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Nhs Hospitals

Volume 406: debated on Tuesday 10 June 2003

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3.38 pm

I like the intimacy of Westminster Hall and the almost one-to-one contact with a Minister. I am grateful to this Minister for coming, because she engages with the debate and takes on board the concerns that are raised. The other reason why I enjoy debates in this Chamber is that I can sit right in the middle, so I am not obviously an Opposition Member or a Government Member. I hope that I can make some helpful suggestions and comments, because my feelings about the NHS are exactly the same as the Minister's, and I desperately want it to succeed in all parts.

My main message in talking about the assessment of quality is that patients are often the best judges of quality, but they are not sufficiently used. I must also point out the dearth of assessment of clinical outcomes. I shall approach the matter in three ways: first, briefly, by looking at past ways of attempting to measure quality; secondly, by considering the current attempts; and, thirdly, with some hopes for and comments on the future.

The first of the past methods was the assessment of the number of complaints made. That was obviously useful, but pretty crude. Community health councils, as the Minister knows very well, were valuable, with their visits, tours of inspection and reports. The charter mark institution was invaluable, because a hospital that applied for a charter mark got it only if everybody involved—including the patients—was consulted.

Possibly the most important measure of quality that was, and still is, used, and which I think is perhaps overlooked, is the inspections of hospitals by the royal colleges for the purpose of accreditation for the training of junior doctors. Included in those reviews is a random selection of case notes for examination. I remember that when the royal colleges visited hospitals where I worked, one had no clue which case notes would be picked out of a trolley. The case notes are absolutely crucial in assessing quality of care, and The Times has recently drawn attention to how important case notes are for litigation purposes. However, if one looked at case notes in one's own hospital for a patient under another consultant, one could see, for example, that nothing was written up for a whole fortnight, in which case one did not know what had happened to the patient during that period. The quality of note-taking and keeping is crucial.

Out of the current attempts, the star ratings have received a lot of flak recently. That flak is, I am afraid, deserved. The system includes the nine key targets, which decide the star rating of a given hospital. On the other issues that are so important, such as the clinical focus, the patient focus, and the capacity and capability focus, the relevant document says glibly that they are taken into account by a balanced scorecard approach. I have yet to find someone who can really explain what that is.

I do not want the Minister to waste time on that now, however, because whatever it means it does not have any effect. The ranges under clinical focus demonstrate that: three star trusts, for instance, score between 37.5 and 80 per cent., whereas no star trusts score between 42.5 and 82 per cent., so if anything their range is slightly better. In the in-patient survey, three star trusts score between 30 and 100 per cent., whereas no star trusts score between only 23 and 80 per cent. Again, there is only a bit of difference. In relation to staff opinion and data quality, all grades of hospital range through all the possible scores, from the lowest to the highest.

I welcome the better base for criticism of the star rating system which the Audit Commission proposed just last week in its paper, "Achieving the NHS Plan". That paper is based on the work of independent, locally-based district auditors, who are examining every trust. I have great respect for that scheme because my local district auditor is one of the very few people who have picked up on the truth about some of the problems faced by my constituents. The Audit Commission sums up the matter in these words:
"There is a statistically significant relationship between performance and managerial adequacy. The number of DH stars awarded is only weakly related to either."
That is in tremendous contrast to "Raising Standards", the Department of Health book published in May 2003, which states:
"The system of star ratings gives a clear and transparent measure of performance, giving everyone information on the relative strengths and weaknesses of local NHS organisations."
Coupled with my rather amateur observations, the Audit Commission raises real concerns that those other factors—clinical focus, the in-patient survey, data quality and staff opinion—are largely disregarded in favour of targets that lend themselves to manipulation.

I was rather surprised by the Secretary of State's comments on star ratings to the Health Committee during the foundation trust inquiry. He said:
"Whether or not the star ratings are right, wrong or indifferent does not really matter."
He went on to explain that, as everyone knows, some hospitals are good, a few are bad and most need to improve. However, we are now in the business of selecting trusts for foundation status, and star ratings matter a lot because they are the only way of selecting hospitals.

The findings of the 22 acute trusts that have been selected show in-patient survey results that go across the whole range, as do those for data quality and staff opinion surveys, so at least one of the trusts going for foundation status has almost the lowest patient opinion survey results of any trust. Casting doubt, as I do, on the value of the star as a mode of selection for foundation trusts goes against paragraph 55 of "Raising Standards", which states:
"Foundation Trusts that achieve NHS Foundation Status will have a proven track record in management and delivery of high quality services to patients."
I move on to Dr. Foster's "Good Hospital Guide". The most recent edition was heralded on the cover by an eminent surgeon, who said that it was the most authoritative insight into hospital quality. Is it? I do not think that it has yet reached that stage. One has only to examine the quality measures that Dr. Foster uses. Ten of them are for available services, five of the remaining 10 reflect a degree of quality of care and the last five reflect only the potential for quality of care. Those factors do not affect the quality or the outcome. For example, if a hospital offers treatment for lung cancer it is half way there; it can achieve the highest standard by having a multi-disciplinary treatment team. That says nothing about the outcome or even the quality of treatment.

The doubt cast on Dr. Foster was accentuated for me when a hospital that I know well was one of seven short-listed for the hospital of the year award. Following a visit to the hospital, the president of the Royal College of Surgeons wrote that
"The situation is bad and the staff have innumerable problems"—
problems that he proceeded to enumerate.

I will not say much about the Commission for Health Improvement because it does not have much longer to run, and I am concerned that the clinical governance reviews may restrict too tightly what it can do.

I have just a few minutes left, and I wish to make some constructive comments and suggestions for the future—nothing particularly original, simply some matters that should be stressed. First, the new Commission for Healthcare Audit and Inspection, or CHAI, has the tremendous responsibility of making the quality measures work. I hope that the commission will bear in mind the work that district auditors are doing. The Audit Commission recommended the following:
"CHAI should in consultation with the DH, consider what use could be made of auditor's assessments to help ensure that their revision of the trust 'star' system produces an accurate way of categorising trusts."
I would hate to see the expertise of the district auditors lost.

Secondly, I would like to see the Royal College of Physicians inspections of hospitals included in the process because they collect a vast amount of incredibly useful information. Thirdly, patient involvement must be increased, made more open and taken into account as part of the star ratings. I am still perplexed about why the 2002 in-patient survey was never published. Even if it does not show the facts that the Government hoped it might, a Government with a huge majority can surely be brave enough to face criticisms openly. It is an inescapable fact that the Government are improving some aspects of the NHS.

Fourthly, the Commission for Patient and Public Involvement in Health—with its primary care trust patient forums—is crucial in helping to ensure that the voice of the patient is heard. Lastly, I understand that Dr. Foster and others are working on measures of clinical outcome, which are exactly what the NHS so desperately needs.

3.52 pm

I am delighted to be here today to engage actively with some of the points raised by the hon. Member for Wyre Forest (Dr. Taylor). This is an important issue, and it is important for patients to have access to information about how their local health care organisations are performing. I remind the hon. Gentleman that this Government have, for the first time, ensured that patients have access to information about the performance of the NHS. Following its inception, there were no means for people to make an objective assessment of how well, or how badly, the NHS was doing locally. I accept entirely that the situation is not perfect, but we have made some dramatic strides in the last few years.

The hon. Gentleman will be extremely familiar with the context in which we are now working in the NHS. After decades of under-investment we now have record amounts of extra resources going into the system. We must ensure that we get the best value out of that investment. I am sure that the hon. Gentleman shares that aim. That is why we need to reform the system, redesign services and examine all the work being done in clinical areas. A key driver for that reform is better information for patients. If patients have power and knowledge, they can help to exert pressure on the NHS by making legitimate demands to drive up performance. Patients can be our allies in the process.

We already have the star ratings system. Those ratings were first issued to all non-specialist acute trusts in September 2001. They were extended in July 2002 to specialist trusts and ambulance trusts, while mental health trusts received an indicative rating. Primary care trusts will receive their first NHS performance rating this summer, which will assess their performance for 2002–03. The process is ongoing.

3.54 pm

Sitting suspended for a Division in the House.

4.7 pm

On resuming—

I want to say a little about the role of the Commission for Health Improvement and the new Commission for Healthcare Audit and Inspection. CHI is the independent regulator of NHS performance. It has taken over responsibility for publishing the performance ratings from this year which, subject to parliamentary approval, will be transferred to CHAI. For the past two years, CHI has played an important role in driving forward the modernisation of the NHS and in improving standards. It has carried out more than 280 reviews and produced 10 reports on serious service failures. It now has a very good body of expertise in the field.

Having acknowledged CHI's achievements, I think that it is also fair to say that the fragmentation between CHI, the Audit Commission and the National Care Standards Commission has led to unnecessary bureaucracy that has placed a burden of multiple inspection on the NHS. It is right to try to find a way through that to minimise the confusion. We are therefore setting up the new, tough and independent health care inspectorate, CHAI, which will bring together the work of CHI, the value for money work of the Audit Commission and the independent health care work of the NCSC.

The hon. Gentleman makes an important point about the role of local district auditors in monitoring performance on the front line. Last week, I read the Audit Commission's report. The information gathered in the process of producing the report has been extremely useful at local level for chief executives and trust boards. It has enabled them to see how they can introduce changes that will help them to raise standards. I certainly agree that we should continue to provide such local information in the new system that we set up.

The new commission will be an even more powerful driver on the quality agenda. It will be an authoritative, independent judge of the quality and efficiency of health care. It will be a driving force for continuous improvement, and it will reassure patients and the public that national standards of quality and service have been met wherever care is provided, whether in the NHS or the private sector. As we move towards a situation in which we have a plurality of providers in the NHS, the not-for-profit sector and the private sector, it will be vital to make sure that people can rely on the same standards of service wherever they are.

The hon. Gentleman has criticised the star rating system. The process is always subject to improvement. We do not pretend that it is perfect, but it has improved vastly. Each year, the indicators are refined and become more sophisticated. The hon. Gentleman outlined the key targets on which trusts are subject to a pass or fail assessment. Those include the three focus areas: clinical focus, patient focus, and capacity and capability. In the clinical focus for acute trusts there are 10 indicators, which include deaths within 30 days of a heart bypass operation, deaths within 30 days of selected surgical procedures and emergency readmission to hospital following discharge—a genuine attempt to assess the quality of care and to determine whether the patient had to be readmitted because something went wrong.

The indicators also include infection control procedures, which are important for patients because of MRSA and other illnesses in hospital, and thrombolysis treatment time. That is another clinical indicator because there is overwhelming evidence that if people receive that treatment within the golden hour, we will save lives. I therefore dispute any claim that all the indicators in the star rating system are non-clinical.

The hon. Gentleman has asked about the balanced scorecard. I shall not go into the technicalities, but I have discussed the matter with my local chief executive, who has found the totality of assessment of his organisation incredibly helpful when talking to staff and clinical managers, and when considering strengths and weaknesses on a wider canvass than merely the top key targets. As well as being important for the public and patients, the balanced scorecard is an incredibly useful tool for managers and clinicians in raising standards locally.

I did not mean to imply that the clinical focus was not there—it obviously is, and it is very valuable. I meant that it was probably not taken sufficiently into account by the balanced scorecard approach.

It is a matter of getting the balance right. CHAI is continuing to refine the available information.

The hon. Gentleman made the important point that patients are often the best judge of quality in the NHS. This Government have introduced patient surveys, which are translating into the star rating system through the patient focus of the indicators. We have often said that the NHS should be judged by those who use it and the taxpayers who fund it. It is right to introduce the citizen and consumer focus into the NHS, and we are, increasingly, endeavouring to do so.

The hon. Gentleman made some interesting suggestions about how we might further refine the process of gathering information about how well the service is doing, including the use of information gathered by the royal colleges when they consider the accreditation of organisations. I shall feed that back through the system to find out whether it is a feasible means of gathering further information. He also stressed the importance of ensuring that the Commission for Public and Patient Involvement in Health, in developing its protocols for patient involvement, be kept in close contact with the development of quality indicators. I agree that that is fundamental if we are to get a genuine patient view about the performance of our organisations.

Let me say a little about how the performance rating system will affect the primary care trusts, because we are venturing into a new area. The approach to PCTs has to be different from that to acute and specialist trusts, because PCTs do not simply provide services. Their performance will therefore be assessed in three areas. The first is services that they themselves provide, which is an established route. The second is access to quality services, because PCTs have a commissioning role, and being able to assess their robustness as commissioning organisations is key. The third area, to which I, as Minister with responsibility for public health, will have particular regard, is the improvement of the health of the community.

PCTs will, like other organisations, be assessed on how they look after the wider public health interests of the population that they serve. I hope that the hon. Gentleman will acknowledge that the system of measuring achievement and standards in the NHS is becoming more sensitive to the new reconfigured NHS that we have been creating, so it ought to give us a good view of its performance.

On assessment against the key targets, the star rating system gives three stars to trusts that perform at the highest level, two star to trusts that perform well overall but have some room for improvement, one star to trusts where there is some cause for concern, and zero stars to trusts that are identified as having the poorest performance. The hon. Gentleman was concerned that the trusts that are eligible for consideration for NHS foundation trust status have some weaknesses in their systems, and the Audit Commission report identified three out of the four trusts which may have some weaknesses. However, I assure the hon. Gentleman that the application process for foundation trust status is not only about having three stars. The Secretary of State must also approve the application, and there will be a robust process to look at the organisation as a whole. It is not just a matter of having three stars and automatically gaining that status, although I recognise the hon. Gentleman's concerns.

It is also important to point out that, although the Audit Commission report includes some concerns about the number of targets, it also recognises that there have been significant improvements in the NHS as a result of the targets that have been used. Targets are in disrepute at the moment, but it is acknowledged in the NHS that without the drive for he system to change we would not have seen dramatic reductions in waiting times or service redesign, so I want to put in a little word for targets. One of the keys to targets is getting local ownership of them, so that everyone in the NHS wants to see changes and to make progress on behalf of their patients, and in those cases targets are appropriate.

The hon. Gentleman also said that there was sometimes a disparity between the star rating system and some of the Dr. Foster assessments published in The Sunday Times. We are always happy to co-operate with Dr. Foster and other independent reviews. The NHS collects the information to which those organisations have access, and we try to ensure consistency of data; however, the surveys that Dr. Foster carries out will, perhaps inevitably, not be as extensive as some of the national surveys.

There will also be differences between surveys. For example, Dr. Foster's measurement of mortality rates is, I think, based on deaths that occur in hospital, whereas the star rating system also measures deaths that occur within 30 days of discharge, which is a different and more complex measure. We also try to take into account the skill mix and the case mix so that we have a more robust measure. It is therefore perhaps not surprising that there are some variations between the Dr. Foster assessments and the central NHS assessments, although we are always pleased to co-operate as far as we can; in helping to raise standards it is important that patients have access to the widest range of information possible.

I hope that the hon. Gentleman agrees that the Government have been open, transparent and straightforward, and that we have shown a real commitment to ensuring that the information is in the public domain. The service is not perfect, and I would not for one moment pretend that it is, but we have made significant progress in ensuring that the public have access to information about the service that they use, depend on and pay for. The hen. Gentleman is a champion of citizens' rights and I hope that he agrees that the Government have demonstrated a commitment to putting the patient at the centre and to ensuring that services are driven by the patient's requirements and needs as much as by any other factor.

It may assist the House if I remind all present that we are playing with up to 21 minutes injury time at the moment, so the next debate must conclude by 4.51 pm.