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“From good to great”: Andy Burnham’s five-year plan

By Mike Broad - 13th December 2009 9:54 pm

Health secretary Andy Burnham addressed NHS chief executives last week, and he used the opportunity to outline a five-year plan for the NHS. He described it as upbeat, gritty and realistic given the consequences of the downturn.

After outlining the progress that the NHS had made under Labour, he said the next challenge was to move the NHS from “good” to “great”. He acknowledged that: “At times, the system can still put its own convenience before that of its patients. It is not yet as good as it could be at promoting good health. We need to be better at early diagnosis. There is still too much variation in service standards and practice; too many people are spending too much time in hospital.

“In places, care has fallen below the standards that all patients have a right to expect. And, we must address all of this whilst adapting more rapidly to new pressures such as our ageing population and the increased prevalence of lifestyle diseases.”

On funding, he said: “The chancellor made clear that protecting the entire NHS frontline is his and the government’s priority. He confirmed that next year’s substantial increase will go ahead as planned and that this uplift will be locked in to frontline budgets for the two years that follow.

“This increase is coming from National Insurance - in the same way that patients elsewhere in the world have to pay higher private premiums to cover the growing costs of healthcare. But we think this is the best way to do it - a fair price to pay for to improve further the best healthcare system in the world.”

Burnham forgot to mention the Chancellor’s other pre-budget report comments affecting the NHS. Namely that public sector workers’ pay will be capped at 1% pay cap for two years from 2011. And contributions from the state to the pensions of public sector workers like chief executives and consultants will also be capped.

He then outlined a six point plan. “First, we will improve the payment system so that it rewards quality and puts patients first. A growing proportion of hospital’s income will be linked to patient satisfaction, rising to 10% of their payments over time. This is a symbolic shift towards the people-centred service I want to see, a service which at times thinks about how things look through the eyes of the patient their family. Poor or unsafe care will not be tolerated - and payments will be withdrawn if care does not meet minimum standards.

“Second, we will provide more choice for patients, giving them the ability to register with a GP wherever they choose by abolishing practice boundaries, an option of seeing a doctor in the evenings and weekends in every area, and more access to services - like chemotherapy and dialysis - at home or in the community.

“Third, more work will be taken out of hospitals. As part of this, we will provide dedicated carers for patients with cancer or serious long-term conditions who can benefit from a more personal approach to nursing. We expect all parts of the NHS to continually review the way long-term conditions are managed and to seek out and adopt best practice. Where appropriate this should include the provision of personalised one-to-one support by a health professional, particularly for more complex conditions. We will consider and cost the possibility of a patient entitlement in this area. This will benefit millions of people. We will also introduce a three-digit national non-urgent number to reduce pressure on hospitals.

“Fourth, there will be new rights to high quality care - including the right to see a cancer specialist in two weeks for urgent cases, and in time, a one-week wait for crucial tests. We will propose the right for patients to die at home. Choice and dignity at the end of life is the mark of a civilised health system. The NHS will ensure a dying patient can choose where they wish to spend their final days.

“Fifth, we will provide more freedom for hospitals. The best NHS foundation trusts will be free to work across a wider area. We will encourage high-performing foundation trusts based in one area to provide both acute and community services in other areas, if the PCTs in those areas want to commission from them. And we want to see more integrated provision across the entire patient pathway. We open the possibility of acute trust providing GP services, if safeguards can be found.

“And finally, we want the NHS to intervene earlier and prevent more disease. I do not want to see history repeated and prevention to be the first thing to go in tough times. Promoting physical activity, as I said before, should be core business for the NHS. We will press on with the ground-breaking NHS Health Checks programme for people between 40 and 74. We will provide access to personal care plans and health-checks for anyone suffering with a long-term condition. Patients will be invited to discuss and agree their care plan with their clinician, giving them a greater say in their care.”

Burnham finished by offering chief executives one of his trademark deals: “As we go through this change, we will support them and empower them to make the changes we need. I will explore whether we can maintain frontline employment across a locality or region - in return for flexibility, mobility and sustained pay restraint.”

The parting message - play ball or face cuts.

Commenting on the plan, Dr Hamish Meldrum, chairman of council at the BMA, said: “We welcome the government’s commitment to maintaining NHS funding in England and to protecting frontline services. However, the scale of the challenge in carrying out many of the plans in this document should not be underestimated. Redeploying budgets and staff, or reconfiguring services, is never straightforward.

“NHS staff are pivotal in delivering effective services to patients, and we welcome the Health Secretary’s commitment to supporting and engaging with us. The BMA will respond positively to such engagement. However, the repeated talk of pay restraint when what is really meant is no pay rise at all, is demoralising. While healthcare workers clearly understand the financial pressures on the NHS, and will want to act responsibly, they should not be punished for a situation which is not of their making.”

Read the full report.

Tags: Andy Burnham, Quality, Ratings
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Shock resignation of Care Quality Commission chair

Healthcare Republic - 7th December 2009 1:22 pm

The chair of the Care Quality Commission (CQC), Baroness Young, is to stand down from 1 February.

The Guardian is reporting that she quit after a ‘difficult’ meeting with health secretary Andy Burnham when it emerged investigators were being sent into an Essex hospital because dozens of patients are thought to have died due to inadequate care.

A month earlier, the CQC had rated the quality of care at the hospital as good, leading to a row about the CQC’s credibility.

Barbara Young said: “Having overseen the major task of creating a single regulator for health and social care and pointed it in the right direction, I have decided that it will be for others to take it forward. I wish all success to the Commission and its staff and to Dame Jo Williams who has agreed to act as chairman until a successor is appointed. Jo will start to take up the reins in January.”

Shadow Conservative health secretary Andrew Lansley said: “I believe Barbara Young wanted to end the flawed Healthcheck assessment system and to have better enforcement powers alongside the registration system from April. Her decision to leave before April demonstrates the breakdown that has happened between Labour ministers and their flagship regulator.”

Twelve hospital trusts “underperforming”, report says

BBC Health - 29th November 2009 2:40 pm

Twelve NHS hospital trusts in England are “significantly underperforming”, a report says, despite eight recently having been rated as good or excellent.

The report by monitoring body Dr Foster also said 27 trusts had unusually high death rates.

But the Care Quality Commission, which has issued its official ratings within the past month, said it saw no need to step in at the moment.

The part-private, part-NHS Dr Foster Hospital Guide rates hospital trusts from one to five based on analysis of a range of “safety indicators”, including errors in surgery, deaths, infection rates and staffing levels.

In this year’s report 12 received the lowest score.

They include University Hospitals Coventry and Warwickshire; Weston Area Health Trust; South London Healthcare Trust; Tameside Hospital Foundation Trust; University Hospital of South Manchester and St Helens and Knowsley Hospitals Trust.

Mid Yorkshire Hospitals Trust; Blackpool, Fylde and Wyre Hospitals Foundation Trust; and Hereford Hospitals Trust are also among the 12, which are completed by Basildon and Thurrock; Lewisham; and Scarborough and North East Yorkshire.

Of these St Helens and Knowsley was rated excellent by the CQC and three others - Mid Yorkshire, Weston Area and Scarborough and North East Yorkshire - were rated fair, with seven of the remainder achieving good ratings.

Basildon is more pressing than climate change

By Mike Broad - 27th November 2009 4:24 pm

A long time ago, I studied a bit of meteorology. My abiding memories are not about occluded fronts and cumulonimbus clouds, but a general wonder at the complexity of the discipline.

Every prevailing weather system is the product of an incredible range of influences from solar cycles and jet streams to ocean currents and the shape of land masses.

There aren’t many things more complicated than a human body, but the weather is probably one of them.

So, to suggest we now understand the weather - for all our sophistication in modelling - is frankly ridiculous. The climate is changing. Human activity probably does have something to do with it. It’s probably worth lowering our carbon emissions, even if in the fullness of time it proves to be less significant than most currently believe. As far as I’m concerned, for the non-expert, that’s about as definitive as you can be.

So, why on earth are doctors’ representatives banging on about it? Doctors from “around the world” have launched the International Health and Climate Council to pressure governments into action over climate change. And The Lancet has backed it up with some articles on the health consequences.

Of course, we should all do our bit to reduce our carbon footprint (and I like to think I do more than most). But, is President Obama’s thinking at the upcoming Copenhagen Summit on Climate Change really going to be influenced by a bunch of doctors and their trade mags offering up sound bites on issues that are far removed from their areas of expertise?

I somehow doubt it. And yet this week they’ve taken the opportunity to pump more hot air into the atmosphere about the health consequences.

It’s funny, but I didn’t hear many of them talking about the real health stories this week at Basildon and Thurrock NHS Trust and Colchester Hospital - not in public anyway.

We’ve got a real crisis on our hands and there’s no nice PR opportunity in it. Standards faltered at Basildon and Colchester, as they did at Mid Staffs, despite a supposedly tight regulatory system. The consequences were severe.

A report by Dr Foster Intelligence rated a dozen hospitals as “significantly underperforming”, despite nine of them being rated good or excellent by official regulator the Care Quality Commission.

Seven hospitals were also found to have considerably higher mortality rates for the past five years.

It raises difficult questions: how do we really tell if a unit is good? Do our current targets subvert clinical priorities? How do we provide a more quality-focused regulatory system that supports learning and development?

These are the issues doctors’ leaders should be debating, not Brazilian rainforests or polar bears. While there are people better qualified for this, few are in a better position to help improve standards in our hospitals.

Tags: Basildon, CQC, Mid Staffordshire, Ratings
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Essex hospital failings prompt calls for reform

BBC Health - 8:27 am

Calls are mounting for urgent reform to the way hospitals are regulated after a report found a catalogue of failings at two hospitals in Essex.

The independent regulator highlighted an unusually high death rate and poor hygiene, including blood-spattered kit.

Basildon and Thurrock NHS trust said concerns were not indicative of wider problems, but a taskforce has been sent in to force through improvements.

Most inpatient care is provided at Basildon University Hospital, which has 777 beds, and outpatient care at Orsett hospital in Grays.

The Care Quality Commission (CQC) rated the trust as “good” overall in October. But a new report from an unannounced inspection team carried out by the CQC found evidence of sub-standard care.

The inspectors reported: floors and curtains stained with blood; badly soiled mattresses in the A&E department with stains soaked through to the foam filling; blood-splattered on trays used to carry equipment; items that should only be used once still in use; and, equipment in the resuscitation room that was past the use-by date.

The inspectors criticised a poor care environment in A&E, in particular a lack of privacy for patients. They also highlighted inadequate arrangements to treat children, with few specialist paediatric staff.

The CQC has asked the regulator of foundation trusts, Monitor, to take action.

An expert taskforce will be sent into the trust with a remit to drive rapid improvements in patient care.

Summary of the Annual Health Check of NHS trusts

By Mike Broad - 20th October 2009 11:11 am

The Care Quality Commission is responsible for assessing and reporting on the performance of all NHS organisations in England against measures and priorities set by government.

It assesses: A. core standards, including safety and cleanliness, safeguarding children, infection control, dignity and respect, and privacy and confidentiality. B. existing commitments, including indicators concerned with waiting times for inpatient and outpatient treatment, and ambulance response times. And C. national priorities, including indicators concerned with patient reported experience of services, infection rates, waiting times for cancer treatment, and a range of public health measures.

All 392 NHS trusts make a public declaration against the 44 parts of the 24 core standards, and the CQC uses a total of 86 performance indicators across the different types of trust to assess the existing commitments and national priorities.

Trusts receive a rating involving an overall quality score; and a score for financial management. It applies a four-point scale of ‘excellent’, ‘good’, ‘fair’, or ‘weak’.

Mixed bag of ratings in 2008/2009

Overall, it is a mixed picture of performance this year.

CQC said the NHS is performing well against a rigorous assessment on quality, with more trusts rated ‘excellent’ or ‘good’. The national compliance rate for core standards is the highest it has ever been, at 96.3% this year.

It also commended the significant improvement in ratings for financial management, positive news as we enter a period of restraint on public spending. The assessment shows big improvements for patients with more people seen in A&E within four hours, more receiving treatment within 18 weeks of referral, more screened for Chlamydia and big reductions in MRSA and Clostridium Difficile cases.

Thirty-seven trusts were rated double-excellent, including The Royal Marsden NHS Foundation Trust, which was double-excellent for the fourth year running. Barking, Havering and Redbridge University Hospitals NHS Trust was the only trust rated double-weak, down from six trusts last year.

But CQC raised concerns about the 20 trusts rated ‘weak’ this year on quality and a further 27 that have not been higher than ‘fair’ for quality and financial management in the last four years.

CQC ascribes ratings to trusts based on their performance across a range of priority areas identified by the government.
For quality, CQC rated 15% of trusts ‘excellent’, 47% ‘good’, 32% ‘fair’ and 5% ‘weak’. Last year, ratings were 26%, 35%, 34% and 6% respectively. On financial management, 26% were rated ‘excellent’, 45% ‘good’, 26% ‘fair’ and 3% ‘weak’. Last year, ratings were 24%, 37%, 34% and 5% respectively.

Primary care trusts earned better results overall, with more than half rated ‘excellent’ or ‘good’ for the first time.

Challenges for acute trusts

But there was a decrease in ratings awarded to acute hospital trusts, with fewer trusts rated ‘excellent’ and more ‘fair’.

CQC said a number of factors were behind the acute trust ratings: more trusts declared they did not meet all core standards; increased scrutiny on child safeguarding and healthcare-associated infection; a significant number did not meet new indicators on quality of basic maternity data and participation in heart disease audits, vital to monitor quality of care; a significant number did not meet required performance on specialist stroke care; and a greater proportion of operations were cancelled at the last minute for non-clinical reasons.

CQC also pointed out that this year it has produced the most comprehensive and rigorous assessment ever of the performance of mental health and ambulance trusts.

Positive improvements for patients

1. More than 98% of the 19 million patients attending A&E waited less than four hours.

2. Between January and March this year, three million patients waited 18 weeks or less from referral to treatment.

3. 16% of people aged 15 to 24 were screened for Chlamydia, up from 5% the previous year.

4. There were 19,400 fewer cases of Clostridium Difficile and 1,500 fewer cases of MRSA in 2008/09 compared to 2007/08 - a reduction of a third for both.

5. Ambulances responded within eight minutes to more than 1.4 million life-threatening calls.

Areas for future improvement

1. There was a drop in compliance with the core standard on child safeguarding down from 96.4% last year to 90.7% this year.

2. While MRSA and C. Diff rates are decreasing, acute trusts still need to do more on infection control. This year 48 acute trusts did not meet at least one of the three relevant standards, compared to 44 last year.

3. 37% of acute trusts meet the required level of performance on specialist stroke care.

4. New measures highlight considerable variation in quality of basic maternity and mental health data that is vital for monitoring quality of care.

5. The proportion of cancelled operations rose for the second year in a row to almost 1%. This equates to 63,000 operations cancelled at the last minute for non-clinical reasons. However, of these cancellations, more were rearranged for a new date within 28 days of the original operation.

Future direction of the Annual Health Check

Next year, CQC will further develop regulation to become more focussed on patients and outcomes. All trusts will need to register with the regulator to legally function.

CQC said compliance with core standards is a good indication of whether a trust is ready for registration. Overall compliance with standards has increased from 95% to 96%. However, only about half of trusts fully met all core standards and compliance declined in the acute sector with 59% fully met this year compared to 69% last year.

Cynthia Bower, CQC chief executive, said: “The NHS has performed well on quality, which is good news in the face of a rigorous assessment. But it is clear that some trusts are struggling and that some issues are proving tough nuts to crack.

“My biggest concern is those trusts that are ‘weak’ and persistently ‘weak’ or ‘fair’. They must do better for their patients.

“I want to ring the alarm bell in the boardrooms of these organisations. Next year, all trusts must register with us to legally function. It is clear that many have significant work to do and a short time in which to do it.”

Details of the performance ratings for individual trusts are available on the CQC website.

Tags: Care Quality Commission, Ratings
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47 trusts must improve performance ratings

By Mike Broad - 17th October 2009 4:55 pm

The Care Quality Commission has warned 47 NHS trusts that they must improve significantly over the next year to be allowed to register with the health regulator and avoid sanctions.

On releasing the 2008/2009 performance ratings for of all 392 NHS trusts in England, the regulator said it would be focusing on improving the standards at persistently under performing trusts (see list below).

The ratings, which are developed from information provided by trusts, inspections and audits, reveal a mixed picture.

More patients were seen in A&E within four hours, more received treatment within 18 weeks of referral and more were screened for chlamydia. There were also big reductions in the number of MRSA and Clostridium Difficile cases, and improvement in the financial management of trusts.

Trusts are given ratings from ‘weak’ to ‘excellent’ based on how they score on quality of care and financial management.

Fewer trusts scored ‘excellent’ for the quality of their care compared with last year’s figures. The drop in ratings was worst among acute hospital trusts.

“My biggest concern is those trusts that are ‘weak’ and persistently ‘weak’ or ‘fair’. They must do better for their patients.

Next year, all trusts will have to register with the CQC to be allowed to legally function. They will have to meet basic standards in order to achieve this.

CQC said compliance with core standards is a good indication of whether a trust is ready for registration. Overall compliance with standards increased from 95% to 96%. However, compliance with fully meeting all core standards in the acute sector fell from 69% last year to 59% this year.

If trusts fail to reach those benchmarks the regulator can impose a range of sanctions including prosecution and closing a service down.

Niall Dickson, chief executive of the Kings Fund, said: “The worry is the 32 trusts who year after year fail to meet these standards. Unfortunately, the ratings on their own do not shed light on why some trusts perform well and others do not.

“Patients served by the hospitals and other services that consistently rank at the bottom have a right to know why these organisations are not providing the quality of services that is expected from them. We need to understand whether the problems are managerial or structural, and what is being done to help them raise their game.”

NHS Confederation chief executive, Steve Barnett, said: “It is extremely heartening to see that for the first time ever, more than 100 trusts scored excellent for financial management - at the same time it is concerning that some continue to experience performance issues.

“With the NHS entering the most demanding period of financial pressure in its history the reasons for this need to be understood if the performance of the best trusts is to be reflected across the whole of the system.”