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Thinking Nurse

This blog will reflect my interests in learning disabilities, nursing, nursing theory, philosophy and politics and my general interests in the arts and literature. (Nursing is an art as well as a science!) Philosophy and nursing have been intrinsically linked since the days of Socrates, his mother was a midwife, and taught him everything he knew!

Tuesday, February 01, 2005

Star Rating System of NHS Acute Hospitals

This press release from the Royal Society of Medicine describes a study that illustrates what many of us have believed about the NHS star rating system since it's inception, that it is a fairly arbitrary process, riddled with problems, that often does not mean very much and can lead to 'misrepresentation of data' (a phrase that translates into English as 'telling lies') and other practices that are not in the interests of patients ('unintended and dysfunctional side effects'). The big problem is that such ratings can influence major funding decisions which can drastically affect local healthcare services:

"The problem with NHS star ratings
Since 2001, the star rating system of NHS acute hospital trusts have given the public the ability to compare one hospital from another using a standard evaluation process. What are the consequences of the results, and is this enhancing patients’ experience in NHS hospitals? Dr Russell Mannion and colleagues at the Centre for Health Economics, University of York present new research in the current issue of the Journal of Health Services Research and Policy, published by the Royal Society of Medicine Press.

The ‘importance’ of star ratings
Although the star ratings system is not the only process in place to measure the performance of NHS acute hospital trusts, the ratings system and its results gain broad media exposure and is therefore scrutinised by the public. They are also viewed as a benchmark for internal processes. ‘In addition to facilitating accountability to patients and the public, they also serve as an important tool for concentrating management attention on key strategic priorities and national targets,’ Dr Mannion writes.

Are star ratings a ‘balanced scorecard?’
Staff members at some of the hospitals surveyed thought that star ratings ‘did not represent a rounded or balanced scorecard of their own organisation’s performance.’ One of the inconsistencies of the NHS star ratings system are the sometimes conflicting results of similar, commercially-funded surveys, the author says. These differences are ‘assumed to be due to the increased weight accorded to clinical indicators in the methodology used’ by other organisations, the article states. Other complaints from staff included that they did not take into consideration ‘local contingencies’ and specific ‘mitigating factors that might help explain variations in the measure performance of hospitals.’ Many of these unique conditions are beyond the hospital’s control and it is therefore viewed as unfair that this would not be taken into consideration when the rating is calculated.

Inaccurate data is ‘not in the patients’ best interest’
This study also highlighted the ‘widespread belief that the data used to calculate the star rating were often incomplete and inaccurate,’ Dr Mannion says, to the extent that the staff at one highly-rated hospital admitted to ‘purposefully manipulating and misrepresenting data in order to improve their rating.’ Some of the tactics used included scheduling cancellations at a time to avoid unfavourable data and re-classifying trolleys as beds. One hospital with a low rating thought this was a result of the accuracy of their data, and another expressed concern that this practice was ‘not in the patients’ best interests.’

Responses to star ratings
In addition to the data and methodology of the star ratings system being evaluated, the internal effects is also relevant in determining its integrity. There were many positive hospital responses to the star ratings, including the alignment of ‘internal performance management and reporting systems with key national targets.’ The communication between central government and hospitals was improved and ‘dysfunctional senior management’ was identified that otherwise may have stayed hidden within the hospital, Dr Mannion asserts. The negative responses included ‘evidence of tunnel vision and a distortion of clinical priorities,’ reduced staff morale and public trust, and ‘bullying and intimidation.’

‘Gaps in knowledge’ and ‘dysfunctional consequences’
The authors conclude that ‘this study highlights some important gaps in knowledge and failings in current policy and practice. That star ratings may be used for good or ill makes it imperative that the Healthcare Commission monitors the impact of these data, not only in terms of the degree to which they lever beneficial change, but also in terms of any unintended and dysfunctional side-effects they generate for patients and staff.’



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