Q&A: NHS star ratings

As the commission for health improvement publishes performance statistics for English NHS trusts, David Batty explains the facts behind the figures

What do the league tables cover?
They rank the clinical and managerial effectiveness of every NHS trust in England. The trusts are given a star rating, from zero at the bottom of the scale, to three at the top, to give patients a simple gauge of how well local health services are run. The 156 acute hospital trusts and 20 specialist trusts, which include children's and orthopaedic hospitals, have been rated on up to 45 areas, ranging from cancelled operations and waiting times, to cleanliness and staff morale. The 88 mental health trusts have been rated against 28 performance indicators, including suicide rates and psychiatric readmissions. The 31 ambulance trusts have been rated on 13 measures, including callout times and paramedic training. The 304 primary care trusts (PCTs), which oversee family doctor services, have been assessed on 46 areas, including teenage pregnancies, access to GPs within 48 hours and medication prescribing rates.

Why have they been drawn up?
The league tables were launched two years ago by the government, which believed there was too much variation in the performance of NHS trusts. The star ratings were seen as a means of driving up standards and making managers more accountable to the public. Ministers also wanted to encourage public sector enterprise by rewarding the top rated trusts with more freedom and greater flexibility to raise funds.

Who has drawn up the table?
For the first time the ratings have been compiled by the commission for health improvement, the independent healthcare watchdog that monitors standards of patient care in the NHS. Previously the findings were published by the Department of Health.

What do the ratings show?
Of the acute trusts, 52 gained three stars, 60 received two, 30 were awarded one, and 14 received no stars. Compared with last year's results, 50 hospital trusts improved their star rating, compared with 35 that lost stars, and 81 that stayed the same. But the gap between good and poor performance grew during the year to the end of March with seven more top rated trusts and two more no star trusts. Of the specialist trusts, 10 gained three stars, nine received two stars, one was awarded a single star and none got zero stars. This was an improvement on last year when only six specialist trusts gained three stars. Of the ambulance trusts, 10 achieved three stars, seven won two stars, nine got one star and there were five with no stars. This was a significant deterioration from last year when none ambulance trusts received zero stars and two more achieved the top rating. Of the mental health and learning disability trusts, 14 achieved three stars, 43 were awarded two stars, 28 gained just one star and three got none. This was a significant improvement on last year when only four mental health trusts gained three stars. Of the PCTs, 45 achieved three stars, 139 were awarded two stars, 98 gained one star and 22 received no stars. This was the first year that PCTs were given a star rating.

Do the ratings reflect quality of care?
Not really. The system places an equal value on cleanliness and mortality rates. The indicators only include a small number of key clinical areas and do not go into detail about the process of care or the quality of a particular operation. What they really show is the effectiveness of the trust's management team rather than standards of clinical care. Matt Muijen, director of the Sainsbury Centre for Mental Health, said the difference between three and zero star rated trusts was not as significant as the rankings suggest. "The impression given to the public is that trusts are either totally good or completely bad. This ignores the fact that across trusts some elements of care are good but others are poor." The shadow health secretary, Dr Liam Fox, noted that some three-star trusts failed to give patients sufficient privacy and dignity, while others which met their cleanliness targets failed to properly deal with hospital acquired infections. And the Chi chairwoman, Dame Deirdre Hine, conceded that the system was "far from perfect". The commission aims to make the ratings more representative of trusts' overall performance.

Is it fair to compare these trusts?
Doctors have suggested it is unfair to compare hospitals in more deprived or elderly communities with those serving more youthful and prosperous areas. The indicators on death rates also do not take into account that teaching hospitals treat more complex cases.

What do the ratings mean for the best trusts' managers?
Managers at the three-star trusts will gain more autonomy from ministers, extra funds and fewer inspections. They also have the chance to become NHS foundation trusts, free to establish private companies, and they will have the ability to vary staff pay over and above nationally agreed terms and conditions.

How will the ratings affect bids for foundation status?
Four of the 29 hospitals being groomed by ministers for foundation status were forced out of the running because they were no longer good enough to qualify for the top three-star rating. Three of the four slumped from three stars to one star.

What do the ratings mean for the worst trusts' managers?
Managers at the zero star trusts will face closer. Long-serving chief executives will have three months to raise standards. Newly appointed chief executives of no-star trusts will get up to a year to improve performance. Those managers who fail to improve performance will be sacked and their jobs "franchised" to senior public services managers, from health and education, or private or voluntary sector experts.

What impact will the ratings have on staff?
Staff may feel demoralised if their hospital is considered to be underperforming or if they think it has been unfairly ranked. The Royal College of Nursing has warned that a no-star rating could also exacerbate recruitment and retention problems, creating "sink" hospitals where nobody wants to work or be treated.

What do the ratings mean for patients?
Very little. Even if patients know their local trust is worth no stars, they have no real choice about where they can get treatment because hospital referrals are decided by GPs.

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