Short abstract
Doctors, managers, and opposition MPs attacked the NHS star rating system last week. Would it be improved if it measured health outcomes and allowed for more local input? Zosia Kmietowicz reports
The publication of star ratings for all NHS trusts in England last week (19 July, p 119) has raised many questions about the value and purpose of this latest government backed appraisals system.
Figure 1.
Health Secretary John Reid (left) claims the system has improved standards. But it was dubbed “pathetic” by Liberal Democrat Evan Harris (centre), and “a gimmick” by Conservative leader Iain Duncan Smith (right)
Credit: (FROM LEFT) CHRIS YOUNG/PA, UPPA/TOPFOTO, CTK/PA
It is two years since the health service league table was first published, and although the system has been overhauled and transferred to independent assessors during that time there is little evidence of what has been achieved. What do the ratings really show, and are they in any way meaningful to the patient who is waiting for hip replacement surgery or a cardiac bypass or who wants to have a home birth?
The government's purpose in introducing star ratings was to lessen variation in performance between trusts, raise standards, and make services more accountable to the public.
On the first count—the attempt to reduce variation—this year's results indicate that the policy has failed in two health-care sectors. In acute trusts and ambulance trusts the gap between the best and worst performers has widened.
There were seven more top rated acute trusts and two more zero star rated trusts than last year. Among ambulance services five more were awarded zero stars and two lost their three star rating. However, in specialist and mental health trusts the gap between good and bad narrowed, with more units ranked among the higher stars and fewer in the zero category.
Whether or not the ratings have improved standards seems to depend on whom you speak to. John Reid, secretary of state for health, judges that they have. This year's results, which have been compiled by the independent Commission for Health Improvement for the first time rather than the Department of Health, confirm that overall hospitals are improving, even though targets are getting tougher, he said.
Professor Nick Bosanquet, professor of health policy at Imperial College, London, says that the ratings have clearly focused healthcare providers' attention on service standards, and there are obvious areas where these have improved. The maximum 48 hour wait to see a GP, due to be fully implemented by 2004, is one example, he says, and one that patients will feel immediately and benefit from.
However, criticism of the system has been rife and is aimed particularly at the way standards are measured. In parliament Iain Duncan Smith called the table “a gimmick.” He quoted James Johnson, chairman of the BMA, who said: “They measure little more than hospitals' ability to meet political targets.”
Speaking on the BBC Today programme, Dr Evan Harris, the Liberal Democrat health spokesman, said patients were dying as hospitals concentrated on hitting targets rather than providing the best care. “This rating system is a pathetic measure of hospital performance. It shows whether hospitals can hit targets, tick boxes, and fill in spreadsheets, but it tells us absolutely nothing about the clinical outcomes that should matter to patients. This is a political exercise which costs patients' lives,” he said.
Len Fenwick, chief executive of Newcastle upon Tyne Hospitals NHS Trust, which was demoted from three to two stars and so lost its automatic right to apply for foundation status, outlined some of the problems that the trust faced. “The suggestion is we need to do better but this does pose difficulties when in these highly specialist areas across such a population mass (three million) we do not control the volume of patients being referred and are constrained by the limited revenues that are earmarked for this trust. Having said that, we shall not be deterred because we believe the trust has a high public confidence rating.”
Many people, however, believe wholeheartedly that the publication of service performance is a sure way to improve standards. Maurice Cheng, chief executive of the Institute of Healthcare Management, is one of those people. But he admits that the system can also have its drawbacks.
“Where we have had reservations in the past it has been about the apparent arbitrary nature of the selection of indicators and the tendency to condemn multimillion pound organisations on the basis of a snapshot of indicators. Even in failing trusts there will always be areas of excellence which will get overlooked in such a broad brush approach,” he said.
As for the government's third aim in introducing the star system—making health services more accountable to the public—little evidence has been shown on how patients might use the data on waiting times, cleanliness, staff morale, emergency readmissions, and infection control to their advantage
John Appleby, chief economist at the health charity the King's Fund, said last week: “The promotion and demotion of hospitals in this year's star ratings may leave some patients feeling unnecessarily confused. The star ratings are a useful management tool for the Department of Health and the NHS but are a poor guide for patients.
“It's time for the government to reconsider the whole picture of NHS targets, indicators, [and] rankings—of which star ratings are a part—to ensure they are more useful and empowering for staff and patients alike.”
His views were echoed by the Patients Association, which called for “more focus on clinical outcomes and the performance of units, teams, and individuals in order [for the public to be able] to make informed choices about hospitals.”
The impact of ratings on staff and service users can only be guessed at. Staff in high ranking units might feel smug or under pressure to improve more, while poor rankings might demoralise staff and erase patients' confidence.
Dame Deirdre Hine, chairwoman of the Commission for Health Improvement, admitted last week that the system of appraisal was far from perfect and that refinements were essential. At the top of her wish list was a means of reflecting deprivation and of capturing patients' experiences of services more robustly.
The responsibility for compiling next year's star ratings passes to the new Commission for Healthcare Audit and Inspection, which Professor Bosanquet refers to as the “super-regulator.” He says that ratings are here to stay but believes that the measures used to compile the league table should be more flexible, with input from local patients' groups, service staff, and local health organisations.
“The main problem with ratings is the total central imposition. If there was a chance for local input then the whole thing would be less negative in its impact,” he said. “There should still be a common core to measures, but with a chance to regulate add-ons for the things that are important locally.”