Watchdog calls for Trust improvements

Of the diagnostics review, Anna Walker, the Commission’s chief executive, said: “[The review] revealed great variations in Trust performance in many areas of diagnostics. Some patients are still waiting too long for diagnosis, delaying their treatment, and too many internal examinations fail to achieve a result, slowing down diagnosis and causing distress to patients.”

The review also found wide variations in performance including unacceptable waits for scans at some hospitals.

DELAYS WARNING
The Commission warned that delays in diagnostic services such as x-rays and scans could hinder some Trusts in meeting the Government’s target of a maximum of 18-weeks’ wait from referral to treatment.

The inspectorate has since published comparative results for diagnostic services at 153 acute hospital Trusts across England, all of which can be accessed on the Health Commission website www.healthcarecommission.org.uk.

The review looked at three types of diagnostic services:

• Imaging (x-rays and scans).

• Endoscopy (examinations of the bowel and stomach).

• Pathology (tests on blood and tissue samples).

All three services are important in areas such as cancer and cardiac care. It assessed the experiences of patients and clinical quality, as well as the efficiency and management of services.

Individual tailored recommendations and action plans for improvement have already been agreed with many Trusts. All acute Trusts have had access to the comparative data used for this review since March and many will have begun to address deficiencies.

Key findings included:

Waiting times for imaging services are improving but there are wide variations in performance across the country.
Typical waits for GP referred or outpatient CT scans have reduced from 49 to 36 days since 2001,1 and those for MRI scans have reduced from 147 to 95 days. This has been achieved alongside significant increases in demand; with a 77% rise in CT scans and a 56% increase in MRI scans.

But the review shows a large variation in performance across Trusts. The best 25 Trusts achieved the top score in the review because no patient waited longer than 13 weeks. All Trusts were advised they would need to meet this by 7 March if they were to achieve the Government’s 18-week target for patient referral to treatment.

At the time of the review, 67 Trusts had patients who had waited more than 26 weeks, after which Government rules say patients must be offered a scan at another hospital. At the worst six Trusts it would have taken at least one month of full time activity to examine every patient who had been waiting longer than 26 weeks.

Wide variations in Trusts’ waiting times for endoscopies.
Nationally, numbers of patients facing very long waits for an endoscopy are falling. The latest figures show that, in June 2006, 4672 patients had been waiting over a year for a non-urgent colonoscopy, down from 7612 in January. However, the likely wait varies between less than two weeks and over a year, depending on where you live in the country. In many Trusts, waits are being reduced too slowly to meet the Government’s 18-week target or the likely surge in demand expected from full implementation of the new national bowel cancer screening programme.

Variation in how imaging exams are reported.
X-ray and scan requests from A&E are often made by junior doctors. Radiologists or other authorised members of radiology staff must produce a formal report to help doctors make decisions about admitting, discharging and recalling patients. Formal reports are also important in providing information for ongoing treatment and patient case files. Such reports were always produced at 30% of Trusts, but more than one in every four exams were never formally reported in a quarter of Trusts.

Improvement needed in recording of success rates for colonoscopies.
A major national initiative is underway to improve the training of endoscopists. Currently, at least 32,000 colonoscopy exams a year do not succeed in reaching and diagnosing the problem area of the bowel. Many Trusts are not recording their success rates for this. Forty five per cent of trusts could not supply success data to the Commission. Of the remainder, only 41% were achieving the 90% success target agreed for the national bowel cancerscreening programme.

Variation in speed of urgent pathology tests.
Fast turnaround of many pathology tests is important, especially for critical requests from A&E or other emergency admission units. For example, the results of urgent blood tests to diagnose whether a patient with chest pain has had a heart attack or injury to the heart muscle often determine the emergency care they need. Fifty five per cent of Trusts usually complete them within one hour, but the slowest 15% of Trusts take over two hours.

Endoscopy units need to do more to ensure that their services are focused on the patient.
Forty per cent of endoscopy units do not have a room where they can talk to a patient in private and 25% do not give patients discharge information on out of hours contacts in case problems develop. These performance ratings will feed into the annual health check, the NHS assessment system that has replaced star ratings. Trusts’ final performance ratings were published on October 12, 2006.

Trusts have been awarded their diagnostic services rating based on performance compared to other Trusts. A score of weak implies that a Trust is lagging behind others in some key delivery areas, but not necessarily that patients are receiving unsatisfactory care. No Trust is weak across all three of the diagnostic departments reviewed. Those that scored excellent are ahead of other Trusts, but may still have room for improvement.

Reviewers appointed by the Audit Commission on behalf of the Healthcare Commission have been working with each acute and specialist Trust to agree specific local recommendations and action plans to spread best practice across the country.

STEP UP IN MEDICINE MANAGEMENT
The Commission made the plea when publishing comparative assessments on medicines management for all 173 acute hospital Trusts in England.

The Trusts scored as follows:

• 18 attained excellent

• 70 were ranked good

• 73 were ranked fair

• 12 were ranked weak

Commenting on the results, Anna Walker said: “Hospitals still have some way to go when it comes to involving patients in decisions about medicine. Trusts need to do more talking to patients about their medicines and their potential side effects. They need to make sure patients feel empowered to discuss any concerns. Hospitals also need to do all they can to minimise risks, particularly when giving injections or using intravenous drugs.” Areas of good performance identified in the review include:

Managing the risk of infection through prescribing and administering medicines.
Hospitals can reduce the risk of infections such as MRSA and clostridium difficile by prudently using antibiotics and by using oral antibiotics in preference to intravenous antibiotics, where appropriate. Forty per cent of Trusts received the top score for this. The 18% of Trusts receiving the bottom score need a clear strategy for improving performance.

Preventing allergic reactions.
Many people are allergic to medicines such as penicillin, which, prescribed in error, can cause serious side effects and even death. Seventy-three per cent of Trusts demonstrated that they had strong systems to prevent these mistakes. Top performing Trusts (34%) took actions such as recording patients’ allergies, whether positive or negative, before administering drugs. Only 1% of Trusts received the bottom score.

Getting patients to use their own drugs.
Getting patients to bring their own medicines into hospital is good practice as it provides continuity of care and enables clinicians to see whether people have the right drugs. Fifty-nine per cent of Trusts did this well, with 24% achieving the top score. Areas needing improvement included:

Giving information to patients.
The national survey of inpatients showed that 48% of patients said potential side effects were not explained and 31% said that they had not received written information with the medicines that they took home.

Involving pharmacists in patient care.
Pharmacists should help develop best practice on wards in order to ensure medicines are being used to best effect and to minimise medication errors. Eleven of the 12 Trusts that scored weak overall performed poorly in this area. Hospitals need to invest in automation of dispensing and find new ways of working so pharmacists can spend sufficient time on wards and in the management of medicines.

Assessing the risks of intravenous drugs.
Intravenous and injectable drugs should generally be prepared in a sterile place, although some lower risk activity can take place on wards. Many Trusts had special sterile pharmacy areas. But 73% had not done a risk assessment on at least 25% of wards to determine which medicines preparation should move into these areas.

Empowering patients to take control of their own medicines.
Most people administer their own drugs at home, but this is often routinely taken over by ward staff in hospital. For some patients this is appropriate, but more patients need to be given the choice to remain in control of their drugs. Trusts need to identify patients who should have the option to administer medicines and allow them to do so.

The Trusts were measured on 21 areas covering a range of issues, from the percentage of patients who had had a comprehensive medicines review to whether patients had a complete medicines record for their stay in hospital.

The medicines management review is the first in a series of ratings which feed into the NHS’s overall performance ratings, the annual health check, which was published on October 12, 2006. As part of the annual health check, each NHS Trust will receive a rating on two parts – one on quality and one on use of resources.

REFERENCE
1 Published by the Audit Commission.