Regulation, Regulation, Regulation
It was hoped by many across the NHS that lessons had been learned from the failings at Mid Staffordshire NHS Foundation Trust. News of troubled times in Essex has been met with widespread media attention and raised new questions about data and the way it is produced. Clare Riley reports.
There are around 45 regulatory bodies authorised to enter hospital premises, inspect them and subsequently issue data indicating performance and standards. The sheer volume of information available to the public and indeed the media is beyond anything the NHS has previously experienced. The data produced by these bodies has the power to expose those Trusts who underperform and gives politicians a valuable weapon, particularly in the run up to the general election.
In March 2009 terrible failings were uncovered at Mid Staffordshire, which saw 400 “unnecessary deaths” and wards described by patients as “war zones”. The NHS was lambasted by the national press for allowing this to happen and doubts were raised about Foundation Trusts (FTs) and their ability to manage and essentially monitor themselves.
After a full investigation by the then Healthcare Commission, recommendations were made and in just two years Mid Staffordshire managed to transform its mortality rate, which is now more than 7 per cent lower than the national average.
But just as it appeared that lessons had been learned, another FT came under the spotlight for equally poor standards. Basildon and Thurrock University Hospitals NHS Foundation Trust was rated “good” overall in October 2009 by the Care Quality Commission (CQC). This rating was based on the Trust’s performance between 1st April 2008 and 31st March 2009 but since then an unannounced inspection found sub-standard care and shocking ward conditions.
Suction machines contaminated with mould growing on the equipment
A blood pressure cuff for children heavily stained with blood
Equipment past its use-by date in the resuscitation room
Items designed for one-use only being used on multiple occasions
A soiled mattress in A&E with stains soaked through to the foam filling
Equipment trays splattered with blood
Floors and curtains also stained with blood
Monitor, the watchdog for FTs, made an announcement on the 27th November 2009 that a special taskforce would be going into Basildon and Thurrock to try and turnaround the situation. The team includes an external medical expert, an external nursing expert and a programme delivery office managed by independent and experienced advisors. There will be increased reportage on the delivery of plans to improve quality of service alongside objective performance metrics, which will be measured and reviewed monthly.
Overall the objective for the taskforce is to “…drive and ensure the swift implementation of actions to secure the provision of high quality care”.
Executive chairman of Monitor, Dr William Moyes explained why this is necessary: “This formal use of our powers is needed to quickly and effectively deliver the improvements in patient care which have been too slow to date. Our concerns about Board effectiveness, together with the concerns that the CQC has raised about quality of care, mean that we are placing a requirement on the Trust to take action with immediate effect to resolve these issues.
“While some progress has been made, the pace needs to accelerate in order to ensure the Trust is in a position to provide the best possible care to patients. We will be reviewing the Trust’s performance regularly and in detail - if we don’t see measurable results quickly, we’ll take further action.”
Cynthia Bower, chief executive of the CQC added that nothing but rapid progress will be accepted in the turnaround: “Swift action is needed at Basildon to nip problems in the bud. Our work has uncovered serious failings. The Trust has high mortality rates for emergency admissions and we have found evidence of significant problems in different parts of the organisation. The Trust has taken our concerns seriously but improvements are simply not happening fast enough. Our confidence in the management’s ability to deliver on commitments and to turn the situation around has been severely dented.”
Bower said that changes to the way the CQC regulates Trusts, which are due to come into effect throughout 2010, would help identify problems earlier. She said the current system, inherited from the Healthcare Commission, is no where near sophisticated enough and the new system allows spot checks and inspections on the ground to replace a tick-box data culture that currently exists.
“From next April, our new regulatory regime will apply, and with this will come a range of further strong powers to bring about change. Every trust will have to meet essential standards of quality and safety in order to function. Without radical improvement, Basildon’s registration will be affected,” said Bower.
Basildon and Thurrock was awarded FT status in 2004 and was one of the first in England to be given greater freedom to manage its own finance. Trust chairman, Michael Large described Monitor’s intervention as a “serious matter” adding that staff are in no way underestimating its gravity.
“I want to reassure our local community that the safety and well-being of our patients is our highest priority. The Trust has a clear strategy for improving patient safety and sets ambitious improvement targets, reporting performance measures monthly. We understand that Monitor needs to assure itself and the public that the concerns that have led them to this intervention are not indicative of wider problems. I am confident they are not.”
But Large’s reassurance hasn’t convinced the Patient Association (PA) which called for more accountability. “Maidstone. Tunbridge Wells. Stoke Mandeville. Mid Staffordshire. Now Basildon. Will this be described as another one off?,” said Katherine Murphy, director of the PA.
“Yet again we find patients being let down appallingly. Lack of monitoring, lack of help with feeding, lack of dignity. How many times do the public need to keep hearing about this before the Government is embarrassed enough to do something about it?
“Yet again the regulators assessment of a hospital has proven to farcical. Will someone be held to account this time? NHS managers and staff should be held to account and not be allowed to move on to other jobs when they’ve let patients down so appallingly.”
And in the same week at the end of November 2009 when failings at Basildon and Thurrock were uncovered, more debate over hospital ratings was sparked by intelligence body Dr Foster and its publication of the Hospital Guide 2009.
The guide, now in its second year, has raised some serious concerns and set many Trusts across the country on the defensive. On page three the editor’s letter asserts that the report is “an independent, authoritative guide to hospital care written for the patient, the politician, the civil servant, the manager and the clinician.” It added that the one key theme that cropped up when discussing what makes patient care quality was safety. Authors said they had a 99 per cent response rate from Trusts.
To begin with Trusts are issued with a score from zero to 100 with the latter being the best. Due to issues with accuracy the scores cannot be compared side-by-side and so Trusts are then grouped into five bands, one for the poorest performing hospitals and five for the best.
A complex ‘z-scoring’ system is then applied, which the report tries to explain: “The methodology identifies top and bottom performers by looking at their score for a certain measure of care and seeing how different this is to other hospitals. Those who are doing much better than the average get high scores and those who are not doing as well get low scores. To put them in bandings, we have calculated the probability that hospitals are among the best or worst, based on their scores.”
This information is stored on DrFosterHealth.co.uk and accessible by the public in the ‘Quality Accounts’ section. It is similar to the ‘Scores on the Doors’ scheme, which publicly rates restaurants on cleanliness and uses a traffic light system to display levels of performance.
Questions which are asked and then answered with scores include; What is the hospital’s overall death rate?; Is the hospital fully compliant with National Patient Safety guidelines?; What is the ratio of hospital staff to bed?; How well does the hospital control infection? and How committed is the trust to patient safety?.
A total of 12 Trusts found themselves in band number one and their Quality Accounts on the website are littered with amber and red dots outlining poor performance across key areas. But all 12 have jumped quickly to defend the ratings.
Basildon and Thurrock said its hospital mortality ratio during the last six months is as expected highlighting that Dr Foster’s figure was for the 2008/2009 period. The statement went on to say: “We moved to the Dr Foster system as it had become the nationally recognised system quoted on the NHS Choices website. It is important to understand that the software was designed as an indicator to flag up to hospitals when the risk of mortality for a particular diagnosis appears to be higher that the national average and this should trigger a review of care in this area. We would also emphasise that the Dr Foster HSMR is a calculation of risk, not a count of the number of patients who died.”
Weston Area Health NHS Trust said it would use the data to look at where it could improve but stressed that there is a distinct difference between calculated data and actual inspections: “On the radio Dr Foster has said there are no concerns about the mortality rate at Weston and he also acknowledged that the safety concerns are technical and not related to care and that the points we make about inspection as opposed to date have validity.”
Hereford Hospitals NHS Trust also outlined its good rating from the CQC with chief executive officer, Martin Woodford saying that patient safety is always of utmost importance and that the Trust is not complacent, despite falls in cases of C.Diff and MRSA.
Other Trusts were more forthright in criticising Dr Foster and its calculations. Blackpool, Fylde and Wyre Hospitals NHS Foundation Trust said it was “extremely concerned about the measures used by Dr Foster”. Its statement quoted a University of Birmingham study which found Dr Foster’s methodology “fundamentally flawed and misleading”. The Trust added that it would be watching how other Trusts react and consider legal action where appropriate.
Lewisham Hospital agreed saying it was “surprised and disappointed by the scoring”. Mid Yorkshire Trust found the data to be “extremely confusing” as did Scarborough and North East Yorkshire Healthcare NHS Trust. Chief Executive, Richard Sunley, said: “Dr Foster data has been proven in recent published research to be less than credible. Like other Trusts we do not fully understand the methodology behind these Dr Foster results and believe the overall result to be misleading, creating an incomplete picture of the good work that is taking place at our hospitals.”
South London Healthcare Trust highlighted that the data relates to a time before the establishment of the Trust. St Helens and Knowsley NHS Trust questioned the effect on the local community. Medical director Dr Mike Lynch said he wanted to defend the Trust. “I am particularly concerned about the impact this publication might have on our vulnerable patients and also our staff. We report frequently and regularly to the NPSA and they recognise that we are among the top performing hospitals around safety in the country.”
Tameside Hospital NHS Foundation Trust has drafted in an external expert to “better understand and address the issues”. University Hospitals Coventry and Warwickshire NHS Trust said the data fails to recognise the in-depth level of inspection carried out by other bodies, fails to highlight the quality care that is provided and uses data considered to be incomplete.
And perhaps the strongest reaction came from University of South Manchester NHS Foundation Trust. It described its “shock and disbelief at this grossly misleading assessment of patient safety at UHSM.” Adding: “In their last report, Dr Foster rated UHSM in the top 10 safest hospitals in the country, based on low mortality rates. Mortality rates at UHSM are even lower this year, yet the same hospital is now being catapulted to the bottom of the National league table.”
Dr Foster responded telling The Source: “We stand behind our methodology. We’ve been doing this for 10 years and what people need to realise is it’s not a case of one report is better or more accurate than the other. The biggest difference is that we measure different things to the CQC. We measure safety and the CQC looks across much broader issues such as the patient experience and financial performance. The public have a right to have as much information as is available and we fully stand by our data.”
There’s no doubt that both Dr Foster and CQC measure important things but as with all facts and figures breaking them down and taking them at face value is a tricky business. Whatever your stance on the debate, you can’t disagree with Andy Burnham’s take on it all: “Patient safety is our overriding concern and there is no room for complacency.”
