NHS star ratings need to be refined

can be learned from the first star ratings that were introduced in September
last year to identify the best and worst performing NHS trusts, according to a
report by the NHS Confederation. Ben Willmott reports

The launch of a star rating system to identify the best and worst NHS trusts
was supposed to help drive up healthcare standards across the UK when it was
introduced in October last year.

But nine months on, a study by the NHS Confederation finds significant
failings with the system, which assesses trusts on the delivery of key targets
such as waiting times, financial performance, cancelled operations and
treatment of staff.

And research by independent think tank Demos also criticises the whole
target-led approach to reforming the health service.

Under the star rating system, top trusts receive three stars while failing
trusts are given zero stars and a limited time period to raise standards before
a management team from a successful trust is brought in to try and improve

The NHS Confederation study Action Points criticises how trusts are assessed
and over what period, and how rating announcements are made.

The study claims the rating system is retrospective and static so trusts
that are rapidly improving or deteriorating are likely to be treated unfairly.
Poor ratings may be a year out of date and give no indication if there has been
improvement over that period, the report finds.

It also warns that some zero-star trusts have reported that their rating has
affected recruitment and retention.

Nigel Edwards, director of policy at the NHS Confederation, believes
target-led approaches to improving the health service such as the star rating
system are too simplistic.

Commenting on the Demos report, Edwards, said: "Complex systems such as
the NHS are difficult to change and simplistic carrot and stick approaches just
don’t work. The Government should set the framework, but the strategy has to
emerge from within the NHS rather than being imposed through central plans
linked to penalties for failure."

"This is a classic example of well intentioned policies that need to
consider the impact on the whole system in a much more sophisticated way."

HR professionals support the star ratings in principle but believe the
approach needs to be refined to iron out problems highlighted by the NHS

John Adsett, secretary of the Association of Healthcare Human Resource
Management, is optimistic that changes in the way the next set of star ratings
are calculated will lead to improvements.

"It appears that the HR element in the ratings are gaining in
importance," he said. "One of the things the Department of Health has
done is to carry out an eight or nine question survey of 500 staff at every
trust which I understand will be fed into the star rating system.

"It is also doing a patient satisfaction questionnaire that is going to
be fed into the star rating.

"I think ratings should be viewed as an indicator to measure trends and
show whether an organisation is moving up or down. They shouldn’t mean that
just because a trust has three stars it has no problems."

Adsett also believes that the announcements of the star ratings need to be
handled sensitively.

"Staff are still working very hard at these zero-star trusts and doing
the things that they ought to be doing. So when you have the local press
stating that their trust is poor it can have a negative impact," he said.

HR director of Kings College Hospital NHS Trust, Mike Griffin, thinks the
star rating system is a good concept but needs to be fine-tuned.

"The principle of providing a visible assessment of the quality
standards provided by public services must be a good thing," he said.
"The health service as a whole supports the idea in principle, but there
is concern over whether the measures that have been used for the initial
ratings are the right ones."

Griffin said there is to be a review of the data used for the next set of
ratings to ensure they paint an accurate picture.

"A very important consequence of this [the star rating system] is that
it forces all hospitals, ourselves included, to produce better quality data.

"The review will provide an opportunity for trusts to look closely at
the data being used. There is an opportunity to challenge the data before it is
reproduced in another set of star ratings," he added.

HR manager at Poole Hospital NHS Trust, Marie Cleary, believes more should
be done to educate the general public about how the star ratings work and that
a greater emphasis should be placed on good practice.

"There is a feeling that the star rating system is limited to an extent
in that you cannot possibly cover all aspects of service provided by hospitals
and some areas of good practice might not be recognised. It could be

She also highlighted the fact that star ratings could be out of date and
said staff morale and recruitment could easily suffer at trusts with poor

"The publicity can also be quite damaging. Patients do not understand
how the rating system works and may have misconceptions about the care they
will receive," she added.

"I think there needs to be more recognition of good practice and good

Healthcare union Unison said the star-rating system is an improvement on the
previous NHS performance indicator system of league tables, but it is concerned
that the system encourages competition at the expense of co-operation.

A spokesman said: "It is an improvement on the old system in that it
includes areas such as cleanliness and treatment of staff, but we are concerned
it involves labelling hospitals as failures.

"We want to encourage hospitals to share good practice rather than to
set hospital against hospital and trust against trust. We want to see a system
that encourages co-operation rather than competition."


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