Sizing up the Annual Health Check

James Gubb, 16 October 2008

The Annual Health Check of NHS organisations, released today by the Healthcare Commission, presents a picture fit for the NHS’ 60th birthday bash earlier in the year. Sixty-two per cent of organisations are now rated ‘excellent’ or ‘good’ on quality of services, up from 41 per cent two years ago, and those rated ‘excellent’ or ‘good’ on use of resources are up a fantastic 45 percentage points to 61 per cent. Can we then pop open the champagne?

Perhaps not so soon. For a start, for an organisation to score ‘good’ on quality of services it is sufficient for them to have ‘almost met’ core standards and existing national targets and ‘good’ for new national targets. Yet core standards include such things as ‘keeping patients, staff and visitors safe’ by ‘having systems in place to ensure that the risk of healthcare acquired infection to patients is reduced’ or ‘having systems to ensure that all risks associated with the acquisition and use of medical devices are minimised’ or ‘having systems to ensure that all reusable medical devices are properly decontaminated prior to use’. These are pretty fundamental things to good medical care. It is concerning then that after such phenomenal investments of cash over the past ten years that 39 per cent of organisations are still only rated ‘fair’ (34 per cent) or ‘weak’ (5 per cent) and that 114 trusts are found wanting on one or more of the three core standards relating to infection control. A similar argument can be applied to use of resources, which again represents something of a minimum requirement.
More fundamentally, it is the content and methodology of the Annual Health Check that should be cause for concern. Two of the three platforms concerning quality of service relate to how well NHS organisations have met national targets, new or old. Yet we have seen time and time again that meeting such targets, particularly those relating to waiting times (all of which are included) and the new Choose and Book system, may actually compromise standards of care for the patient, even to the point of putting them in danger. Yet such considerations enter the Health Check far too infrequently; the focus is on process, not outcomes and the actual experience of patients.
The third platform relates to core standards, which are more acceptable, but still offer a very State-centred concept of care that is uneasily applied. It requires, for example, that ‘healthcare organisations co-operate with each other and social care organisations to ensure that patient’s individual needs are properly managed and met’. But what exactly does this mean and how exactly is it be measured? Though obviously out of the Healthcare Commission’s hands, the ability of organisations to do this has been ripped apart by constant ‘re-disorganisation’, the perverse incentives created by payment-by-results and the purchaser-provider split. Other core standards do deal more with the direct care of patients, such as ‘healthcare organisations have systems in place to ensure that staff treat patients, their relatives and carers with dignity and respect’. But again, what exactly does this mean? So a system is in place, but you cannot just prescribe such things as dignity and respect as they require a carefully nurtured culture that supports it. Unfortunately, too many NHS staff recognise the priority at the moment is meeting targets and getting the finance right.
The inspection regime is also beginning to create a substantial bureaucratic burden for organisations. An NHS Confederation report documented how an estimated 58 per cent of all regulation could not be used for any internal purpose, nor was useful, with managers highlighting the replication of data required by the Healthcare Commission and other organisations, and the amount of time, uncertainty and preparation needed to demonstrate compliance with the Annual Health Check. The Healthcare Commission does not conduct spot-checks, so preventing the phenomena of preparing for inspection, but much is still self-reported.
It is ironic that as most conventional indicators of NHS performance are improving, and quite dramatically in some cases, most measures of patient satisfaction and experience have remained pretty much static. A part of this is surely the sheer number of incentives still in place for NHS organisations to look upwards, rather than respond to its patients. No-one is saying that regulation of healthcare or inspection shouldn’t happen, but it is the nature of it that should be of concern. But what exactly is the point of the parts of the Annual Health Check that merely re-record data on pre-existing national targets and require organisations to draw up systems proving whether or not they can create neatly-crafted documents?
Would it not be better to expend this time on visiting the place and seeing what is been done to understand and improve services for patients?