hospitalGuide2007

iintelligence
Special Edition Hospital Guide
How healthy
is your hospital?

About Dr Foster Intelligence
Hospital Guide 3
Dr Foster Intelligence is a public-private partnership that aims to
improve the quality and efficiency of health and social care through
better use of information. We make it easier for professionals and the
public to access information about health and social care through a
range of innovative products and services.
The partnership is a 50/50 joint venture between The Information
Centre for Health and Social Care (a special health authority of the NHS)
and Dr Foster, a commercial provider of healthcare information.
DrFosterIntelligencewaslaunchedoperationallyon13thFebruary2006.
At the launch, Lord Warner, former minister of state (NHS Reform),
said, “Better information is vital for health and social care systems to
deliver the highest standards of patient and client care in the most
effective way. The public have told us that better information is key to
them exercising choice and taking more responsibility for their own
health. They need this information in a usable form. This creative
partnership between The Information Centre for Health and Social
Care and Dr Foster will help to establish an information market which
will empower managers, frontline staff and the communities they
serve. The key beneficiary will be the public.”
The Dr Foster Unit at Imperial College of Science, Technology and
Medicine has developed pioneering methodologies that enable fast,
accurate identification of potential problems in clinical performance
– and areas of high achievement.
Dr Foster Intelligence works to a code of conduct that prohibits political
biasandrequiresit toactinthepublicinterest.Thecodeismonitoredby
the Ethics Committee, an independent body chaired by Dr Jack Tinker,
emeritus dean of the Royal Society of Medicine.
4 Foreword
6 Introduction
Quality: A moving target?
8 Scaling the peak of perfection
Measuring quality of healthcare
14 Feature
Is waiting still an issue?
16 Raising the standard
Measuring patient safety
18 Practice makes perfect
Following clinical guidelines
24 Feature
Getting a grip on infection control?
26 Measuring hospital performance
Mortality rates
32 Trust of the year
Which trusts are top performers?
34 References and acknowledgements
Contents

Foreword Tim Kelsey
4 Hospital Guide
In the first issue of Intelligence a few months ago, we looked at
the achievements of a number of trusts and individuals who had
innovated in the use of information to improve their performance.
In this special edition we publish our annual audit of hospital
quality and best practice, incorporating mortality rates and trends
for all hospitals in England as well as the findings from our annual
survey of trusts and hospitals across the UK.
What strikes me this year is the sense of positive progress, not only
in the national reduction in mortality rates and waiting times
(though challenges undoubtedly remain) but, interestingly, in the
accelerating development of an information culture in healthcare.
This is difficult to pin down, but it is certainly the case that no one
really disputes the value of measuring and publishing mortality
rates these days. No one questions the importance of highlighting
variations in practice and performance. No one challenges the
principle of clinicians and managers working as a team to
understand and resolve quality and efficiency issues.
Far from making me complacent, this merely brings into focus the
next set of information challenges. For me, two are urgent. First, the
pressing need for the NHS to rise to the challenge of improving
the measurement and reporting of patient safety. And to be more
transparent about it. We have taken the initiative to start adapting
a set of patient safety indicators in common use in the US, and are in
active discussion with trusts and others about their value in the NHS.
Second, it is surely time for the healthcare community to start
recognising patients themselves as an important source of data.
The quality of healthcare is, of course, about hard clinical outcomes,
but from the perspective of the patient, it is also about their
experience of healthcare and the impact it has on their overall quality
of life. As one patient recently commented to me: “I sometimes
get asked about how the treatment has been; I never get asked
about how well I’ve been cared for.” At Dr Foster Intelligence,
we have already developed tools for routinely obtaining feedback
on patients’ experiences, and we intend to promote the use of
patient-reported outcome measures.
Ihopethatinthenext Hospital Guide, we willbeabletodemonstrate
clearly the progress the health sector is making on both these counts.
Tim Kelsey
Chair, Executive Board
Dr Foster Intelligence

Dr Jack Tinker
Emeritus Dean, Royal Society of Medicine
Chairman, Dr Foster Ethics Committee
Introductory message Dr Jack Tinker
Hospital Guide 5
Delivering safe, high quality patient care is every doctor’s passion,
that is why most of us chose a medical career.
In practice, we rely on good information to make decisions – from
making a diagnosis to when and how to treat a particular condition –
what medication to prescribe, whether to operate or not. As doctors
we are used to taking in complex data and acting on it.
For too long, many of us have relied on patchy or otherwise limited
data to help us understand, compare and improve the quality of
clinical practice. We have also sometimes been wary of transparency
around such information.
Since I began chairing the independent Dr Foster Ethics Committee
in 2000, we have seen a fundamental shift in attitudes to performance
information. It is no longer quite such an uncomfortable experience
– an ‘imposition’ on the professional community by those that
don’t understand it. It has become an invaluable tool in our desire to
deliver the best quality care. There’s now a demand from clinicians
for information about their performance, the performance of their
teams, including clinical outcomes and financial information.
Clinicians are beginning to participate in this process– but we really
need to be leading it.
The value of information, and in particular the Hospital Guide,
is not just about public accountability. It is that it acts as a catalyst
for informed partnerships. Partnerships within clinical teams and
between managers and clinicians, in particular, but also with their
patients and the wider community.
Armed with robust information, professionals are able to ensure
thattheirteamsareprovidingthebestqualitycare.Theyarealsoable
to fulfil their role in directing and managing the limited resources of
the NHS. By making this information available to the public, people
are reassured that variations in performance between hospitals are
understood and are being addressed; and as patients they are better
equipped to participate in decisions about their care.
Transparent and robust information and transparency are essential
if we are to create an environment where professional values can
flourish, and in which clinical leadership, professionalism and
working in partnership are intertwined.

Introduction Quality: A moving target?
6 Hospital Guide
For the past five years, Dr Foster has
publishedanalysesofhospitalperformance
through the Hospital Guide. As ever, the
public can access information about trusts
and individual consultants, and compare
performanceattrustlevelonkeyindicators
at www.drfoster.co.uk/hospitalguide. This
reportis,however,aimedatboardmembers,
managers and clinicians of acute trusts,
providing high level results of our analyses
of quality, safety and best practice.
Our aim is not only to inform, but to act
as a catalyst. Dr Foster was founded on the
belief that only through better information
and better measurement could hospital
performance be improved and variations
in performance reduced. We know that
information makes a difference: we work
with three-quarters of NHS acute trusts
in England who use our analytical tools
every day to improve quality and safety of
care for patients.
The message this year is in many ways a
positive one. Not only is national mortality
improving,butthevariationsbetweenNHS
trusts are diminishing. Many more trusts
are achieving better than expected
performance levels than in 2000/01. There
are also fewer poor performing trusts, and
the outliers are less extreme. Waiting times
are falling, though the 18-week challenge
will be significant for diagnostics and
orthopaedics in particular.
Variations in performance nevertheless
persist.Sixtrustsareoutsideexpectedlevels
of performance for mortality for fractured
neckoffemur.Therearefour-foldvariations
in mortality for trusts performing coronary
Inthechallengetoraisequality,
measurement is the key to
improving health services
DATA COVERAGE
The data relating to mortality and
waiting times in this report is based
on Hospital Episode Statistics (HES).
HES data covers the NHS in England
only. It is Dr Foster Intelligence’s aim
to include Scotland, Wales and
Northern Ireland and the private sector
in our assessments of quality and
safety, using comparable routinely
collected data. Organisations would
benefit from being able to compare
themselves with their peers across
the UK. Therefore we are discussing
access to datasets with the relevant
organisations and hope to produce a
comprehensive guide to quality of
healthcare in the UK in the future.
“Patient safety must come first. To design
safe healthcare systems where levels of
reliability are high, organisations need
a much improved understanding of high
performance. The starting point for
professionals should be the continuous
analysis of information to prompt action.”
Professor Sir Ara Darzi KBE HonFREng
FMedSci, professor of surgery, Imperial
College London
Photography: Getty

Hospital Guide 7How do individual trusts perform? See pages 28 – 31 >>
artery bypass grafts. Adherence with
established best practice is patchy. Too
few trusts are meeting clinical guidelines
for fractured neck of femur and stroke, for
example, or guidance published by the
National Institute for Health and Clinical
Excellence (NICE).
There remain aspects of hospital activity in
which there is simply not enough reliable
or comparable information to identify or
explore performance issues. This issue is
mostsignificantinrelationtopatientsafety.
TheNHSstilllacksmeaningfulinformation
onhowwellorpoorlyhospitalsaredoingin
preventing adverse incidents and providing
safecare.Infectioncontrolisacaseinpoint.
Only10trustsfromacrossthecountrywere
able to provide us with robust data to show
that they source isolate over 90 per cent of
patients carrying MRSA.
Wewanttocontinuetoencourageclinicians
and managers to work together to
review information about their hospitals’
performance and to co-operate on
improvement initiatives. We know that
this kind of shared endeavour generates
thebestresults. Inourrecentstudy1
of how
the NHS is using information to innovate
and improve, we recounted 21 examples
of clinicians and managers taking action
to achieve measurable improvements in
care. Teamwork was an important element
in nearly every account.
Measuring hospital performance is a
complex business. We understand that
complexityandweknowthatleaguetables
are simplistic and cannot tell the whole
story. Those working in the NHS need
information that is relevant to their
professional objectives, presented as an
overview. Such ‘dashboards’ need to be
regularly updated as well as allowing
drill-downs into the detail of different
aspects of performance. Clinicians and
managers need to be able to look at
comparative data. We are working with
manyintheNHStoachievethis.Thisreport
provides an important annual snapshot
of performance and progress on carefully
selected measures. We hope that from
next year, we will be able to incorporate
measures of patients’ experiences and
patient-reported outcomes into our
analyses of hospital performance.
Havingbeenthefirstintheworldtopublish
Hospital Standardised Mortality Ratios
(HSMRs), and having done so every year
since, this report updates those analyses
for 2006, together with information on
mortality rates in relation to specific
procedures. Five years on from the NHS
plan,wealsolookatwhetherwaitingtimes
are still an issue.
Another unique component of analyses in
this report is provided by data collected
directly from trusts on selected evidence-
based process indicators of best practice
in some key specialties, developed in
consultation with clinicians.
Theinformationonthemethodologiesused
to produce this report can be found at
www.drfoster.co.uk/hospitalguide/methodology
KEY POINTS
• Ninety-five per cent of trusts in England have reduced their mortality
rates over the past five years.
• More trusts have mortality rates that fall within the range expected,
and fewer trusts are performing poorly in relation to others.
• All trusts performing coronary artery bypass grafts have mortality
rates that fall within the expected range – although there is a four-fold
variation in performance between organisations.
• Six trusts were above the expected range of mortality for fractured
neck of femur for 2005/06.
• On average 77 per cent of patients admitted as an emergency with
fracturedneckoffemurreceiveanoperationwithin48hours.Ninetrusts
operateonlessthan 50 percent of patients withinthatcrucialtimeframe.
• Effective measures of patient safety should be developed as a matter of
urgency, led by clinicians.
• Waiting times (in the NHS in England) are falling year on year, but our
analysis confirms the key challenges in orthopaedics and diagnostics.
• Waiting times for hip replacement have fallen from nearly 250 days in
2000/01tounder150days,butthisisstill12weeksoverthe18-weektarget.
• The average wait for an MRI scan is now 64 working days, an almost
50 per cent improvement on last year. But the variation is from 47 days
in the North East to 100 days in Wales.
• Inonlythreeregions(London,theNorthEastandYorkshireandHumber),
isthe NHS providing CT scans within the four weeks recommended by
the Department of Health.
• All acute trusts now have a specialist stroke unit.
• Sixty-four per cent of stroke patients in England are administered
CT scans within 24 hours of admission, but in three NHS regions,
the proportion of patients receiving early diagnosis has fallen.
• There is significant variation in the provision of diagnostic and
treatment services for prostate cancer.
• Fifty-four per cent of trusts follow NICE guidelines on the use of
drug eluting stents.
• Twelve per cent of NHS trusts are using hip replacements that aren’t
recommended by NICE, up by one per cent from last year.
• One in 10 eligible MS patients are not receiving beta interferon.
• More than 97 per cent of NHS hospitals across the UK have multi-
disciplinary teams working with both lung and colorectal cancer patients.
However,onlyaround30percentofhospitalsintheprivatesectorreport
that they comply with this NICE recommendation.
• Only 10 UK trusts provided robust data, showing that they source
isolated over 90 per cent of patients carrying MRSA. Many trusts
have screening and isolation policies, but do not gather the data to
monitor their implementation.
“Effective decision-making, both clinical
and managerial, requires the right
information. As professionals we need to
know how well we compare with our
peers and whether other teams, providing
similar services to similar patients, achieve
better results than we do. If so, why?
Weneedtoknowwhodoeswhattowhom,
with what outcome – and ideally – at what
cost.Whenthistypeofinformationismade
available to both doctors and managers,
we can work together to create the best
possible care for patients. That is, after
all, the business we are in.”
Professor Jenny Simpson, chief executive,
British Association of Medical Managers

8 Hospital Guide
Scaling the peak of perfection
DATA COVERAGE:
NHS England
In the challenge to measure quality of healthcare, are mortality rates the answer?
Photography: Getty

Dr Foster Intelligence is passionate about
improving quality measurement and
promoting an information culture in the
NHS. We are equally committed to
increasing transparency about the
performance of healthcare organisations
in ways that make sense to the public.
In 2000, we started to work with Professor
Sir Brian Jarman who has pioneered the
methodology for calculating Hospital
Standardised Mortality Ratios (HSMRs)
using routine administrative data, the
Hospital Episode Statistics (HES). This
collaboration resulted in the first ever
national publication of standardised death
rates anywhere in the world. We have
published the HSMRs for English trusts
every year since, still under the direction
ofProfessorJarmanandDrPaulAylinwho
run the Dr Foster Unit at Imperial College,
London. Three quarters of acute trusts in
England are now using this data, in near
real-time, on a routine basis as part of
their quality improvement programmes.
Measuring quality in healthcare is
complex. Dr Foster Intelligence invests
heavily in the continuous improvement
of existing measures and in the search
for new indicators. Yet we also believe
that complexity is no excuse for inaction,
and the most valuable measures of quality
are often the most simple. Mortality
continues to be one of the most effective
ways of comparing clinical performance,
safety and quality.
Our ambition in the future is to be able
to include measures of quality that
incorporate the views of patients not only
on their experiences of care, but on the
outcomes of that care. In order for that to
happen, the healthcare community will
need to rise to the challenge of gathering
such data systematically and valuing
what it says to them.
In this chapter we provide national trends
and analyses in relation to the HSMRs,
as well as focusing on developments in
mortality and readmission rates for
orthopaedics. More detailed trust level
informationonmortalityratescanbefound
on pages 26 to 31.
National trends in mortality rates
Mortality rates continue to fall in the vast
majority of trusts. Looking at the trend in
HSMRs over the past five years, we found
that 95 per cent of trusts in England
have improved their performance. This is
reflected in the marked decline in the
national ‘crude’ rate (or the number of
observed events divided by the number
of admissions multiplied by 100).
It is also good to see that the variation
in mortality rates between trusts has
diminished.Thefunnelplotbelowillustrates
an overall positive (ie, downwards) shift in
hospitals’performance.The2005/06version
below shows that:
• More trusts are achieving better than
expected performance than in 2000/01
• There are fewer poor performing trusts
(36 this year compared to 44 in 2001/02,
using current trust configurations and
2005/06 risk model)
• If all trusts with higher than expected
mortality rates were to reduce these in
line with the expected rate, 7,400 deaths
would have been avoided in 2005/06
Overall mortality appears to be decreasing
in many more trusts than those that
have seen their mortality increase. This is
because, on average, HSMRs are falling
year on year.
Overview of hospital performance
We looked at how individual trusts were
improving over the last five years. Chelsea
andWestminsterHospitalNHSFoundation
Trust has reduced its HSMR by 35.8 per
cent.Chiefexecutive,HeatherLawrence,is
justifiablyproudofthetrust’sachievement,
but is clear that it is down to a number of
factors. She says: “In particular, we have
focused on and invested in initiatives to
improvethesafetyofpatients.Forexample,
we’ve introduced a robot in the hospital
pharmacy to increase the accuracy of
dispensing.We’vealsostronglyemphasised
reviews of clinical incidents and audit
of our performance to highlight areas for
improvement and learn from these.”
Hospital Guide 9What does a funnel plot show? See page 11 >>
Decreasing mortality rates in the NHS, 2000/01-2005/06 National crude rate
– England acute trusts Source: Hospital Episode Statistics 2001/02-2005/06
Financial YearCruderate
6.4%
6.6%
6.2%
6.0%
5.8%
5.6%
5.4%
5.2%
5.0%
2001/02 2002/03 2003/04 2004/05 2005/06
HSMRs for all acute NHS trusts in England
Adjusted relative risks (observed/expected) with 95% and 99.8% control limits
Source: Hospital Episode Statistics 2005/06
Expected events
RR=observed/expected
130
140
150
160
120
110
100
90
80
70
60
500 1000 1500 2000 2500 3000 3500 40000

Information about performance, such as
the HSMR, provides a baseline for
organisationslikeChelseaandWestminster
to track the impact of these initiatives.
As Lawrence says: “Good quality, detailed
information about our clinical services
provides the evidence that clinical leaders
need to engage doctors, nurses and other
clinicians in service improvement. It’s only
through working together that we can
identifysolutionsandimprovepatientcare.”
DartfordandGraveshamNHSTrusthasalso
demonstrated significant improvement –
its mortality rate has fallen by 25.4 per
cent. Mark Devlin, the chief executive,
takesacontinualapproachtoimprovement.
Hesays:“Performancereviewisanongoing
process for us. We are continually looking
atwhereimprovementscanbemade.This
meansallaspects ofcare: fromtheservices
thatwedelivertopatientsthroughtotheway
inwhichwecollectandrecordinformation.”
The trust has developed, embedded and
improved clinical governance within the
trust.AsDevlinsays:“Thesafetyofpatients
and quality of care is our highest priority.
Clinical governance and audit allow us to
ensurethatproperproceduresandinplace
andmonitored.Wealsohaverobustsystems
in place to identify potential areas of risk.”
Trusts that are improving less quickly
acknowledge the value of comparative
performance information, despite the fact
thatitcanbeanuncomfortableexperience.
Ed Neale, medical director at Bedford
Hospital NHS Trust, says: “How do we feel
about having data about our performance
published?Well,whenit’sgoodinformation
we’redelighted.Whenit’snotsogood,we’re
not so delighted. That’s human nature.”
Mortality rates at Bedford Hospital NHS
Trust have improved less than those at
other trusts over the last five years.
However, the trust’s mortality rate is still
within expected levels of performance.
The trust has put a lot of effort into
improving its clinical coding. As Neale
says: “We realised that our accuracy of
coding, for various reasons, was not as
good as it could or should be. As clinicians
we were concerned about the quality of
the data and the lack of information we
weregetting,ortheopportunitytoquestion
thedata.”Thetrusthassubsequentlymade
significantimprovementsinitsdataquality.
At West Hertfordshire Hospitals NHS
Trust medical director Professor Graham
Ramsayandhisteamareworkingtotackle
hospital associated infections. Professor
Ramsay says: “West Hertfordshire has had
a bad reputation for MRSA and C. difficile,
and I’m sure that’s one of the contributory
factors to the higher SMRs.” The trust is
trialling new methods of preventing
C. difficile, which, it is confident will help
to eradicate the infection completely.
Professor Ramsay is hoping to bring his
learning from working in the Netherlands
to West Hertfordshire.“You want care that
is easily accessible, but you want to know
when you come into hospital that you
won’t get worse. Patients deserve a clean
environment. In Holland and Scandinavia,
if an incidence of MRSA does crop up in a
hospital all staff on the ward and all other
patients are screened and the ward is
closed down until the results are known.”
Barts and the London NHS Trust faces
a particular challenge in that it has
sustained a comparatively low mortality
rate since 2001. Dr Charles Gutteridge,
the trust’s medical director, said: “Given
the existing low mortality rates at the trust
it is a challenge to sustain dramatic rates
of improvement year on year without a
significant step change in our safety
culture. It is for this reason, and because
we have such an excellent track record on
mortality rates, that the trust is one of the
first in the UK to participate in the Safer
Patients Initiative. The trust will be
working with the Health Foundation and
Measuring quality Scaling the peak of perfection
10 Hospital Guide
Most/least improving trusts over five years
Source: Hospital Episode Statistics 2001/02-2005/06
Financial year
Hospitalstandardisedmortalityratio
(2005benchmark)
180
160
140
120
100
80
60
40
2001/02 2002/03 2003/04 2004/05 2005/06
George Eliot Hospital
NHS Trust
South Tyneside NHS
Foundation Trust
Heatherwood and
Wrexham Park Hospitals
NHS Trust
Dartford and Gravesham
NHS Trust
West Hertfordshire
Hospitals NHS Trust
Bedford Hospital
NHS Trust
Improving performance
Most improving The following trusts
showed most change in their HSMR over
five years between 2001/02 and 2005/06
• Barnet and Chase Farm Hospitals
NHS Trust
•Chelsea and Westminster Healthcare
NHS Foundation Trust
•Dartford and Gravesham NHS Trust
•Heatherwood and Wexham Park
Hospitals NHS Trust
•TheRoyalBournemouth&Christchurch
Hospitals NHS Foundation Trust
Least improving The following trusts
showed least change in their HSMR over
five years between 2001/02 and 2005/06
•Barts and the London NHS Trust
•Bedford Hospital NHS Trust
•George Eliot Hospital NHS Trust
•Lancashire Teaching Hospitals NHS
Foundation Trust
•South Tyneside NHS Foundation Trust
•West Hertfordshire Hospitals NHS Trust
•Whipps Cross University Hospitals
NHS Trust
“How do we feel about having data about
ourperformancepublished?Well,whenit’s
good information we’re delighted. When
it’s not so good, we’re not so delighted.
That’s human nature.”
Dr Ed Neale, Medical Director, Bedford
Hospital NHS Trust

experts from the US-based Institute for
Healthcare Improvement to explore the
best ways of making hospitals safer for
patients. The aim is to reduce the number
of adverse events that happen to patients
by half and reduce mortality rates by 15
per cent, and to take our safety culture to
truly world-class levels.”
Delving beneath the overall mortality rate
in a trust illustrates both how performance
is improving and the extent of variation
that remains. We looked at a number of
quality measures for key procedures.
Spotlight on coronary artery bypass
graft (CABG)
CABGisahighvolumeprocedurethatcan
have a profound impact on the quality of
life for sufferers of heart disease. Each year,
over 20,000 people in the UK undergo a
CABG operation. Clinical outcomes are
generally very successful and average
mortalityratesare1.25percentforisolated
CABG according to our analyses.
However, since the Bristol Inquiry into
paediatric deaths from heart surgery in
2001, cardiothoracic surgery has been
under intense scrutiny. In response, the
cardiothoracic surgeons were the first
professional group to publish surgeon-
specific outcome measures last year.
We looked at three years of HES data
from 2003/04 to 2005/06 for those centres
providing isolated CABG operations,
analysing in hospital mortality, 30-day
mortality and 365-day mortality. Our data
showsthatthisyearalltrustsarewithinthe
expected levels of performance for the first
time since we have published this data.
Trusts have demonstrated year-on-year
improvement since we started measuring.
However, there is still a four-fold variation
in mortality rates between organisations.
Thereareanumberofpossibleexplanations
for the wide variation in results. The
most likely is that these are due to chance
fluctuations, as almost all the points are
within the 99.8 per cent control limits.
An explanation for apparent variations in
performance can be that the intake of
patients is different between hospitals in
terms of case-mix. However, analysis takes
account of age, sex, whether an admission
is elective or non-elective and the level of
socio-economic deprivation in the area in
which a patient lives. In addition, in order
to create a more level playing field, we have
deliberatelychosentoexcludeanycomplex
operations that might skew the results. In a
furtheranalysis,wehavetriedtocompensate
for other factors that might affect death
ratesandcontributetothewidevariationin
results we see and that we weren’t able to
measure(sometimescalled‘overdispersion’).
Theimpactofchangesincarepracticeson
outcomes is currently being studied by the
NationalConfidentialEnquiryintoPatient
Outcome and Death. It is investigating
“whetherthereareanyidentifiablechanges
in care processes, including the functioning
of cardiac teams, that impact on patient
outcome, following a first-time isolated
CABG.” Results of the three-year study are
due to be published next year.
Spotlightontraumaandorthopaedics
From our data we looked at a number of
key outcome measures for trauma and
orthopaedics.Welookedatoneemergency
procedure – fractured neck of femur, and
two high volume elective procedures – hip
and knee replacement.
Fractured neck of femur is a serious
consequence of falls in the elderly.
In 2005/06 over 68,000 patients were
operated on for a fractured neck of
femur. Many patients have complex
co-morbidities and mortality after a
fractureishigh(10percentwithinamonth;
20 per cent within four months and 30
per cent within a year).
We looked at in hospital mortality for
fractured neck of femur. Our analyses
were standardised for factors such as age
and sex. Nevertheless, six trusts were
above the upper 99.8 per cent control
limit suggesting that their performance
diverges significantly from the mean.
Recent guidance from the NHS Institute
for Innovation and Improvement focuses
on the care pathway for fractured neck of
femur. The Institute looked at the
characteristics of organisations providing
high-quality care and value for money.
These include an emphasis on putting
CABG in-hospital mortality Adjusted Relative Risks (observed/expected) with
95% and 99.8% control limits Source: Hospital Episode Statistics 2003/04-2005/06
Expected events
6040 503020100
0
300
400
350
250
200
150
100
50
100 = baseline risk
DATA EXPLAINED
Funnel plots
Funnel plots (or control charts) are a
graphical method used to assess
variation in data and are used to
compare different trusts over a single
timeperiod.Theseplots(HSMRfunnel
plots) show the position of each trust’s
HSMR. Control limits form a ‘funnel’
around the benchmark and reflect
the expected variation in the data.
Each chart has five lines:
• A centre line, drawn at the mean
(the national average, RR=100)
• An upper warning limit (upper 95
per cent control limit)
• An upper control-limit (drawn three
standard deviations above the
centre line – upper 99.8 per cent
control limit)
• A lower warning limit (lower 95 per
cent control limit)
• A lower control limit (drawn three
standard deviations below the
centre line – lower 99.8 per cent
control limit)
Data points falling within the control
limits are consistent with random or
chancevariationandaresaidtodisplay
‘common-cause variation’. For data
pointsfallingoutsidethecontrollimits,
chance is an unlikely explanation and
hence they are said to display ‘special-
cause variation’.
Hospital Guide 11How do individual trusts perform? See pages 28 – 31 >>

into place processes that maximise the
chance for an early operation and meet
the patient’s health and social care needs.
Patients with fractured neck of femur
must be operated on swiftly. There is
clear evidence that if patients with a
broken hip do not receive surgery
promptly, their chances of recovery are
greatly reduced. Analysis by the Dr
Foster Unit at Imperial College showed
that if death rates in patients for less
than one day’s delay in time to surgery
had been repeated throughout the 151
trusts studied, there would have been
an average of 581 fewer deaths for each
of the three years of data1.
In our Hospital Guide questionnaire
(see page 18) we asked all trusts in the
UK for the percentage of patients
admitted as an emergency with fractured
neck of femur, who were operated on
within 48 hours. On average, 77 per cent
of patients were operated on within
that time.
Eight trusts said that they operated on
less than 50 per cent of patients presenting
as emergencies within 48 hours. In
Measuring quality Scaling the peak of perfection
12 Hospital Guide
East
Midlands
Eastof
England
London
NorthWest
SouthEast
Coast
SouthWest
South
Central
West
Midlands
Yorkshireand
theHumber
Scotland
Wales
NorthEast
0%
80%
90%
70%
60%
50%
40%
30%
20%
10%
Fractured neck of femur in-hospital mortality Age and sex adjusted Relative
Risks (observed/expected) with 95% and 99.8% control limits Source: Hospital
Episode Statistics 2005/06
Expected events
12080 1006040200
0
150
200
175
125
100
75
50
25
225
250
Fractured neck of femur
operations within 48 hours
Least – Trusts operating on less than
50 per cent of patients admitted with
fractured neck of femur within 48 hours
• Blackpool, Fylde & Wyre Hospitals NHS
Trust
• Mayday Healthcare NHS Trust
• Plymouth Hospitals NHS Trust
• Sandwell&WestBirminghamHospitals
NHS Trust
• SouthDevonHealthcareNHSFoundation
Trust
• Stockport NHS Foundation Trust
• UniversityHospitalsofLeicesterNHSTrust
• WorcestershireAcuteHospitalsNHSTrust
Most – Trusts operating on 100 per cent
of patients admitted with fractured neck
of femur within 48 hours
• Aintree University Hospitals NHS
Foundation Trust
• Barking, Havering &RedbridgeHospitals
NHS Trust
• BarnsleyHospitalNHSFoundationTrust
• Barts and The London NHS Trust
• Bromley Hospitals NHS Trust
• Dartford and Gravesham NHS Trust
• Dumfries and Galloway NHS Board
• Maidstone&TunbridgeWellsNHSTrust
• North Bristol NHS Trust
• NorthernLincolnshire&GooleHospitals
NHS Trust
• TheQueenElizabethHospitalKing’sLynn
NHS Trust
Percentage of patients admitted with fractured neck of femur who received
an operation to repair within 48 hours
Source: Hospital Guide questionnaire 2005/06
NB: Insufficient data available for Northern Ireland
In-hospital mortality for
fractured neck of femur
Highest – the following trusts lie outside
expected levels of performance for fractured
neck of femur
•Basildon & Thurrock University Hospitals
•Chesterfield Royal Hospital NHS
Foundation Trust
•Good Hope Hospital NHS Trust
•Heart of England NHS Foundation Trust
•NorthamptonGeneralHospitalNHSTrust
•UniversityHospitalsof LeicesterNHSTrust

comparison, 11 trusts operated on 100 per
cent of patients within that time.
All six trusts outlying on mortality for
fractured neck of femur, fell below the
averageforpercentageofpatientsoperated
on within 48 hours. Their performance
ranged from 68.4 per cent at Basildon
and Thurrock University Hospitals NHS
Foundation Trust, to 40.2 per cent at the
UniversityHospitalsofLeicesterNHSTrust.
Elective orthopaedic procedures, such as
hip replacement, can cause significant
improvements in quality of life. In the past,
capacity of orthopaedic services has been
a key issue for the NHS; waiting times for
the specialty were longer than others (see
page 14). The introduction of increased
capacity via the independent sector and
initiatives focusing on improving quality
and efficiency have delivered impressive
reductions. However, despite this focus on
improving care, there remain variations in
quality and efficiency.
One key indicator of quality of the care
processistherateofemergencyreadmission.
We looked at emergency readmissions for
both hip and knee replacement. High rates
ofreadmissionsfortheseoperationscanbe
a sign of, for example, inappropriate
discharge processes or inadequate support
after leaving hospital.
No trusts are above the expected level
of emergency readmissions for hip
replacement (see graph below). But
significant variations in performance
remain and should be explored by
individual organisations.
Some commentators have suggested that
there are higher levels of readmissions at
independent sector treatment centres.
However, we do not currently have data of
sufficient quality to test this hypothesis.
Conclusions
Mortality and readmissions are good
indicators of the outcome of the care
process. From our analyses over the last
five years, it is clear that outcomes are
improving. Ninety-five per cent of trusts in
England have reduced their mortality rates
over the past five years. More trusts have
mortality rates that fall within the range
expected, and fewer trusts are performing
poorly in relation to others. On key
procedures more trusts are within expected
levels of performance.
But there continue to be variations in the
quality of care. Trusts need to explore their
own performance, in comparison with
that of their peers, in order to highlight
areas for improvement and deliver better
patient care.
“It’sinallofourintereststhatweensurethat
healthandsocialservicesareresponsiveto
theneedsofolderpeople.Fracturedneckof
femurisakeychallenge:itisacommonresult
of falls, accounts for a significant number
ofbeddaysandrequiresclosecrossagency
working.Reducingtimetosurgeryimproves
outcomesdramatically,andallorganisations
should be operating on patients within 24
hours in line with established standards.”
Professor Ian Philp, National Clinical
Director for Older People
Is orthopaedics on track to meet the 18-week target? See page 14 >>
Emergency readmissions for hip replacement
Financial Year 2005/06 with 95% and 99.8% control limits
Expected events
80 9050 60 704020 30100
0
120
160
140
100
80
60
40
20
180
200
220
DATA EXPLAINED
The Hospital Standardised
Mortality Ratio (HSMR)
The Hospital Standardised Mortality
Ratio (HSMR) is an internationally
recognised measurement of mortality.
The HSMR is case-mix adjusted and
covers 56 diagnosis groups that
account for 80 per cent of all deaths
(there are 258 diagnosis groups in
total). All in-hospital deaths that relate
to one of the above diagnosis groups
are included to calculate a hospital’s
HSMR. It is expressed as a relative risk,
whereariskratingof100representsthe
national average. This is calculated by
dividingtheactualnumberofdeathsby
the expected number and multiplying
the figure by 100.
Healthcare systems in the US, Canada,
Netherlands, Sweden and New South
Wales,Australia,routinelyuseHSMRs
to inform their quality management
and improvement programmes. The
use of HSMRs calculated from routine
datasetsrapidlytookholdinthiscountry
following the Bristol Royal Infirmary
Inquiry into paediatric cardiac surgery
in 2001. One of Professor Sir Ian
Kennedy’s conclusions was: “Bristol
was awash with data. There was
enoughinformationfromthelate1980s
onwards to cause questions about
mortality rates to be raised both in
Bristolandelsewhere,hadthemindset
to do so existed. Little, if any, of this
informationwasavailabletotheparents
or to the public. Such information as
was given to parents was often partial,
confusing and unclear. For the future,
there must be openness about clinical
performance. Patients should be able
to gainaccess to informationaboutthe
relative performance of a hospital, or
aparticularserviceorconsultantunit.”
“Delayed operation after hip fracture was
associated with an increased risk of death
in hospital, which was reduced but still
persisted we adjusted for comorbidity.
There was large variation between trusts
in operative delay. Hospital episode
statistics could be used for monitoring
purposes, with outlying trusts becoming
the focus of further investigation to assess
why operative delay, mortality in hospital,
or readmission rates are increased.”
Dr Alex Bottle and Dr Paul Aylin,
Mortalityassociatedwithdelayinoperation
after hip frature: operational study,
BMJ 22 March 2006
Hospital Guide 13

14 Hospital Guide
Waiting and access to services has long
been an issue of public concern. The
government has sought to address the
issue through a series of targets. Previous
targets have focused on particular
components of the patient’s journey
through the healthcare system, such as
Accident and Emergency and outpatients
and inpatients appointments.
The NHS is now under pressure to meet
the 18-week target from GP referral to
treatment. This target will come into force
from the end of 2008, and the average
waiting time is expected to be just seven
weeks. Trusts are now collecting data for
waiting times for referral to treatment and
15 key diagnostic tests.
At present, the government monitors
waiting times through waiting lists; the
proportion of people being seen within a
given time. According to existing targets,
inpatients should be seen within six
months and outpatients within 13 weeks.
The Department of Health’s latest figures
showthat76percentof inpatientsareseen
within that 13 weeks and that 85 per cent
ofGPreferralsforfirstconsultantoutpatient
appointments are within eight weeks1.
An alternative approach is to estimate
how long people are actually waiting for
procedures, using routinely collected
administrative data, taking into account
both outpatient and inpatient waits.
Waiting times are improving
Our analysis shows that over the past six
years, hospitals in England have made
significant progress in reducing waiting
times for patients. In 2001/02, the average
waiting time for a hip replacement was
nearly 250 days, or 30 weeks. This figure
startedtofallin 2004andisnowjustunder
150 working days. The average waiting
times for both cataract repair and CABG
were nearly 200 days in 2001. They have
both now fallen to around 70 days.
However, for all three procedures,
improvement seems to have levelled out
in the past year. Further reductions will
be needed in order to meet the 18-week
target, particularly in orthopaedics.
The 18-week initiative is prioritising
orthopaedics and recognises that currently
only one in five patients are treated within
18 weeks, less than any other specialty.
A baseline exercise carried out by the
Department of Health found that 35 per
cent of admitted patients were seen
within 18 weeks2.
How well prepared is the NHS
for the 18-week referral-to-
treatment target which comes
into force next year?
Feature Is waiting still an issue?
DATA COVERAGE:
England/Wales/Scotland/
Northern Ireland
Waiting times for NHS trusts in England, 2001 – 2006
Averagewaitingtimes(days)
Q1
Q2
Q3
Q1
Q3
Q4
Q2
Q1
Q2
Q4
Q3
Q1
Q2
Q4
0
250
300
200
150
100
50
Q4
Q1
Q3
Q2
Q3
Q1
Q4
Q2
Averagewaitingtime(days)
2001/02 2002/03 2003/04 2004/05 2005/06 2006/07
CABG (isolated first time)Cataract repairHip replacement
Photography: Getty

Hospital Guide 15
Diagnostics: the ‘hidden wait’
The timely provision of diagnostic services
is instrumental to the delivery of the 18-
week target. To this end, the Department
of Health set an interim target that by
March this year, all diagnostics should be
provided in less than 13 weeks.
Waiting times data for diagnostic tests has
recentlybeenpublishedbytheDepartment
of Health as part of the18-week initiative.
This data shows that 92 per cent of MRI
scans and 97 per cent of CT scans are
carried out within 13 weeks3. We asked
all trusts for data on the average number
of working days patients waited for
Magnetic Resonance Imaging (MRI) and
Computerised Tomography (CT) in the
financial year 2005/06. The good news is
that in comparison to the same collection
lastyear,waitingtimesfordiagnosticshave
improvedenormouslyinalmostallregions.
The average wait for an MRI scan is now
64 working days, almost a 50 per cent
improvement on the previous year.
Hospitals in the West Midlands have
demonstratedthemostdramaticreduction
in MRI waiting times. In particular,
Shrewsbury and Telford Trust went from
735 days in 2004/05 to 68 days in 2006.
TrishRowson,deputychief executiveof the
Princess Royal Hospital, within Shrewsbury
and Telford Trust, said:“The single biggest
factor in reducing waiting times for MRI
scans for our patients has been the
introduction of a second scanner early last
year.” But the dramatic progress the trust
has made is not just a matter of increased
capacity.“We’vehadtoensurewemakebest
useofthatadditionalcapacity,whichwe’ve
donebyincreasingproductivityalongwith
robust waiting list management. So much
so that we are now in a position to meet
the new 13-week target for MRI scans.”
National variations
Despite the progress that many
organisations have made, there are still
significant variations in waiting times.
Depending on where patients live, they
may need to wait longer. Patients in
Wales can expect to wait 100 days for an
MRI scan where as those in the North
East can expect to wait only 47 days.
Similarly, patients are waiting just three
days at University College London to
receive a CT scan but 141 days at Norfolk
and Norwich University Hospital NHS
Trust. The Department of Health has
estimated that diagnostics need to be
provided,onaverage,inthreetofourweeks
in order to meet the 18-week target. Only
three regions(London, the North East and
Yorkshire and Humber) are meeting this
targetforCT.For thefinancialyear2005/06,
60 trusts were above the 13-week wait for
MRIand30trustswereexceeding18weeks
of waiting for an MRI scan alone.
Commenting on our survey results,
Professor Janet Husband, president of
the Royal College of Radiologists, said:
“Imposing an 18-week target for the
delivery of the entire patient pathway is a
powerful tool for tackling waiting lists.
This target has placed a spotlight on the
bottlenecks in the system, particularly
on the hidden waits created by delays in
providing CT and MRI. The patient’s
pathwayhasspeededupconsiderablysince
lastyearandNHSstaffhavedoneextremely
well in reducing waiting times for the 12
million diagnostic tests carried out each
week. However, in some areas there are
stilllengthydelays.Atthisrate,sometrusts
will struggle to meet the 18-week target.
The onus is now on professionals and
managerstoputthebestpracticeinplace.”
Waiting times for non urgent MRI scan
Source: Hospital Guide questionnaire 2002/03 – 2005/06
Days
0
160
180
140
120
100
80
60
40
20
2002-2003 2003-2004 2004-2005 2005-2006
EnglandWalesScotland
CT waiting times
Longest WaitingtimesforaroutineCTscan
are over 120 days at the following trusts:
•George Eliot Hospital NHS Trust
•Mater Infirmorum Hospital HSS Trust
•Norfolk & Norwich University Hospital
NHS Trust
•Royal United Hospital Bath NHS Trust
•UlsterCommunity&HospitalsHSSTrust
ShortestWaitingtimesforaroutineCTscan
are under five days at the following trusts:
•Airedale NHS Trust
•Frimley Park Hospital NHS Foundation
Trust
•MoorfieldsEyeHospitalNHSFoundation
Trust
•Royal Brompton & Harefield NHS Trust
•The Lewisham Hospital NHS Trust
•University College London Hospitals
MRI waiting times
Longest Waiting times for a routine MRI
scan are over 170 days at the following
trusts or boards:
•Barking,Havering&RedbridgeHospitals
NHS Trust
•Cardiff and Vale NHS Trust
•Carmarthenshire NHS Trust
•Fife NHS Board
•Royal National Orthopaedic Hospital
NHS Trust
•Royal United Hospital Bath NHS Trust
Shortest Waiting times for a routine
MRI scan are under ten days at the
following trusts:
•Hinchingbrooke Health Care NHS Trust
•The Queen Victoria Hospital NHS
Foundation Trust
•TheRobertJonesandAgnesHuntOrtho-
paedic and District Hospital NHS Trust
•South Warwickshire General Hospitals
NHS Trust
•The Royal Marsden Hospital NHS
Foundation Trust
DATA EXPLAINED
Deriving waiting times
from HES data
Average waiting times were calculated
from HES data for three high volume
procedures: hip replacement, heart
bypass and cataract repair. Waiting
timeisderivedbythedifferenceindays
between the date on which it was
decidedtoadmitthepatient(elecdate)
and the actual admission date
(admidate).Thewaitingtimeiscounted
by weekdays and is for inpatients. We
have made certain assumptions in
these calculations, but it is the best
available measure of waiting from
referral to treatment.
Are trusts meeting clinical guidelines? See pages 18 – 23 >>

Raising the standard Measuring patient safety
16 Hospital Guide
As waiting times become less of a public
issue and as media interest in infection
and MRSA shows, there is an increasing
appetite for assurance that hospital care
is delivered safely. However, the NHS
currently lacks measures of patient safety
that allow national and local comparisons
and that are meaningful to clinicians and
patients alike. At Dr Foster Intelligence,
we challenge ourselves to improve the
qualityofinformationavailabletoclinicians
and managers in the NHS, and to push
the boundaries in terms of the methods
of performance measurement.
Working with our partners in the Dr Foster
UnitatImperialCollegeLondon,wehavefor
thefirsttimeeverundertakenananalysisof
the performance of acute trusts in England
against a set of patient safety indicators,
basedonthoseoriginallycreatedbyAgency
for Healthcare Research and Quality and
widelyusedintheUS.Theindicatorsfocus
on potentially preventable complications
and iatrogenic events. These events are
likely to be indicative of failure at system or
provider level, and therefore amenable to
prevention by organisations – from
implementing technological changes such
as electronic medical record systems, to
improvingstaffawarenessof riskstopatient
safety.AHRQcarriedoutanextensivereview
of the literature, before testing shortlisted
indicators with expert panels, including
clinicians and information professionals.
WehaveanalysednineoutoftheAHRQ’sfull
set of 20 and we have collaborated with the
Healthcare Commission in translating the
codes for each indicator. Individual trusts
havebeenprovidedwithdatashowingtheir
results against the national picture.
An advantage of these indicators is that
they are designed to be constructed from
routinely collected data and therefore to
allowcomparison.Yetthisadvantageisput
in doubt by concerns over the quality of
coding of secondary diagnoses within
the Hospital Episode Statistics1
. These
concerns suggest that it is not possible to
make a valid comparison between the
results for individual trusts – a hospital
which appears to be‘less safe’, may in fact
be better at recording information about
potential incidents.
On the advice of the Dr Foster Unit at
Imperial College, London we have stopped
short of publishing the full comparative
analysisatthisstage.Wehavecommissioned
a review of the quality of secondary coding
and are working with trusts to explore
whetherandhowtotakethisissueforward.
However, we are able to share the results of
the analysis completed at national level
(see table, right).
The results for decubitus ulcer or bed
sores are shown in the funnel plot and
table to the right. The data indicate that
the crude rate for contracting bed sores in
hospital varies between trusts from zero
to just over 3 per cent. Rates appear to be
above the expected level in 36 trusts. For
death in low mortality HRGs (see funnel
plot), there is less variation between
organisations in terms of their crude rate.
One potential explanation is that death is
well coded in comparison to secondary
events or conditions such as bed sores.
The question remains whether these
variationsareduetovariationsinrecording
practices within organisations or whether
theyareanaccuratereflectionofvariations
in the safety of hospital care.
In the US, healthcare providers are using
the indicators to monitor the indicators
overtime.Theyareabletobenchmarktheir
performance against comparator groups
and set thresholds. Some hospitals, for
example, are adopting an approach where
they view all adverse incidents as
preventable and therefore measure any
deviations fromzero.TheAHRQindicators
act as a prompt for hospitals to investigate
their own data as the Agency itself states:
“Although quality assessments based on
administrative data cannot be definitive,
they can be used to flag potential quality
problems and success stories, which can
then be further investigated and studied.”
Defining and measuring safe
healthcare is one of the key
challenges for professionals
Photography: Getty
DATA COVERAGE:
NHS England

Professor Charles Vincent, professor of
clinical safety research, and a leading
expert in patient safety is clear that more
systematic measurement of known
problems is needed. Not least, so that
safety improvement programs can be
evaluated. As Professor Vincent says:
“If routine monitoring is developed,
patient safety initiatives could be more
proactive, with adverse events and patient
outcomes monitored in near real time.
Organisations must move towards active
measurement and an improvement
programme on a scale commensurate with
the human and economic costs of unsafe,
poor quality care.”
We believe that pressure will continue to
mounttodevelopandpublishmeaningful
comparisonsofpatientsafetyperformance.
Commissioners will increasingly want to
buildqualitytermsintotheircontracts,and
the public will demand reassurance. This
is undoubtedly the start of a bigger debate.
Decubitus ulcer Age and sex adjusted RRs (observed/expected) with 95%
and 99.8% control limits Source: Hospital Episode Statistics 2005/06
Expected events
250200150100500
0
300
400
350
250
200
150
100
50
Deaths in low mortality HRGs Relative risks (observed/expected) with 95%
and 99.8% control limits Source: Hospital Episode Statistics 2005/06
Expected events
0
2,500
2,000
1,500
1,000
500
302520151050 35
100 = baseline risk
Hospital Guide 17
Death in low-mortality HRGs
Decubitus Ulcer
Foreign body left during procedure
Selected infections due to medical care
Post-operative hip fracture
Post-operative sepsis
Obstetric trauma – vaginal delivery with instrument
Obstetric trauma – vaginal delivery without instrument
Obstetric trauma – Caesarean section
0.39 0 7.29 0 2,625 4 5
8.16 0 30.79 0 384 58 36
0.04 0 0.47 0 343 37 1
0.90 0 6.90 0 612 49 18
0.04 0 5.40 0 15,219 93 1
4.22 0 15.45 0 371 26 5
60.52 14.81 144.16 24 236 15 8
29.73 6.95 187.41 24 633 49 28
2.90 0 30.87 0 1,096 33 1
National crude rate
per 1,000
PATIENT SAFETY INDICATOR
Crude rate
per 1,000
Relative risk Number of
outlier trusts
Low High Low High Low High
DATA EXPLAINED
AHRQ’s 20 patient safety indicators
1. Complications of anaesthesia
2. Death in low mortality DRGs*
3. Decubitus ulcer*
4. Failure to rescue
5. Foreign body left in during procedure*
6. Iatrogenic pneumothorax
7. Selectedinfectionsduetomedicalcare*
8. Postoperative hip fracture*
9. Postoperativehaemorrhage/haematoma
10.Postoperativephysiologicandmetabolic
derangements
11. Postoperative respiratory failure
12.Postoperative pulmonary embolism
or deep vein thrombosis
13.Postoperative sepsis*
14.Postoperative wound dehiscence
15.Accidental puncture or lacerative
16.Transfusion reaction
17. Birth trauma – injury to neonate
18.Obstetric trauma – vaginal with
instrument*
19.Obstetric trauma – vaginal without
instrument*
20.Obstetrictrauma–Caesareandelivery*
*
Indicators analysed for English acute trusts by
the Dr Foster Unit at Imperial College, London
How do individual trusts perform? See pages 28 – 31 >>

Our analyses are based on data from
the Hospital Guide questionnaire. The
survey is unique in that it is impartial
and universal in its coverage, both across
the UK and in both the NHS and the
independent sector. A comprehensive
set of the results of the survey is available
at www.drfoster.co.uk – a searchable
database used by patients to make
informed choices about their specialist
providers, linked to information about
individual consultants.
Results of our research indicate that
recommendedservicesarenotuniversally
available and that there are some stark
geographical inequities of provision.
Spotlight on stroke
Stroke is the third biggest cause of
death in the UK and the largest single
cause of severe disability. Each year
more than 110,000 people in England
will suffer from a stroke1. Consequently,
one of the standards of the National
Service Framework for Older People
aims to reduce the incidence of stroke in
people, and ensure that sufferers have
prompt access to integrated stroke care
services2. In addition, the Government is
focusing resources on the modernisation
of stroke service provision. In partnership
with health professionals, voluntary
organisations and stroke survivors, the
Department of Health is developing a
National Stroke Strategy that will focus
on a range of issues including hospital
care, emergency response, workforce
and post-hospital care.
Upon hospital admission for stroke,
patients should be scanned as soon as
possible in order to determine the best
course of treatment. On average, 64 per
cent of stroke patients in England are
administered CT scans within 24 hours
of admission. This rises to an average of
70 per cent in Wales, 71 per cent in
Scotland and 73 per cent in Northern
Ireland. However, regional disparity in
this area is high: in a number of trusts
100 per cent of patients are scanned on
admission (for example, Barnet and
Chase Farm Hospitals NHS Trust, Guy’s
and St Thomas’ NHS Foundation Trust
and West Middlesex University Hospital
NHS Trust). In comparison, other trusts
scan as few as 10 per cent of patients
admitted as an emergency with a stroke
(such as Hereford Hospitals NHS Trust
Within each clinical specialty there are hundreds of guidelines, produced by bodies including
the Department of Health, the National Institute for Health and Clinical Excellence,
Royal Colleges and professional societies. We have chosen to focus on a number of key areas:
two important conditions (stroke and prostate cancer), and uptake of NICE guidance on new
technologies and drugs, and developments in clinical practice
Practice makes perfect
DATA EXPLAINED
Hospital Guide questionnaire
The questionnaire was developed in
consultation with clinical experts,
patients groups and NHS Trusts. The
final version was approved by the
Department of Health’s Review of
Central Returns (ROCR) process,
which ensures central collections of
information minimises the burden
on the NHS of submitting data.
The questionnaire was sent to every
acute NHS Trust, NHS Board and
private hospital in the UK along with
selected specialist trusts whose
services were covered by the
questionnaire.Thesurveywastailored
where policy differs in England,
Scotland, Wales or Northern Ireland.
The questionnaire consisted of a set
of questions covering core services
and key issues, including diagnostics,
generalservicesandinfectioncontrol.
Respondents then selected questions
abouttheservicesrelevanttotheirtrust
(for example, paediatrics, urology,
ophthalmology).
The period covered the financial year
of April 2005-March 2006. Census
questions asked for a response as at
1st September 2006.
95 per cent of NHS acute trusts and
boardsrespondedtothequestionnaire.
The response rate for the UK private
sector was 94 per cent.
Thedatawereceivedfromrespondents
was returned to them in spreadsheet
form and they were asked to validate
the information we had. All trusts
submitting data validated their return
byemail.Validateddatawerereviewed
by in-house data analysts and an
external validator. Questionable or
outlying data were returned to trusts
for confirmation. Our final analyses
and methodology was approved by an
external quality assurance statistician.
Stroke patients receiving CT Scan within 24 hours of admission
Source: Hospital Guide Questionnaire, 2004/05-2005/06
%ofadmittedpatients
East
Midlands
Eastof
England
London
NorthWest
SouthEast
SouthWest
South
Central
West
Midlands
Yorkshireand
theHumber
Northern
Ireland
Scotland
Wales
NorthEast
0%
80%
70%
60%
50%
40%
30%
20%
10%
2004-2005
2005-2006
18 Hospital Guide
DATA COVERAGE:
England/Wales/Scotland/
Northern Ireland

and Doncaster and Bassetlaw Hospitals
NHS Foundation Trust).
Comparisons with data collected in 2005
suggest that most hospitals are increasing
the proportion of admitted patients
receiving a scan. Notably, however, three
regions have reduced the proportion of
patients receiving early diagnosis (North
East, South West and Yorkshire and
the Humber).
The evidence is clear that outcomes for
stroke patients are better when they are
cared for by specialist stroke teams
within specialist stroke units. Compared
to patients that stay on in a general ward,
such patients are more likely to survive,
to have fewer complications, to return
home and regain independence. One
hundred per cent of acute trusts (not
including specialist trusts) now report
that they have a unit with beds dedicated
to stroke patients. In most of these units,
the staff have specialist training in the
care of stroke patients. However, because
this figure was measured at trust level, it
may be possible that some smaller
hospitals do not provide this facility. In
these cases, transfer arrangements to
larger units are crucial.
The Royal College of Physicians’ Stroke
Guidelines recommend that stroke
services should be organised so that
patients are admitted under the care
of a specialist team for their acute care
and rehabilitation.3 Trusts were asked
whether they employed stroke specialist
nurses or consultant nurses with
specialist knowledge of stroke. There was
a notable difference in provision. In the
North East, 88 per cent of trusts reported
that they employed a stroke specialist
nurse, but this figure dropped to 38 per
cent in Yorkshire and the Humber. In
three English regions all trusts reported
that they did not employ a consultant
nurse with specialist knowledge of stroke.
The transfer from hospital to the
intermediate or community services is
an important watershed for patients. Our
data suggests that there is a wide
variation in the management of stroke
patients. On average, 65 per cent of trusts
in the UK jointly manage the care of
stroke patients with community health
services and social services as an
integrated service. This ranges from 25
per cent in the East Midlands to 92 per
cent on the South East Coast. As a direct
result of the integration of Health and
Social Services, Northern Ireland reports
that 100 per cent of patients receive
a joined-up service because of the
structural integration with health and
social services.
While trusts have made significant
progress, for example in the provision of
specialist stroke units, there is still some
way to go in terms of early scanning for
patients admitted as an emergency and
in the provision of appropriate levels of
staffing and support. As Dr Anthony
Rudd, consultant stroke physician, Guy’s
and St Thomas’ NHS Foundation Trust
says: “No patient admitted for stroke
should miss out on potentially life-
changing rapid diagnostics. All stroke
patients should receive the best care
from specialty doctors and nurses in
dedicated acute stroke beds. It is clear
that patients’ transfer to the community
Hospital Guide 19How long are waiting times for diagnostic tests? See pages 14 – 15 >>
Joint management of the care of stroke patients with community health
services and social services as an integrated service
Source: Hospital Guide Questionnaire, 2005/06
%oftrusts
East
Midlands
Eastof
England
London
NorthWest
SouthEast
Coast
SouthWest
South
Central
West
Midlands
Yorkshireand
theHumber
Northern
Ireland
Scotland
Wales
NorthEast
0%
80%
90%
100%
70%
60%
50%
40%
30%
20%
10%
Provision of specialist staff
%oftrusts
East
Midlands
Eastof
England
London
NorthWest
SouthEast
Coast
SouthWest
South
Central
West
Midlands
Yorkshireand
theHumber
Scotland
Wales
NorthEast
0%
80%
100%
60%
40%
20%
% of trusts with a
consultant nurse with
specialist knowledge
of stroke
% of trusts with a
stroke specialist nurse
StrokeHS Trust
The following trusts CT scan 100 per cent
of patients admitted as an emergency
with a stroke, have a stroke specialist
nurse and jointly manage care with
social services
•Barnet and Chase Farm Hospitals
NHS Trust
•Guy’sandStThomas’NHSFoundation
Trust
•Stockport NHS Foundation Trust
•University College London Hospitals
NHS Foundation
•West Middlesex University Hospital
NHS Trust

can still be managed better. What better
way to integrate health and social care
than around the needs of stroke sufferers?
Despite the improvements in stroke
services in the past few years, there is still
much more to be done.”
Spotlight on urological cancer
Prostate cancer has overtaken lung
cancer as the most common cancer
diagnosed in men. Each year, nearly
32,000 men are diagnosed with the
disease and 10,000 men die from it.4
The rapid provision of diagnostic
services is vital in order to commence
the appropriate treatment as soon as
possible. Most patients with cancer of
the bladder or kidney have visible blood
in the urine known as haematuria.NICE
guidelines on the treatment of urological
cancers states that diagnostic services
should be organised so that they carry
out sufficient tests to determine whether
cancer is present during a single visit.5
We asked trusts whether they hosted a
specialist haematuria clinic that can
provide on-site access to upper tract
imaging and cytoscopy on their first visit.
The results suggest that there is a high
regional variation in the provision of
such clinics. Fewer than 80 per cent of
trusts in Scotland, Northern Ireland and
Midlands provide this service. Provision
ranges from 17 per cent of patients in
Northern Ireland to 94 per cent in the
East of England.
Prostate biopsy – the removal of a sample
of tissue to assist the identification of
disease – is another important diagnostic
stage.Themajorityoftrustsareabletooffer
an appointment for transrectal ultrasound
and prostate biopsy in three weeks.
The most appropriate treatment options
for early localised prostate cancer depend
on the stage of the cancer. Current
treatments include active surveillance,
radical prostatectomy, external beam
radiotherapy or brachytherapy. Few
trusts offer all modalities of treatment
because of the volumes needed to
maintain specialist teams. As the NICE
guidance on Improving Outcomes
in Urological Cancers notes,6 there are
still uncertainties about the best form
of management for patients with early
prostate cancer.
Surveillance is only of benefit to certain
patients. Those who show signs of
progression will go on to receive surgery
or radiotherapy. The remainder will
continue under observation and may
never need intervention. This treatment
option is therefore an important first step
for patients. However, our data suggest
that the number of trusts recording
surveillance as a primary treatment is
variable, ranging from 13 per cent of
trusts in South Central and the East
Midlands to 24 per cent in the North East.
Comparable figures are not available for
the private sector because so few
hospitals returned data on this question.
Radical prostatectomy is an operation
that removes the prostate and some or all
of the seminal vesicals. NICE guidance
recommends that clinical teams should
carry out more than 50 cystectomies
and radical prostatectomies per year.7
However, of the 117 trusts reporting that
they perform radical prostatectomy, 24
per cent reported doing 30 procedures or
more and only nine per cent did more
than 50 procedures per year.
Radical external beam radiotherapy is a
treatment that focuses high energy
radiation on the prostate and seminal
vesicals. Brachytherapy is a subset of
Following clinical guidelines Practice makes perfect
20 Hospital Guide
Waiting times for transrectal ultrasound and prostate biopsy
Average waiting times
NHStrusts/boards
0
60
50
40
30
20
10
< 1 week 3-4 weeks2-3 weeks > a month1-2 weeks
Access to treatment options for early localised prostate cancer
%oftrusts
East
Midlands
Eastof
England
London
NorthWest
SouthEast
Coast
SouthWest
South
Central
West
Midlands
Yorkshireand
theHumber
Scotland
Wales
NorthEast
0%
25%
20%
15%
10%
5%
Surveillance
Radical
prostatectomy
Brachytherapy
Insufficient data available for Northern Ireland

radiotherapy whereby radioactive seeds
are inserted into the prostate. As the
Department of Health notes, the role of
brachytherapy will increase as more
prostate cancer is identified through
early diagnosis.8 This treatment will be
particularly attractive to patients as it
avoids major surgery and is thought to
have fewer side-effects than other
treatments. Accordingly, the Prostate
Cancer Advisory Group, a panel
representing health professionals,
prostate cancer charities, researchers and
the Department of Health, recommends
that each cancer network has procedures
in place to refer appropriate patients with
localised prostate cancer to facilities
offering brachytherapy either within or
outside their network.9 However, our data
shows that there is high regional variation
of brachytherapy provision. Fewer than
one per cent of trusts in the North West,
West Midlands and Wales offer
brachytherapy, compared with almost
seven per cent on the South East Coast.
As the recommendations outlined in
the Improving Outcomes in Urological
Cancers guidance are implemented,
fewer trusts are equipped to offer
comprehensive services for patients with
prostate.10 Consultant urologist at
Hammersmith Hospitals NHS Trust and
clinical lead for Service Improvement at
the West London Career Network, Simon
St Clair Carter, says: “These figures show
that centres treating larger number of
patients are becoming apparent because
of the increasing specialisation of care.
There still remain many areas of
uncertainty about the optimum form of
treatment for patients with urological
cancer. It remains to be seen whether
this initiative will improve outcomes in
the long term.”
Spotlight on NICE guidance
The monitoring of implementation
of NICE guidance is not systematic.
Compliancewithguidanceisarequirement
of the National Core Standards, but not
routinely monitored by the regulator, the
Healthcare Commission. Various surveys
show that implementation of NICE’s
clinical guidelines happens more quickly
in some places than others.11
NICE produces guidance on health
technologies and clinical practices for
the NHS in England and Wales, and on
interventional practice for England,
Wales and Scotland. We asked trusts in
England, Scotland and Wales whether
they were compliant with guidance in
three key areas: in the use of drug eluting
stents in cardiology, in hip replacements
in orthopaedics (excluding Scotland),
and in the prescribing of beta-interferon
for patients with multiple sclerosis.
1. Cardiology: drug eluting stents
Every year more than 300,000 people
suffer an acute myocardial infarction
(AMI), and coronary heart disease (CHD)
is the biggest cause of mortality.12 A wide
range of initiatives exist to improve the
prevention, diagnosis, treatment and
rehabilitation of heart disease.
AMIs and angina pains are caused by
impaired blood supply to the heart.
Patientd may be treated by receiving
percutaneous coronary intervention
(PCI).This is a technique for opening the
arteries by inserting a balloon into the
blocked artery on the end of a catheter.
A stent is left in place to provide a stiff
support that allows blood to flow more
easily. However, a significant limitation
of the technique has been the problem of
‘restenosis’. This is where over-exuberant
cell re-growth can itself re-narrow
the vessel.
Drug eluting stents (stents that elute an
antiproliferative drug into the arterial
wall for some days or weeks after
implantation) have been extremely
successful at preventing restenosis and
have greatly reduced the need for patients
to have repeat angioplasty procedures.
NICE has therefore recommended that
drug eluting stents should be used
routinely where PCI is the clinically
appropriate procedure for patients with
either stable or unstable angina, or with
acute myocardial infarction.13
We asked trusts whether they followed
NICE guidelines on the use of drug
eluting stents. On average, 54 per cent of
trusts reported that they did. Regional
variation is still considerable: only 24 per
cent of hospitals in the North West are
likely to adhere to the NICE guidelines
about the use of drug eluting stents as
opposed to 75 per cent in South Central.
Compliance with this measure remains
high in the private sector. Of the 17 private
hospitals that carried out angioplasty
last year, 82 per cent reported following
NICE guidance on the use of drug
eluting stents.
However, there has been recent concern
that these benefits may come at the price
of a later rare complication – sudden
thrombotic occlusion of the stent, known
Adherence to NICE guidance on drug eluting stents
%oftrustsobservingNICEguidance
East
Midlands
Eastof
England
London
NorthWest
SouthEast
Coast
SouthWest
South
Central
West
Midlands
Yorkshireand
theHumber
Private
Sector
Wales
NorthEast
0%
80%
100%
60%
40%
20%
“As the patient choice agenda continues
to strengthen across the NHS, it is vital
that patients and the public have as much
information about healthcare providers
as possible in order to make informed
decisions about where, when and from
whom they receive their healthcare.
Good information is important not just to
allow patients to reach decisions about
where to be treated, but also to enable
them to ask good questions and to help
clinicians and managers work together to
improve services.”
Dr Gill Morgan, chief executive of the NHS
Confederation
How can patient safety be measured? See pages 16 – 17 >> Hospital Guide 21

as late stent thrombosis. This may occur
more than a year after PCI treatment,
and may in part relate to delayed or
impaired healing of the vessel due to the
drug eluted by the stent. The rarity and
lateness of this complication means that
there is still much uncertainly about its
significance and there is much on-going
research into this issue.
As Dr Peter Ludman, consultant
cardiologist at University Hospitals
Birmingham NHS Foundation Trust
and a representative of the British
Cardiovascular Intervention Society
comments: “At this stage the relative
balance of the risk of early complications
(with bare metal stents) versus the risk of
later complications (with drug-eluting
stents) is not clear, and will inevitably
vary according to the type of patient and
type of vessel being treated, and the
duration of drug treatment with aspirin
and clopidogrel after the angioplasty.
The current concerns relate only to late
and very late stent thrombosis. Judging
by the available evidence, there may be a
small, but important excess of very late
stent thrombosis in drug-eluting stents
compared to bare metal stents. However,
further scientific data is required to
confirm this.”
2. Orthopaedics: hip prostheses
Last year, we looked at whether hospitals
use the hip prostheses recommended by
NICE.14 These prostheses are approved
because they are proven to last for more
than ten years. In 2005, our data showed
that the use of approved hips varied
nationally. This is still the case. On
average, 12 per cent of NHS trusts are
using hip replacements that aren’t
recommended by NICE, up by one per
cent from last year. Regional adherence
ranges from 100 per cent in the East
Midlands to 75 per cent in the North
East. Ninety-four per cent of private
hospitals use the approved hips.
3. Multiple sclerosis: beta interferon
We asked trusts whether they followed
best practice in the prescription of drugs
for sufferers of multiple sclerosis.
Multiple sclerosis is a disease affecting
the central nervous system. Although
there is no cure for the disease, certain
treatments are available. Currently there
are three drugs called beta interferons
that can modify the course of the
disease. These drugs are available to
patients with multiple sclerosis on the
NHS under the Risk Sharing Scheme to
patients who meet specific criteria.15
Despite this scheme, one in ten eligible
multiple sclerosis patients are still not
receiving beta interferon. Of the English
trusts offering multiple sclerosis services,
100 per cent in the North East follow
NICE guidelines in the prescription of
beta interferon for patients eligible for
treatment under the risk-sharing
scheme. This drops to 85 per cent on the
South East Coast.
NICE chief executive, Andrew Dillon,
outlines the value of NICE guidance:
“Determining how to use a limited
budget is difficult and organisations
have to make tough decisions about how
to allocate funding. One of the reasons
why NICE guidance is important is that it
can help decision makers to prioritise
the use of NHS funds in order to provide
the best possible care and treatment
for patients.” But Dillon is concerned
about the pace of implementation in
some organisations. “NICE guidance is
developed using the expertise of the
Following clinical guidelines Practice makes perfect
22 Hospital Guide
Percentage of trusts using joint replacements recommended
in NICE guidelines Source: Hospital Guide Questionnaire, 2005/06
%oftrusts
East
Midlands
Eastof
England
London
NorthWest
SouthEast
Coast
SouthWest
South
Central
West
Midlands
Yorkshireand
theHumber
Private*
Wales
NorthEast
0
80
60
100
40
20 2005
2006
Multidisciplinary teams
%oftrustshostingMDT
East
Midlands
Eastof
England
London
NorthWest
SouthEast
Coast
SouthWest
South
Central
West
Midlands
Yorkshireand
theHumber
Private
Northern
Ireland
Scotland
Wales
NorthEast
0%
80%
60%
100%
40%
20%
% of trusts hosting
an MDT for
colorectal cancer
% of trusts
hosting an MDT
for lung cancer
*Data not available for 2005

NHS and its implementation is crucial
to improving the quality of care for
patients. It is encouraging to see that
compliance with NICE guidance is
generally high, although we recognise it
needs to improve in some areas.”
4. Multidisciplinary teams
Multidisciplinary teams (MDT) for
certain types of cancers are widely
recommended in the provision of joined-
up care.16 For example, NICE’s guidance
on improving outcomes for cancer
services states that cancer services are
best provided by teams of clinicians
comprising staff with all the necessary
skills to ensure high quality diagnosis,
treatment and care. It also helps to
ensure the effective co-ordination and
continuity of care for patients. For
cancers such as colorectal and lung,
there is strong evidence that patients
treated by specialist teams are more
likely to survive.
NHS hospitals in England, Wales and
Scotland have a high level of team-
working for both lung cancer (97 per
cent) and colorectal cancer (98 per cent).
Only two trusts in London and two in the
North West do not have an MDT for lung
cancer. Similarly, only two trusts in the
North West do not have an MDT for
colorectal cancer. However, the private
sector has a very low level of compliance
with this recommendation. Of the 30
private providers who responded to this
question, only 29 per cent of respondents
reported that they had a multidisciplinary
team for lung cancer, and 31 per cent for
colorectal cancer. We did not ask trusts in
Northern Ireland about their level of
multi-disciplinary team working because
NICE’s remit does not extend to their
health service.
NICE’s Andrew Dillon is heartened by
the progress that has been made in the
introduction of MDTs and in changing
clinical practice: “The NHS has responded
welltothedevelopmentofmultidisciplinary
teams for cancer patients.”
Conclusions
There is a rich evidence base to support
the claims that patient outcomes are
better when their care is informed by the
best clinical practice. Yet the rapid pace
of medical research means that best
clinical practice is constantly evolving
and, as the results of our survey show,
there can be fairly wide variation in the
extent to which recognised good
practice is implemented. It might be
argued that this is in some degree
inevitable but healthcare providers must
still ensure they are able to explain the
reasons for variation, and take action if
not. This depends on access to good
quality benchmarkable information
about service availability, treatment
options and outcomes, not just for
providers but for commissioners and
patients too.
Some developments in good practice, such
as the treatment options for urological
cancer, require an increasing specialisation
of skills. Specialist services will necessarily
become concentrated in particular centres,
resulting in geographical disparities
within regions. This presents both
clinicians and managers with a significant
communications challenge: to explain
why moving services away from their
local unit actually means a better service
forthem.Thereisastrongparallelherewith
anumberofongoingpublicdebatesabout
hospital reconfigurations. Clinicians and
managers need to harness the evidence
baseandhonetheircommunicationsskills
togettheirmessageacrossmoreeffectively.
Percentage of English NHS Trusts following NICE guidelines in the prescription of
Beta Interferon for patients with MS Source: Hospital Guide Questionnaire, 2005/06
%oftrustsprescribing
BetaInterferon
East
Midlands
Eastof
England
London
NorthWest
SouthEast
Coast
SouthWest
South
Central
West
Midlands
Yorkshireand
theHumber
NorthEast
0%
80%
60%
100%
90%
70%
50%
30%
10%
40%
20%
Does the Trust follow
NICE guidelines in the
prescription of Beta
Interferon for patients
with MS who are eligible
for treatment under the
risk-sharing scheme?
Hip replacement
The following trusts reported that they
do not routinely use NICE recommended
prostheses for patients receiving a hip
replacement.
•BarnsleyHospitalNHSFoundationTrust
•Buckinghamshire Hospitals NHS Trust
•City Hospitals Sunderland NHS
Foundation Trust
•EastandNorthHertfordshireNHSTrust
•The Ipswich Hospital NHS Trust
•Kingston Hospital NHS Trust
•Lancashire Teaching Hospitals NHS
Foundation Trust
•The Luton and Dunstable Hospital
NHS Trust
•North Bristol NHS Trust
•Northumbria Healthcare NHS
Foundation Trust
•TheQueenElizabethHospitalKing’sLynn
NHS Trust
•Royal Cornwall Hospitals NHS Trust
•Southampton University Hospitals NHS
Trust
•UniversityHospitalsofSouthManchester
•Wrightington, Wigan and Leigh NHS
Trust
“Good quality information is invaluable
in driving up performance and standards.
Those working in the NHS need accurate
and timely information to improve
services for patients. The public too need
transparent information so that they can
make comparisons and choose the right
care to meet their needs.”
Sir Ian Carruthers OBE, Chief Executive,
South West Strategic Health Authority
How do individual trusts perform? See pages 28 – 31 >> Hospital Guide 23

Feature Getting a grip on infection control
24 Hospital Guide
It goes without saying that hospital-
associated infections such as MRSA and
C-difficile are a major cause of concern for
professionals and the public alike. It’s
estimated that infections such as these cost
the NHS as much as £1billion each year1
.
Screening for infection
However, it remains the case that data on
potential carriers of infection and
compliance with best practice guidance at
organisation level is frequently not
robust. Our analysis this year shows that
not only are the approaches taken to
infection control, such as screening and
isolation, highly variable, but approaches
to information collection are, too.
Early identification of patients carrying
the MRSA bacteria – and their
subsequentisolation–iskeytominimising
infection. We therefore asked trusts about
their methods of screening, and the
number of carriers identified of both
MRSA and C-difficile.
Best practice guidance from the
Department of Health leaves the method
of screening for MRSA up to NHS trusts.
However, it notes that rapid testing at the
point of care should be the norm in the
future.Consequently,weaskedtrustswhat
method of MRSA testing they used from
Hospitals are failing to understand the extent of infection risk because they are not collecting the right data
MRSA: under the microscope
Photography: Science photo library

Hospital Guide 25
a range of options: culture-based results
in 48–72 hours, culture-based results in
24–48 hours or molecular/other method
result in less than 24 hours. Approximately
half of all trusts are taking between 48
and72hourstodiagnoseinfectiousdiseases.
The screening of patients with infectious
diseasesisapressingrequirementfortrusts.
Clearly the faster carriers can be
identified, the faster patients can be
isolated, and therefore, the risk of further
infection minimised.
Wealsoaskedtrustsabouttheirapproaches
toisolation.Worryingly,only18trustswere
abletoindicatehowmanypatientsidentified
as carrying MRSA were source-isolated in
a single room or infection control ward.
Isolation of infected patients
Many trusts have isolation policies, but
do not gather the data to demonstrate
that the policies are being implemented.
Some of the comments we received are
indicative of the situation:
•“Data not held for period under review...
in the main, there was good compliance
with this policy.”
•“Theseareunknowntousasatthemoment
– we have no way of collecting this data.”
•“Thisdataisnotrecordedbytheinfection
control team.”
•“It is our policy that all patients [with
C-difficile] be isolated... this would
depend on bed pressures at the time.”
•“All patients are isolated eventually –
some had gone home by the time they
were identified.”
Sometrustsareaheadofthecurveinterms
of measuring and reporting infection data.
For example, Maidstone and Tunbridge
Wells NHS Trust has been gathering data
since April 2006. It’s available to all staff
and updated daily.
Reporting of MRSA bacteraemia is now
mandatory, whereas for C-difficile
organisations only need to report cases in
over-65s. Therefore, many hospitals are
only collecting data for that group.
One measure which can help reduce rates
of C-difficile is to closely monitor the rates
of in-hospital antibiotic prescribing.
Some hospitals are now introducing
antibiotic pharmacists who will ensure
that prescribing is at an appropriate level.
Our survey asked trusts whether they
have an antibiotic pharmacist in post.
There was considerable regional variation
in percentages of organisations with
antibiotic pharmacists in post. Ninety-one
per cent of trusts in the South Central
region told us that they have an antibiotic
pharmacist compared to just 38 per cent
of trusts in the East Midlands. Rates are
lowest in Wales – just 25 per cent.
Commentingonthedata,ProfessorRichard
James,directoroftheCentreforHealthcare
Associated Infections at the University of
Nottingham,said:“Ifwearetoevaluatethe
performance of locally-held policies and
their impact on MRSA rates in hospitals,
thenwemusthavepubliclyavailabledata.”
Trusts need to improve the information
they collect if they are to tackle infection
controleffectivelyandtrackimprovement.
Nationaldatacollectionsarelimitedintheir
usefulness. Trusts need effective systems
to collect data regarding compliance with
their own policies in order to understand
whether they are meeting best practice.
Source isolation of MRSA
The following trusts isolated over 90 per
centofpatientsidentifiedashavingMRSA:
•BarnsleyHospitalNHSFoundationTrust
•Birmingham Children’s Hospital
•Christie Hospital NHS Foundation
Trust
•Derby Hospitals NHS Foundation Trust
•Hereford Hospitals NHS Trust
•The Queen Victoria Hospital NHS
Foundation Trust
•Royal Brompton & Harefield NHS Trust
•Royal Liverpool Children’s NHS Trust
•York Hospitals NHS Foundation Trust
MRSA screening What method of MRSA screening do you use?
0%
60%
80%
70%
50%
40%
30%
20%
10%
Molecular or other
method result in
less than 24 hours
Culture-based results
in 24-48 hours
Culture-based results
in 48-72 hours
AntibioticpharmacistsPercentage appointed, by trust region
East
Midlands
Eastof
England
London
NorthWest
SouthEast
Coast
SouthWest
South
Central
West
Midlands
Yorkshireand
theHumber
Scotland
Northern
Ireland
Wales
Privatesector
NorthEast
0%
80%
90%
100%
70%
60%
50%
40%
30%
20%
10%
How can patient safety be measured? See pages 16 – 17 >>

26 Hospital Guide
Hospital mortality ratios are an effective
way to measure and compare clinical
performance, safety and quality. Deaths in
hospital are important and unequivocal
health outcomes. They are also relatively
straightforward to measure, being clearly
definedeventsthatmustbereportedbylaw.
Our aim in publishing this data is, as ever,
to encourage dialogue between clinicians
and managers around improving the
quality of care, and to help them track
changes over time and assess the impact
of clinical governance. Good information
combinedwithgoodleadershipiseffective
in improving quality of care sufficiently to
reduce hospital mortality. Experience tells
usthattheeffortmustbecommunity-wide
and must include good local evidence,
as well as accurate, reliable data from
across each trust.
Hospital Standardised Mortality Ratios
(HSMRs)comparethenumberofexpected
deaths with the number of actual deaths.
The data are based on the diagnoses that
lead to 80 per cent of all deaths and are
adjusted for factors statistically associated
withhospitaldeathrates.Severityofillness
is an important factor on mortality and
our methodologies now acknowledge this
by using a measure of co-morbidity
called the Charlson index, which looks at
a number of secondary diagnoses and
scores them according to severity.
There are a number of other factors which
affect mortality at hospital level. Key
amongst these are the number of hospital
doctors per hospital bed and the number
of GPs per head of the population. In both
cases, the more doctors, the lower death
rates. In 1994 the UK had 1.6 physicians
per1,000population.By2004,thishadrisen
to 2.3 per 1,000 (compared to the OECD
average of 3.1). We have not adjusted for
numbersofdoctors,becausetheyarewithin
the control of the health system.
Thetablesonthefollowingpagesshowthe
HSMRs for all hospital trusts in England.
The HSMR is expressed as a relative risk,
where a risk rating of 100 represents
the national average. The tables show the
HSMRsforthepreviousoneandthreeyears
as well as the relevant confidence intervals.
These show the range within which there
is 95 per cent certainty that the true
underlying mortality figure lies. The final
column shows the percentage change in
HSMR since last year.
Looking at mortality rates over three years
provides a more stable measure of quality
thatdoesnotreflectyear-to-yearvariations.
The one-year figures enable trusts to track
howtheirHSMRhasmovedrelativetoother
trusts in the year.
The Royal Free Hampstead NHS Trust has
the lowest HSMR of any English trust,
both for 2005/06 and over the three years
to 2005/06.
The chief executive of the Royal Free
Hampstead NHS Trust, Andrew Way, said:
“We’reveryproudtohaveoneofthelowest
mortality rates in the NHS. Hospital
mortality rates are regarded as a very good
indicator of overall clinical performance
so this is a significant achievement.” The
trust has developed a balanced scorecard
approachtomonitoringitsmortalityaspart
of a monthly performance improvement
system. Using information in this way
allows senior clinicians and managers
at the trust to track their improvement.
HSMRs are now widely used in the US,
Canada, the Netherlands and Sweden,
as well as the UK. The tables [above and
Measuring hospital performance Mortality rates
DATA COVERAGE:
NHS England/US/Holland
DATA EXPLAINED
The Hospital Standardised
Mortality Ratio – methodology
The Hospital Standardised Mortality
Ratios (HSMR) in this report are
based on the routinely collected
administrative data (NHS Wide
Clearing Service data) for England
for the year ending March 2006 and
combined with Hospital Episode
Statistics for the three years ending
March 2006. We calculated death
rates for the diagnoses that lead to
80 per cent of all deaths in England.
Adjustments are made for sex, age
group (in five year age bands up
to 90+), method of admission
(emergency or elective), the socio-
economic deprivation quintile of the
area of residence of the patient, and
the primary diagnosis (based on the
Clinical Classification System (CCS)
group). This year for the first time, we
have also adjusted the data to take
intoaccountco-morbidities,numbers
of previous emergency admissions
and whether a patient is being treated
within the specialty of palliative care.
Expected counts were derived using
logistic regression, adjusting for these
factors. The outcome of interest was
in-hospital death.
US HSMRs using year 2000 as reference
Source: Analysis by Professor Sir Brian Jarman
Year
60
105
100
110
95
90
85
80
75
70
65
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
HSMRs first sent to
hospitals early 2002
For the sixth year, Dr Foster published Hospital Standardised
Mortality Ratios (HSMRs) for all acute trusts in England

] show US and Dutch HSMRs
improving over time. Other countries show
similar rates of improvement. But as
Professor Sir Brian Jarman says:
“Variations between individual centres
persist. We are working on developing
ways for organisations to compare their
performance within their counterparts
abroad, but still adjusting for variations
in case mix.”
In the US, HSMRs have been used as a
keymeasureoftheInstituteforHealthcare
Improvement’s ‘100,000 Lives campaign’
and Canada’s ‘Safer Healthcare Now’
initiative. Hospitals participating in the
campaignwereabletoevaluatethesuccess
of quality improvement initiatives and set
their own targets.
But hospitals and the public in North
America are not able to compare how they
are doing with other organisations, since
the data are not publicly available. On his
blog, Paul Levy, president and chief
executive of the Beth Israel Deaconess
Medical Center in Boston has issued a
challenge to his peers: “With a national
debate swirling about the cost of care and
value of academic medical centers, what
would be more powerful than a grand
display of openness about our progress
in trying to kill fewer people?” It seems
that in relation to an information culture,
the NHS is some way ahead of the US.
Hospital Guide 27
135 130 140
132 127 137
126 121 130
125 120 130
124 120 128
123 119 128
123 119 128
121 116 126
120 117 123
119 116 123
Three-Year mortality Three-year 95% conﬁdence intervals
Burton Hospitals NHS Trust*
George Eliot Hospital NHS Trust*
Kettering General Hospital NHS Trust
Mid Staffordshire General Hospitals NHS Trust
Bolton Hospitals NHS Trust*
Good Hope Hospital NHS Trust
Tameside and Glossop Acute Services NHS Trust*
South Tyneside NHS Foundation Trust
University Hospitals Coventry and Warwickshire NHS Trust
Dudley Group of Hospitals NHS Trust*
POOR PERFORMING NHS TRUSTS ON MORTALITY 2003-2006
70 67 73
72 69 74
80 76 84
82 77 87
82 80 84
82 80 85
83 80 86
84 81 87
84 82 87
85 82 88
Three-Year Mortality Three-Year 95% Conﬁdence Intervals
Royal Free Hampstead NHS Trust*
The Hammersmith Hospitals NHS Trust*
St Mary's NHS Trust
Chelsea and Westminster Hospital NHS Foundation Trust
Brighton and Sussex University Hospitals NHS Trust*
Bradford Teaching Hospitals NHS Foundation Trust
Royal West Sussex NHS Trust*
Guy’s and St Thomas’ NHS Foundation Trust*
University Hospital of South Manchester NHS Foundation Trust
Barts and The London NHS Trust
BEST PERFORMING NHS TRUSTS ON MORTALITY 2003-2006
Dutch HSMRs over time using year 2003 as the standard
Source: Analysis by Professor Sir Brian Jarman
Year
HSMRs(95%CIs)
80
120
125
115
110
105
100
95
90
85
1998 1999 2000 2001 2002 2003 2004 2005
Note: Specialist trusts are excluded from our HSMR
analyses due to their particular case mix
* Trusts that appeared in last year’s list of good/poor
performing trusts
Which trust is ‘Trust of the Year’? See pages 32 – 33 >>

Measuring hospital performance Mortality rates
28 Hospital Guide
DATA EXPLAINED
Mortality indicators
explained
One-year mortality
The adjusted Hospital
StandardisedMortalityRatio
(HSMR) for 2005/06.
One-year confidence
intervals
The lower and upper
confidence intervals given
year-to-yearvariationsinthe
expected number of deaths
for 2005/06.
Three-year mortality
The adjusted Hospital
Standardised mortality ratio
(HSMR) for 2003/06 for the
conditionsthatleadto80per
cent of deaths. 120 shows 20
per cent more deaths than
expected. 80 represents 20
per cent fewer deaths than
expected from Hospital
Episode Statistics (HES) and
NHS-Wide Clearing services
(NWCS).
Three-year confidence
intervals
The lower and upper
confidence intervals given
year-to-yearvariationsinthe
expected number of deaths
for 2003/06.
Change since last year
PercentagechangeinHSMR,
2004/05 to 2005/06.
Aintree University Hospitals NHS Foundation Trust
Airedale NHS Trust
Ashford and St Peter’s Hospitals NHS Trust
Barts and The London NHS Trust
Bradford Teaching Hospitals NHS Foundation Trust
Brighton and Sussex University Hospitals NHS Trust
Bromley Hospitals NHS Trust
Cambridge University Hospitals NHS Foundation Trust
Chelsea and Westminster Hospital NHS Foundation Trust
City Hospitals Sunderland NHS Foundation Trust
Doncaster and Bassetlaw Hospitals NHS Foundation Trust
East Cheshire NHS Trust
Gateshead Health NHS Foundation Trust
Guy’s and St Thomas’ NHS Foundation Trust
The Hammersmith Hospitals NHS Trust
Harrogate and District NHS Foundation Trust
Homerton University Hospital NHS Foundation Trust
King’s College Hospital NHS Foundation Trust
Leeds Teaching Hospitals NHS Trust
Maidstone and Tunbridge Wells NHS Trust
Norfolk and Norwich University Hospital NHS Trust
North Bristol NHS Trust
North West London Hospitals NHS Trust
Nottingham University Hospitals NHS Trust
Plymouth Hospitals NHS Trust
Poole Hospital NHS Trust
Royal Cornwall Hospitals NHS Trust
Royal Devon and Exeter NHS Foundation Trust
Royal Free Hampstead NHS Trust
Royal Surrey County Hospital NHS Trust
Royal United Hospital Bath NHS Trust
Royal West Sussex NHS Trust
Sheffield Teaching Hospitals NHS Foundation Trust
Shrewsbury and Telford Hospital NHS Trust
South Tees Hospitals NHS Trust
St George’s Healthcare NHS Trust
87 85 – 90 86 81 – 90 -5.7
87 84 – 91 91 84 – 98 -0.9
93 90 – 96 96 90 – 101 -3.0
85 82 – 88 89 84 – 95 -0.5
82 80 – 85 79 74 – 83 -8.9
82 80 – 84 85 81 – 90 0.7
92 89 – 96 88 82 – 94 -10.9
87 84 – 90 81 77 – 86 -10.2
82 77 – 87 88 80 – 97 7.7
95 92 – 97 91 86 – 95 -10.3
95 93 – 98 95 91 – 100 -3.9
91 88 – 96 93 86 – 100 -10.6
93 89 – 96 95 89 – 101 -3.7
84 81 – 87 82 77 – 87 -4.9
72 69 – 74 75 71 – 80 5.8
87 83 – 91 87 80 – 95 0.1
87 81 – 92 81 72 – 91 -10.1
92 89 – 96 94 88 – 101 -6.3
87 86 – 89 84 81 – 88 -10.7
91 88 – 94 95 90 – 100 -1.2
94 92 – 96 95 91 – 99 -2.4
90 87 – 92 87 82 – 91 -9.3
94 91 – 97 91 86 – 96 -13.4
88 86 – 89 86 83 – 89 -3.8
90 88 – 93 95 90 – 100 -3.9
95 92 – 98 98 92 – 103 0.8
95 92 – 98 96 91 – 100 -7.2
92 89 – 95 91 86 – 96 -11.5
70 67 – 73 74 69 – 79 2.5
91 87 – 95 96 90 – 103 21.9
94 92 – 97 94 89 – 99 -6.9
83 80 – 86 84 79 – 90 1.0
92 90 – 94 89 86 – 93 -10.8
94 92 – 97 91 86 – 96 -10.3
90 87 – 92 93 88 – 97 -0.6
88 85 – 91 80 75 – 85 -13.0
Three-YearMortality
Three-Year95%
ConﬁdenceIntervals
One-YearMortality
One-Year95%
ConﬁdenceIntervals
This table shows standardised mortality ratios for NHS
acute trusts in England. Trusts are listed alphabetically
and by low, average and high mortality ratio. Trusts are
determined high or low if they fall outside 99.8 per
cent (3 sigma) control limits on a funnel plot.
TRUST LOW MORTALITY
PercentageChange(%)

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