Hunt's hospital rating system threatens transparency

As part of the coalition government’s response to the Francis report, the secretary of state Jeremy Hunt announced a new rating system for NHS organisations. Curated by a new chief inspector of hospitals and not unlike the star ratings of the early 2000s, we are told that this new score will be the “single version of the truth” telling all of us the standard of our local NHS services.

The fact the government wants to reinvent healthcare ratings is not worrying in itself. The fact they believe that there can or should be a single version of the truth raises many concerns.

‘We are told transparency and participation are key to achieving the ambitions of a safe and efficient NHS’

In 2009, I co-authored a report for Dr Foster Intelligence, endorsed by the National Patient Safety Agency, where we named 11 hospitals with patient safety problems and raised serious concerns about Basildon and Thurrock Foundation Trust. This institution was rated “good” for quality of care by the Care Quality Commission’s Annual Healthcheck: the “single version of the truth” rating of its day. The apparent conflict between these two results caused meltdown across the system, ultimately contributing to the resignation of Baroness Young, the CQC’s chair.

Fast forward to 2012 and the Dr Foster Hospital Guide commended Cambridge University Hospitals Foundation Trust as the top hospital, measured using a transparent basket of quality and efficiency indicators. In the same week, Monitor, the foundation trust regulator, raised concerns about this trust in terms of cancer waits and A&E performance.

Neither party claimed their information was the single version of the truth. Indeed, the Dr Foster and Monitor teams worked together to understand each other’s conclusions and make sure both made sense. This approach benefited everyone. Monitor was able to raise an alarm without having their authority challenged, Dr Foster had some scrutiny of their findings and the trust was able to commend staff for doing well in the quality and efficiency measures and take steps to fix the problems identified by Monitor.

The response in the main (some HSJ reader comments aside) was that − since there was transparency about the different things being measured by Monitor and Dr Foster − most people could grasp the reasons for these apparently contradictory results.

Liberating data

But what’s more concerning is the challenge the “single version of the truth” rating makes to NHS England’s transparency programme. Championed by Tim Kelsey, the national director for patients and information, we are told that transparency and participation are key to achieving the ambitions of a safe and efficient NHS.

‘At best, it is a recipe for damaging and distracting bickering. At worst, it will interfere with the momentum of the transparency agenda’

Transparency is about liberating data sets that for far too long have been the preserve of clinicians or civil servants. Participation means, in part at least, that we − from established companies, to enthusiasts at NHS Hack Days, to academic institutions − get to use and analyse this information and find creative ways of presenting it that patients might find useful. Where does that leave the single version of the truth?

Say for example a patient uses NHS Choicesto choose a hospital for their knee replacement because the car parking is free and there is a low rate of orthopaedic readmissions, yet the new chief inspector rates this hospital as “poor”, perhaps because of quality issues in the maternity unit at a different site and poor patient feedback about A&E. What is the truth here? That the patient is making a sound evidence-based decision about her surgery? That the patient has an indefinable sense of dread about that hospital being a bad choice?

Legitimate concerns

Worse, say a team at the NHS Hack Day mash up some Patient Opinion and iWantGreatCare data and find concerns about a mental health service, yet the chief inspector using the “friends and family” test and outpatient survey information (the latter of which is inevitably 18 months old) rates this service as “good”.

There is a real worry that since the Hack Day info doesn’t form part of the “single version of the truth” rating, legitimate concerns will not be taken seriously and the service will continue to be thought of as “good”.

That the government wants to rate hospitals − in effect aggregate some predetermined metrics to form an opinion of an NHS services, and describe this in some way − should be commended. That they are convinced this should be the only version of the truth is incredibly worrying. 

At best, it is a recipe for the sort of damaging and distracting bickering we’ve witnessed about hospital standardised mortality ratios over the past decade.  At worst, it will interfere with the momentum of the transparency agenda, which is a real shame as it’s had such a good start. 

Alex Kafetz is a director at ZPB