Standards for Better Health: fit for purpose?

The Healthcare Commission is about to consult on measures for assessing the performance of healthcare providers in England. The standards against which it will be making these assessments were laid down in July by the Department of Health in Standards for Better Health.¹ Despite their potential impact on service development, and on the ability of the commission to make valid and reliable assessments, the standards have received little attention. Yet they deserve to—for they provide a weak basis for assessment and improvement.

The standards' main aims are to assure safe and acceptable services through compliance with minimal “core” standards; promote development by continuous improvement against optimal standards; reduce the burden of unhelpful standards and guidance; and underpin fair, responsive, and effective services. They consist of both core standards, which are assumed to be met already by all provider organisations, and developmental standards, which are to provide goals for service improvement.

The standards are presented in seven domains designed to cover the full range of health care (see box). These domains—a mixture of quality attributes, management, and public health—do not match any existing conceptual models such as the NHS Performance Assessment Framework,² the EFQM Excellence Model,³ international external evaluation,⁴ or assessment templates from Canada⁵ and Australia.⁶ Within the domains there is no apparent architecture (policy, structures, procedures, resources) or hierarchy (to differentiate between standards and criteria). The standards themselves are inconsistent in depth, scope, and specificity. For example, protecting whistleblowers gets as much attention as the entire management of health records. The domain of clinical and cost effectiveness has nothing on costs, waste, or utilisation. Several other single issue items would be better as criteria than as separate standards (MRSA, child protection, and under-representation of minority groups).

As for content, key features of organisation and management are bundled into unmeasurable concepts. General references to best practice, principles of clinical governance, and financial management (two lines) undermine the standards as a tool for development or assessment. Moreover, many longstanding NHS priorities are not included. For example, one standard requires healthcare organisations to “make information available to patients and the public on their services,” but not on their performance.

The standards repeatedly refer to the need for evidence based clinical practice and local planning but give no basis for their own authority. Without such references it is difficult to see where the standards came from, what they replace, or how they will “reduce the burden of unhelpful standards and guidance on the NHS.” What is clear is that the standards were drafted by one agency (the Department of Health), the criteria and assessment process will be developed by another (the Healthcare Commission), and the products will be approved by a third (the Secretary of State). This does not bode well for coherent development or independent assessment.

The seven domains

Safety

Clinical and cost effectiveness

Governance

Patient focus

Accessible and responsive care

Care environment and amenities

Public health

The standards include a catch all requirement that “healthcare organizations meet the existing performance requirements set out in the annex.” These very specific targets pre-empt the development of criteria by the Healthcare Commission. Moreover, whether even these will be achieved is not clear. For example, the NHS Plan stated that by December 2004 people would have guaranteed access to a primary care doctor within 48 hours. Official figures show that performance had improved from 75% of cases in March 2002 to 97% in February 2004,⁷ but independent surveys by the Picker Institute put the figure at 54% in 2004.⁸

No allowance is made for standards to be tested by providers and assessors to ensure they are understandable, relevant, and achievable. Nor is there provision for training of assessors or for preparatory self-evaluation by providers. The criteria and assessment process must be finalised by March 2005 and put into effect from April 2005. There is no process or timetable for evaluation and revision.

The Healthcare Commission is faced with the impossible task of developing from these standards a robust and fair assessment process inside eight months. Experience in other countries suggests that the first cycle of a standards based assessment programme needs well defined procedures, simultaneous development of standards and criteria, and at least three years of preparation.⁹

The interests of all concerned, including the public, could be better served. For a start the Department of Health should publish where the standards came from and how they were selected. Reviews in the first year should be regarded primarily as tests of the system rather than true assessments of individual organisations. Radical redesign of the standards should begin after six months' use (in September 2005), rather than waiting for 2006-7.

International guidance¹⁰ should be followed in the design, development, and application of standards. The same guidance should be used by the Healthcare Commission to develop realistic, understandable, and measurable criteria for assessment and to adopt an assessment process that is proved to be reliable.

The Department of Health has misjudged the research, technical expertise, and time needed to develop and test a fair and reliable process of external assessment. The burden will fall on the fledgling Healthcare Commission as assessor and on the early guinea pigs who are assessed.