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News Analysis: Patients have their say

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The Healthcare Commission has just published the results of its annual survey of hospital inpatients. Richard Staines analyses the findings

The latest inpatient survey by the Healthcare Commission has, as in previous years, revealed variations in standards of care in the NHS – as judged by patients (NT News, 20 May, p3).

Findings were based on a survey of nearly 76,000 inpatients at 165 acute trusts across England conducted last year.

As before – the survey has been conducted five times since 2002 – questions covered topics such as perceptions of hygiene standards and staff courtesy.

Although the vast majority of inpatients were happy with the care they received, the survey demonstrates how negative publicity generated by health scandals can damage public perceptions of hospitals. Some of the trusts that scored badly, according to the commission’s rating system, were those that have featured in the national media for poor performance.

For example, Maidstone and Tunbridge Wells NHS Trust, where an outbreak of Clostridium difficile in 2005–2006 was linked with the deaths of around 90 people, scored badly in most areas.

Patients reported that nurses often did not wash their hands between touching patients – raising continuing concerns in the media about infection control at the trust.

But is it right to place so much importance on the results of a patient survey? The trust says not.

Sara Mumford, the trust’s director of infection prevention and control, said the survey was skewed because it took place shortly after the publication of the commission’s report into the C. difficile outbreak but several years after the outbreak itself.

The resulting negative publicity had shaken patients’ confidence in the organisation, resulting in low scores despite a drive to improve standards at the trust, according to Ms Mumford.

‘We do believe that the increase is down to the publication of the Healthcare Commission’s report. Patient perception was low no matter what you ask of them because of the negative publicity we received,’ she said.

The findings of the patient survey do not match the results of the trust’s own infection control audits.

‘Our weekly hand hygiene audit shows nurses are 90% compliant. We are hoping that our patients will see our healthcare-associated infection rates are well down, with a 35% reduction in C. diff,’ said Ms Mumford.

However, she said that although she was disappointed with her trust’s poor results, the survey was a useful reminder that it takes time to reinstate confidence in a hospital.

‘In some ways it refocuses everybody,’ she said. ‘When [healthcare-associated infection] levels come down, there is a risk people become complacent. There is a risk people think that they are historical – that it is in the past.’

Helen Moss, director of nursing and governance at Mid Staffordshire NHS Foundation Trust, which also scored poorly in handwashing, expressed frustration that the report’s findings were more than a year out of date.

The trust is currently being investigated by the regulator over suggestions that its patient death rate is high compared with similar trusts across England, and has previously been the subject of negative publicity about C. difficile rates.

The worst performing trust, as judged by the survey, was Ealing Hospital NHS Trust in London. Like the other examples, the trust, while disappointed, made the point that the results were already a year old.

Paul Reeves, director of nursing at the trust, said: ‘We are now carrying out surveys of patients on our wards every week to gain up-to-date information from them, which we can act on quickly.’

However, for trusts that have scored well in the patient survey, it is a welcome opportunity to gain some good publicity.

One that did so was Royal Cornwall Hospitals NHS Trust, which has recently been branded as failing in the Healthcare Commission’s separate annual health check rating system.

According to the scoring system in the patient survey, the trust was performing at or above national average in all areas.

Scott Jenkin, an RCN steward at the trust, said: ‘Everybody has worked very hard. It makes a change from being the whipping boys.’

Nurses can, however, take heart that on the whole, patients continue to value and respect them – 74% said they ‘always’ had confidence and trust in nursing staff.

The findings suggest Lord Mancroft’s claims in the House of Lords in February about ‘grubby and promiscuous’ nurses, following his stay at Bath’s Royal United Hospital, cannot be viewed as being representative of the profession. Nearly 80% of nurses never talked with other staff as if patients were not there – though 5% did, according to patients.

Around nine out of ten also rated how well nurses and doctors worked together as ‘excellent’, ‘very good’ or ‘good’, and in only 5% of occasions were nurses unable to give patients satisfactory answers to important questions.

Additionally, the survey throws some light on patient perceptions of staffing levels. The results showed that 12% of patients thought staffing levels were inadequate, the same figure as the previous year, with only just over half saying there were always enough nurses on duty.

But Unison’s head of nursing Gail Adams said that patient surveys were not accurate in measuring whether wards were adequately staffed.

‘What is busy to them may not be busy to a nurse,’ she said. ‘It might seem like everyone is running around like headless chickens but it might not really be like that.’

However, the question remains whether the survey is a useful tool in driving up standards in the NHS.

According to a snapshot poll on nursingtimes.net, 80% of visitors think the survey does not improve patient care.

This appears to be borne out by the Healthcare Commission results themselves. The percentage of patients rating their overall care as ‘poor’ has remained static at 2% for the last four years of the survey. While the percentage rating their overall care as ‘excellent’ has shown a steadily increasing trend recently, it has fluctuated very little over time.

The HCC may have described the latest ‘excellent’ figure, 42%, as an improvement on the 38% figure recorded in 2002, but it was also 42% in 2004 before dipping to 40% a year later.

The same is true for virtually all other questions in the survey – with very little fluctuation of no more than one per cent in most cases.

Despite these concerns, the survey appears to be here to stay.

‘It reminds staff that they are supposed to be role models, setting examples for patients and visitors as well. It is not great but we are using it in a positive way,’ said Ms Mumford.

The top 5 rated trusts

  • Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust, Shropshire

  • Queen Victoria Hospital Foundation Trust, West Sussex

  • Papworth Hospital Foundation Trust, Cambridge

  • The Cardiothoracic Centre, Liverpool NHS Trust

  • Clatterbridge Centre for Oncology Foundation Trust, Wirral

based on percentage of patients rating them as excellent

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