Hospital Guide 2008

Dr Foster reveals the health of our hospitals in the annual Hospital Guide. This year's report focuses on three dimensions of quality: patient safety, effectiveness of care and patient experience.

Key findings include: market reforms beginning to bite in the NHS; another year where overall mortality ratios have fallen; wide variations in access to cancer treatments and much more...

In his Next Stage Review, Lord Darzi emphasises the importance of defining and consistently measuring quality, making information about the quality of care widely available to pinpoint variations and focus on improvement and finally, to recognise and reward good performance.

He goes onto define three dimensions of quality:

• Patient safety
• Effectiveness of care
• Patients' experiences

In this year's Hospital Guide report, we have taken each of these dimensions in turn, and identified and analysed performance across the English NHS against selected indicators.

Our purpose is simple. Dr Foster was founded on a belief in the need for greater transparency about variations in healthcare performance. In so doing, we not only seek to inform patients but to help hospitals assess their own changing patterns of performance and seek out opportunities for improvement. These analyses are intended to be as useful to commissioners as to providers, for some analyses we have therefore analysed by PCT as well as by acute trust.

Summary of findings in each chapter of the report

1. Choice and Competition

• At trust and specialty level, finances are beginning to reflect the fluctuations in income that are to be expected under patient choice and payment by results
• We relate how a number of trusts are responding in this more competitive and challenging environment: refocusing services to meet patient needs; stepping up action on issues that concern patients like safety; and establishing new business models
• Last year, more than one third of NHS hospital trusts in England saw a fall in the amount elective surgical activity they undertook

2. Dimensions of Quality: Patient Safety

• 32 trusts achieved lower than expected HSMRs this year, 21.5% of all trusts in England
• Fewer trusts have HSMRs that are higher than expected, compared with the last Hospital Guide, but there are still 30 trusts in this category
• 4 trusts have consistently improved their HSMR over the past 3 years, showing overall reductions of at least 30%
• A more refined measure of mortality focuses on diagnoses, such as vasectomy or migraine, where death in hospital is unexpected. Still at trial stage, data quality indicates 72% accuracy
• Testing out other new safety indicators, our analysis suggests much variation in performance across the NHS in England on two areas prioritised in national patient safety initiatives: central line infections and in-hospital venous thromboembolisms

3. Dimensions of Quality: Effectiveness of Care

• Focus on breast cancer surgery: comparing rates of breast conserving surgery with mastectomies, we identify two PCTs commissioning exceptionally high proportions of mastectomies given their populations
• Eight PCTs had significantly low proportions of mastectomies
• Women from the most deprived population quintile were 37% more likely to have a mastectomy than those in the least deprived quintile
• Focus on surgery for fractured neck of femur (broken hip): there is wide variation in compliance with the standard that patients with broken hip should have surgery within 48 hours.
• In four trusts, more than 80% of their patients had surgery within 48 hours. However, five trusts met this standard for fewer than 30% of their patients
• Focus on revision rates: rates of revision for total hip replacements within one year of the original operation are as high as 6.3% - against a national average of 1.7%
• Three trusts have hip revision rates that are significantly higher than expected, while ten trusts have significantly lower than expected rates
• Rates of revisions for total knee replacements within one year of the original operation are as high as 6.6% - against a national average of 1.5%
• Nine trusts have knee revision rates that are significantly higher than expected, while 24 trusts have significantly lower than expected rates
• Focus on children's surgery: the proportion of trusts where all elective paediatric surgery is carried out by designated surgeons who have had at least six months' training in a specialist unit has not improved since 2006, and there are still 33 trusts who said they were not meeting this indicator
• The proportion of trusts reporting that anaesthetists with responsibility for paediatric anaesthesia participate in at least one paediatric list per week has fallen very slightly from 2006, with 26 trusts not meeting the indicator

4. Dimensions of Quality: Patients' experiences

• Focus on patient feedback: the acute inpatient survey administered by the Healthcare Commission demonstrates that patients are not consistently asked for their views on the quality of care. In 141 organisations, fewer than 10% of patients reported being asked for their views on the quality of their care
• Some trusts stand out but there is a long way to go if trusts are to meet the Secretary of State's intention to request that every hospital trust collects immediate feedback from patients on their experiences of care
• Focus on issues which shape patients' experiences and perceptions: Guidance from the Department of Health says that by March 2009 all elective admissions should be screened for infection either on or before admission. Our survey of hospital trusts suggests that many have some way to go before meeting this guidance: only 26% of trusts who responded say that they screen for MRSA pre-admission; and 67% do not screen patients admitted via A&E or into medical reception units
• All the trusts who responded to our questionnaire have isolation policies and, where medically appropriate, isolate patients with C difficile in single rooms. Only 31% trusts reported having a dedicated isolation unit