Devon LMC

Summary - The State of Healthcare in 2008

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Extract of Summary - The State of Healthcare in 2008

This is our final report to Parliament on the state of healthcare in England and Wales. We have used the opportunity to look afresh at our findings over the last five years, and what they tell us about healthcare as it is provided, and experienced, in 2008.

This summary, and our report as a whole, has been organised to reflect the balance of our work over the past year. The topics that we have selected present a good overview of where we are in health and healthcare today. Some issues cut across these topics however, and so are highlighted in our summary.

The backdrop for this report is a health service that is receiving more money than ever before, that employs more staff than ever before and is providing more care than ever before. There is much about the NHS that is very positive. This is recognised by those who use it and reflected in the satisfaction they express through our surveys.

Our assessments show that the NHS as a whole is getting better at using and managing its resources, and that it is performing better against the wide range of national targets it has to deliver and the core standards it has to meet.

Over the last few years, the NHS has made some dramatic progress.The work towards meeting the maximum waiting time of 18 weeks from referral by a GP to treatment in hospital has been particularly significant. This is a considerable achievement. We have also seen improvements in the speed with which ambulance services are able to respond to people in emergencies. Community mental health services such as ‘crisis resolution home treatment’ and ‘assertive outreach’ are now in place across the country and are delivering care to thousands of people.

We can also see falling rates of death from the big killers such as cancer and heart disease and a continuing improvement in life expectancy. Good progress has been made in tackling some of the major challenges to public health, for example levels of smoking have decreased and rates of teenage pregnancy continue to fall.

Importantly, we are starting to see a real shift in the attention given by healthcare organisations to the safety of care. Safety is now on the agenda, arguably as never before. This is shown by, for example, the concerted effort to tackle the problem of healthcare-associated infections, such as those caused by MRSA and C. difficile.

All of this is good news, and we do not underestimate the effort it has taken. Staff working in healthcare should be congratulated. Alongside this picture of improvement, however, there are inevitably areas of concern.

While overall measures of life expectancy and premature deaths are heading in the right directions, inequalities in health status between those in the richest and the most deprived parts of England are persistent and, in some cases, growing wider. Obesity, excessive alcohol consumption and sexually transmitted infections remain a major concern and are storing up health problems for the future.

While we are pleased to report that the safety of healthcare has a higher profile than in previous years, we continue to have concerns about the ability of healthcare providers to collect good information on the safety of care and to use it to improve their services and to protect patients. Stronger leadership in this area is still needed in all healthcare organisations to ensure that safe care is their first priority. More attention needs to be given to a wider range of matters relating to patients’ safety: better reporting of incidents; more systematic learning from incidents and implementation of improved practices; and better information to compare performance in the provision of safe care. Everyone needs to recognise that improved safety is the first step towards a better health service.

While we have seen improvements in the performance of healthcare organisations, there remains a need for better information on the outcomes that people experience from the care they receive. This is the case across all sectors of care, from acute to primary, and all groups of patients. There is a great deal of work underway, often led by the Government, that seeks to address this shortage of information. We look forward to seeing it have an impact on the quality of healthcare.

We are concerned by the variable picture of quality that our in-depth reviews and studies have revealed. Our national reviews of maternity services, mental health services and of urgent care all showed a wide variation in performance. They provide a benchmark against which organisations can measure their progress and test the quality of their services against that of other providers. To do this successfully, healthcare organisations need to collect, analyse and disseminate information of good quality on the care they provide. Too often, we have found that the systems in place locally to gather and use information about care are either not there or not good enough.

One of the biggest challenges facing the NHS in England is getting the purchasing (commissioning) of healthcare right. Our work has give us a limited view of the quality of commissioning, but enough to suggest that more attention is needed.

We have continuing concerns about the ability of healthcare organisations to meet the needs of the more vulnerable in our society. Our work, and the work of others, show that too often people with learning disabilities are not well provided for. There are clear barriers to them gaining access to mainstream services for both physical and
mental health problems.

Our work looking at services for children provides a mixed picture. While we have found evidence of very good practice, particularly in specialist hospital services, we have concerns about care in more general settings. We also have concerns about the care received by children and young people with complex needs. Finally, we have concerns about the arrangements in healthcare for the safeguarding of children.

We continue to have concerns about care for older people. Our work has highlighted the importance of dignity and respect, but we are yet to see substantial improvement in the experiences that people report to us.

Looking more broadly at the experience of patients and users of services, it is clear that levels of satisfaction are high, but further progress is needed to ensure that patients really are at the centre of care. Patients tell us that they want to be able to make meaningful choices, be fully involved in decisions about their care, and have the information they need, when they need it.

The big picture

Health
The overall picture is positive, with targets relating to the health of the population either met or on the way to being met:

• Life expectancy is increasing.
• Rates of premature death due to cancer and circulatory disease are falling.

However, there are underlying concerns. Inequalities in health status are persistent and, in some cases, are widening, despite targets aimed at reducing inequality.

The experience of patients
While overall satisfaction remains high, we have seen little change in the scores that trusts get for the experience of patients.

Finance
Funding has increased substantially in recent years, and the NHS receives a level of funding comparable to that in other similar countries.
NHS organisations are managing their resources better. The Audit Commission’s annual assessments (reflected in our annual health check) show year-on-year improvements in this area.

Activity and workforce
The NHS in both England and Wales is busier than ever before. There have been major increases in consultations in primary care, admissions to hospital, visits to A&E, the use of community mental health services, and take-up of newer services such as NHS Direct and walk-in centres. The NHS is also employing more people than ever before, with an increase of around 26% between 1997 and 2007.

Value for money
The available measures of value for money do not yet include enough information on quality of care and outcomes for patients to allow any robust view of how the NHS is doing. Better information on quality and outcomes is vital, if in future we are to have good measures of value for money.

Performance
Our annual health check of NHS organisations in England has shown year-on-year improvement in performance in meeting core standards and national targets.

Policy and reform
The NHS in England is in the middle of a period of extensive reform, aimed at radically improving commissioning, giving organisations more local flexibility and developing ‘patient choice’. It will take time for the full impact of these changes to work through. Significant changes are also planned in Wales, including the ending of the split between commissioning and provision of care.

Assurance & reassurance

Meeting standards
• The NHS in England has made year-on-year improvements in meeting the national standards set by the Government.
• Relatively high levels of compliance with core standards are good news ahead of the new system of registration for the NHS in England in 2010.
• However, more than a third of trusts still only achieve a score lower than “fully met”, and more work is needed, particularly in the domains of ‘safety’ and ‘governance’.
• We have adopted a new approach to inspecting independent providers of healthcare, which allows us to focus our attention on those establishments which cause us the greatest concerns. Our work suggests that there has been some improvement overall.
Providing safer care
• Our work shows that the safety of patients has noticeably moved up the agenda for providers of healthcare and that there are some examples of good practice.
• Only around half of trusts in England comply with all of the Government’s core standards relating to safety.
• There is a growing body of evidence about what works to improve safety. Our work shows the importance of leadership and of making safe care the core of the organisation’s activity. Wider agreement is needed on what ‘good’ safety looks like.
• Our assessments show that effective systems are not always in place to understand safe care and risk, report and act on individual incidents, and analyse and act on wider lessons. The new registration requirements for health and social care should include such systems.
• Organisations still need to do more to encourage a culture of openness in identifying and reporting in the case of untoward events.
• More systematic reporting is needed particularly from GPs.
• Better comparative information about safe care needs to be generated at national, organisation and service level, to give confidence that good practice is being followed and risks are being addressed.
• A national database of serious untoward incidents should be compiled with clear responsibilities as to who should take what action in relation to them.

Tackling healthcare-associated infections
• The NHS has made a major impact on reducing MRSA infections, and the national target for reducing infections has been met. But almost half of trusts did not meet their individual targets for reducing or minimising MRSA infections during 2007/08.
• C. difficile is still a major problem for the NHS, but there are encouraging signs of recent improvement in dealing with it.
• Trusts are clearly tackling infection prevention and control vigorously. However, few trusts fully comply with the hygiene code, but we have found few breaches of the code that posed an immediate risk to patients. Trusts do need to ensure they have comprehensive systems in place to maintain the decrease in infection rates.
• Healthcare providers need to ensure that they improve their systems to tackle all infections, and not just focus on MRSA and C. difficile. This should be underpinned by agreement at a national level on what infections should be measured and how.

Six pictures of healthcare

A picture of health and healthcare in the community
• A greater focus on commissioning is evident from both Government and PCTs. We welcome the work that is underway, but all would recognise that there is some way still to go. This is very important for local people, because in our in-depth reviews we have often found that where services are poor, this is because commissioning is poor. Our reviews have also identified many high-performing organisations, showing that progress is possible.
• It is clear that people trust and value their GPs, but also want more flexible access to them. We welcome both the Government’s proposed introduction of regulation for GP’s practices, and their efforts to resolve issues of access in primary care.
• We have seen progress in some areas of public health including smoking, teenage pregnancy and access to sexual health clinics. However, progress has been more limited in other areas, such as obesity, alcohol misuse and sexually transmitted infections such as chlamydia. The greatest progress has been made where there are clear objectives and targets.
• Our annual health check has highlighted some improvement in the ability of PCTs to understand and meet the needs of people with longterm conditions. But too many organisations have not delivered all that they planned in this area.
• There is a lack of robust information about how well community services are performing.

A picture of urgent care and care in hospital
• The level of activity in A&E departments is increasing.
• The ability of the NHS to respond quickly to urgent need has improved.
• Both NHS acute hospital trusts and ambulance trusts have shown year-on-year improvements in our assessments of the quality of their services.
• However, more work is needed on measuring outcomes for patients.
• Our review of urgent and emergency care has highlighted a lack of integration between the services provided locally by a wide range of organisations.

The picture for mothers
• The number of births in England and Wales has risen by 16% since 2001, putting additional pressure on maternity services. Providers and commissioners face real challenges in meeting the needs of a growing, mobile and diverse population.
• Most women are satisfied with their maternity care, but we have found wide variations in the quality of services offered by the NHS in England and women do not always get the level of care to which they are entitled.
• In the least well-performing organisations, we have found a pattern of lower levels of staff, poorer access to training for staff, poor relationships between professional groups and problems in collating and using information about maternity services.
• Essential data about maternity services is not always routinely collected, making it difficult for local heath services and national bodies to assess the quality of care provided, and to make the right changes to improve services. We welcome and support efforts by the Department of Health to make the national minimum dataset for maternity services a reality.
• During 2008, the Government has announced additional funding for the improvement of maternity services, and new standards for maternity services have been issued by the relevant Royal Colleges. Both of these developments are to be welcomed.

The picture for children and young people
• While children are generally healthy, inequalities in health linked to deprivation persist, including death in infancy. Other key challenges in relation to children and young people include obesity and sexual health.
• While death in childhood is uncommon, there are too many cases involving avoidable factors.
• Although the overwhelming majority of NHS organisations declare that they comply with the core standard for child protection, we have some underlying concerns about the priority given, in some organisations, to issues relating to children, the levels of essential training in child protection among clinicians, and lines of accountability and responsibility for child protection. At the Government’s request, we will carry out a national review of
arrangements in the NHS for the safeguarding of children.
• Children and young people with complex needs, including children with disabilities or those in situations that make them vulnerable, do not always get the attention and care from healthcare services that they need.
• Our work on acute hospital services has shown that children receive better care in settings where they are the main focus (such as inpatient paediatric units) than in more general settings.
• However, our work in acute hospitals also found some evidence of failure to recognise serious illness in children, due to a lack of training in paediatrics or a lack of supervision.
• Services for children with mental health needs have improved, but are still patchy.
• As for other services, there is a lack of good data with which to measure children and young people’s access to services, and the outcomes they get.

The picture for people with mental health needs
• Compared with other trusts, specialist mental health trusts have tended to perform best in our annual health check.
• Good progress has been made towards the national target for reducing suicide.
• Substantial progress has been made in expanding the range of community-based services. People using these services report high levels of satisfaction.
• We have seen progress in inpatient services, helped by national initiatives.
• However, the quality and safety of both community and inpatient services vary enormously from area to area.
• There continues to be a greater representation of inpatients from black and minority ethnic groups than in the wider population, suggesting the need for better understanding of what could be done to avoid admissions for this group.
• Major work is underway to expand access to talking therapies for people who experience depression and anxiety, but access to a range of therapies for all with mental health needs could still be improved.
• There are major gaps in the availability of information about the quality of mental health care.

The picture for people with a learning disability
• We have concerns about the commissioning of health services for people with learning disability. We are carrying out further work in this area and will report on this in 2009.
• Specialist healthcare services for people with learning disabilities are generally safe. However, they do not always adequately meet the wider needs of those people using them.
• There are still barriers for people with a learning disability in gaining access to mainstream services, and so their physical health needs are too often poorly addressed. Within mainstream services, staff lack an awareness of how to respond to someone with a learning disability.
• We have too little information about care for people with both a learning disability and mental health needs, but we have concerns and so we have included in the annual health check for 2008/09 a measure of performance in this area.

How does it feel for patients?

• Patients and users of healthcare services are generally very positive about the care they receive from the NHS, but they also want:
- More flexible access to their GPs
- Better information
- Greater involvement in decisions about their care
- Meaningful choice
- Respect for their dignity.
• Waiting times for acute hospital care have fallen in both England and Wales.
• We continue to have concerns about access to mental health services, particularly access to talking therapies and out-of-hours crisis care.

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