C07e (82.6%) - requires organisations to challenge discrimination, promote equality and respect human rights. This was also one of the standards with the greatest decline in compliance, down from 85.5% last year.
* C09 (85.2%) - requires organisations to have a systematic and planned approach to the management of records.
* C11b (86.4%) - requires organisations to ensure that staff participate in mandatory training.
* C04b (86.7%) - requires organisations to minimise risks associated with the use of medical devices.
* C04a (88.5%) - requires organisations to ensure that the risk of healthcare associated infection to patients is reduced, with particular emphasis on hygiene and cleanliness. This was also one of the standards with the greatest improvement in compliance, up from 84.3% last year.


Source: The Healthcare Commission (England, UK).

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