Nearly half of NHS staff feel so overstretched they fear they cannot do their jobs properly, a survey shows.

The Healthcare Commission poll of 160,000 workers across England also showed many did not feel valued.

Unions said the figures were worrying as under-staffing was one of the key problems highlighted in the critical report on Stafford Hospital last week.

But ministers said more people than ever were being employed by the NHS and the problems reported were improving.

NHS employers need to listen to staff and must act when they are told they do not have enough time or people to do their jobs properly and deliver quality patient care Karen Jennings, of Unison

The poll, which is carried out each year by the regulator, covers the full range of NHS staff from doctors and nurses to support staff.

Some 47% of staff said they did not feel there were enough people to do the job, down from 51% in 2007.

A third said they did not feel valued by bosses and just over a quarter had experienced work-related stress - however both of these had fallen slightly in the previous year.

The poll also revealed that half of ambulance staff had said the vehicles were not kept in a good state of repair.

Anna Walker, chief executive of the commission, said progress was being made but more work was needed.

"There are real lessons to be learned from this survey about leadership, management and team work."

'Worrying'

Karen Jennings, head of health at Unison, said the findings were worrying, pointing out that inadequate staffing levels were at the heart of the critical report into Stafford Hospital's emergency care where death rates were significantly above average.

"NHS employers need to listen to staff and must act when they are told they do not have enough time or people to do their jobs properly and deliver quality patient care."

But the survey has been published as the latest workforce census showed that NHS staffing levels have hit a record high.

There are now nearly 1.4m staff employed in England - a rise of over 25 percent in the past decade.

Health minister Ann Keen said it was clear working in the health service was a "rewarding career" as many more nurses, matrons, consultants and GPs were now being employed.

She said staff across the NHS were helping "deliver high quality patient care to all".

But the Tories accused the government of creating too much bureaucracy as the figures also showed that the rise in managers was outstripping that of many clinical staff.

Shadow health secretary Andrew Lansley said: "These spiralling management costs show that Labour's repeated pledges to spend NHS money on the things that matter most were just empty rhetoric."

http://www.nhsunlocked.org/FindAHospital.aspx

Many NHS doctors and nurses are inadequately prepared to spot and act upon signs of child abuse or neglect, a damning report on the aftermath of the Baby P scandal warns.

The detailed survey by the Care Quality Commission exposes a failure inside the health service even among some paediatric specialists and GPs to get to grips with the challenges of safeguarding children.

It says many clinicians have not received up-to-date mandatory training in child protection, while health visitors are overwhelmed by excessive case loads.

The review was ordered after it emerged that NHS staff in Haringey, north London, including some employed by Great Ormond Street children's hospital, saw Baby Peter, as he is now known, on 35 separate occasions in his short life and, on all but one occasion, failed to realise he was in danger.

Highlighting the inadequate response by health trusts, Cynthia Bower, the commission's chief executive, said: "Immediately after the Baby P tragedy, everyone agreed that everything possible must be done to prevent a recurrence. This must not prove to be hollow rhetoric. The NHS has got to play its part by getting these safeguarding measures in place.

"It is clear that safeguarding has not been as high on the agenda of trust boards as it should have been ... In some cases NHS staff have not been given the support they need in terms of training and clear procedures for handling concerns. If that were to change, it would be an appropriate legacy for Baby Peter."

The 17-month-old Baby Peter, who had been also monitored by social workers and police, was seen by a consultant paediatrician, Sabah Al-Zayyat, two days before he died in Haringey in early 2007. She had not been not given the full picture of Peter's history before the examination, although a subsequent internal Great Ormond Street inquiry said she should have identified his injuries as signs of abuse.

After he died, Peter was found to have serious injuries including a broken back and fractured ribs. His mother, her boyfriend and a lodger were later sentenced for causing or allowing the child's death.

The report says that only 54% of eligible NHS staff have received basic child protection training, a "worryingly low" proportion. According to the inspectors, in 20 of the primary care trusts surveyed, as few as 10% of GPs were up-to-date with what was said to be a "basic" level of training.

On health visitors, the investigation discovered that 29 out of 152 primary care trusts were dealing with caseloads of more than 500 children each, "well above [the] recommendation of 400".

Among other findings were that only 37% of trusts have a dedicated budget for training staff in child protection issues, while 65% of GPs either do not have appropriate training or there is no data to say whether they do or don't. Only 58% of A&E or urgent care staff have adequate training in child protection.

Last year about one in 10 GP consultations were with children aged 14 or under; nearly three million children under 16 attend A&E departments ever year.

In 2008-09, the year that the Baby P scandal erupted, more NHS trusts did admit that they could not comply with national core standards – one of which deals with child protection. The numbers declaring compliance fell marginally from nearly 97% to 94% – suggesting a slight increase in self-criticism.

More than one in 10 trusts "did not appear to comply with the statutory requirement to carry out criminal records bureau checks for all staffemployed since 2002," the report said. "We are particularly concerned with the large proportion of trusts that do not have a process for following up children who miss outpatient appointments."

Commenting on the findings, Jo Webber, deputy director of policy at the NHS Confederation, said: "Despite the progress many NHS organisations have made, and the commitment of individuals working in the health service, there is clearly much more that can be done to make sure children are protected properly. This means promoting a culture of questioning amongst staff."

The Liberal Democrat health spokesman, Norman Lamb, said: "It's disgraceful that some parts of the NHS are still failing to comply with basic child protection requirements like carrying out criminal record checks on staff."

The health secretary, Andy Burnham, said: "I want trusts and PCTs to use this report to support a coordinated programme of action to assure and sustain essential levels of safeguarding in activities relating to children."

http://www.guardian.co.uk/society/2009/jul/16/baby-p-child-protection-nhs

The state can do terrible things to people. While libertarians worry about big brother CCTV cameras, information stored on computers or the shameful power to lock people up without trial for 28 days, even worse happens behind closed doors at the state's behest.

Every day in hospitals, nursing homes and at home, the state not only permits but orders the torture of the terminally ill. Confined within bodies too frail to help themselves, people are denied assistance from doctors to end their lives peacefully. If anyone counted up the numbers of the dying and the months of agony they suffer against their will in the many dying rooms of the nation's institutions, then the 1961 Suicide Act would emerge as the cruellest torture instrument.

Because dying happens far from the public eye, the sheer scale of suffering is a secret garden the medical profession prefers to keep hidden, denying doctors' limited skills to prevent thousands ending up in a state everyone hopes will never happen to them. (Doctors, though, are among those most likely to kill themselves when terminally ill, knowing what lies ahead).

Let's be graphic: morphine (and its derivatives) is no wonder drug, though it is the only effective painkiller available. It usually dulls pain, but not always. At high enough doses it can induce unpleasant hallucinations. It is a depressant: don't imagine you end life on some glorious high, floating away in a cloud of pleasurable dreams. It causes acute constipation, so the dying spend their last weeks thinking mostly of their bowels, of laxatives and enemas punctuated by explosive "accidents". Elevated end-of-life thoughts and feelings are often banished by pain and the indignity of bodily functions.

Palliative-care doctors and nurses can be wonderful: I have seen them at their best, caring for my mother and for others close to death. But collectively they strongly oppose giving their patients the right to die – and their voice carries extra weight inside and outside the medical profession because they are the experts in death. They tend to claim that with the best care, anyone can live out their last days with enough comfort and dignity not to want a mercy killing. But following in the footsteps of Mother Theresa and Dame Cicely Saunders, this is a branch of medicine exceptionally heavily dominated by the deeply religious who believe only God disposes. Either they deceive themselves or else they deny the evidence of their own eyes and ears about many patients' experience. Their influence in this debate has been immense – and baleful.

They are right that too few people get good end-of-life care; the Dying Matters coalition, set up by the National Council for Palliative Care, reports that the least affluent get the least care, as in life. But many, like my family, report excellent care that still can't save a dying person from dreadful last days.

It was a cabal of bishops, rabbis and assorted religious enthusiasts who wrecked the Joffe bill in the Lords through a devious putsch that broke Lords' procedural practice, denying the bill a Commons debate. Even more spurious were their arguments, summarised by the Bishop of Oxford's opinion that "we are not autonomous beings" and so must wait for God to release us.

This week the law lords opened the door to a gentler way of death by a small chink, after the admirable Debbie Purdy's long campaign for her own autonomy. Keir Starmer, the director of public prosecutions, must set out his interpretation of when people will be prosecuted for easing someone's exit. But it should not be for one man to determine what to do once a law has become redundant. It is for parliament to debate how to replace the Suicide Act, now hundreds of relatives of the terminally ill – and even of the severely disabled, but not terminal – have not been charged for assisting relatives to die. The Commons needs to bring forward a bill urgently. Every poll in the last decade has shown between 74% and 87% of the public want the terminally ill to have the right to ask a doctor for a peaceful death.

Safeguards are not hard to devise: someone in sound enough mind to write their will can be judged fit enough to choose when it's time to die, without undue duress from greedy relatives. Besides, the loss of independence and becoming a burden to others may be a valid part of the reason why someone feels life has become undignified and past bearing.

Each person has their own threshold, with their own sense of what makes life worth living. When my friend Jill Tweedie, late of this paper, was dying of motor neurone disease, she was driven to rage by sanctimonious people telling her to consider how Stephen Hawking found so much value in life despite severe disability. What mattered to her was what she found bearable. She took her own life while still mobile, probably far earlier than if she had been guaranteed assistance from a doctor at a later stage. Every one of us will die and many will not have a quick and painless death. Experience in Oregon shows that simply knowing you can call for an injection eases anxiety and makes it less likely people will end their lives prematurely.

The absurd state of the law now means only the well-off can fly to Zurich and many are probably still too well to need to die quite yet: 800 Britons are on the waiting list. When my mother in her last days begged me to take her to Switzerland, it was too late. But I would have dreaded taking her while she was still fit enough to travel, before the last stages. The very idea of a funereal last flight to a strange place is horrible to contemplate. The prospect of that tastefully anonymous Dignitas death chamber seems a desperately grim way to go, all because of the hypocritical British law. Most people want to know they can die at home, surrounded by family or friends at a time of their choosing, with an injection no more distressing than a pre-operative anaesthetic. We might never need it, we might never choose it, but to know there is an easeful escape is to take away fear of dying.

Surveys of candidates show the next parliament is set to be filled with a socially as well as politically conservative cadre of new MPs. There is not long left for this House of Commons to change the law. This is among many other progressive reforms Labour has neglected, but there is still time – just.

http://www.guardian.co.uk/commentisfree/2009/jul/31/assisted-suicide-law...

Some chronically ill patients are so overburdened by treatment that it makes their health worse, according to a new study in the BMJ medical journal.

The paper, by clinicians from Glasgow and Newcastle universities, says badly co-ordinated care leads to "wasted resources and poor outcomes".

It calls for more "minimally disruptive medicine" that is tailored to the realities of patients daily lives.

The findings of the paper are based on 10 years of research.

The paper, led by Carl May, professor of medical sociology at Newcastle University, states that patients can be burdened by much more than drug management and self monitoring.

We are calling for minimally disruptive medicine that seeks to tailor treatment regimens to the realities of the daily lives of patients Professor Frances Mair Glasgow University

He said: "It includes organising doctors' visits and laboratory tests. Patients may also need to take on the organisational work of passing basic information about their care between different healthcare providers and professionals.
"In some countries, they must also take on the contending demands of insurance and welfare agencies.

"Patients are thus overwhelmed not just by the burden of illness, but by the ever present and expanding burden of treatment."

The paper highlights cases where patients have suffered due to such a burden.

Among these cases is that of a man treated for heart failure who rejected the offer to attend a specialist heart failure clinic to improve his condition.

He said that over a two-year period he had made 54 individual visits to specialist clinics for consultant appointments, diagnostic tests and treatment - the equivalent of one full day every two weeks.

'Wasted resources'

Frances Mair, professor of primary care research at Glasgow University and co-author of the paper, said the findings showed the need for "better co-ordination of care".

"Thinking seriously about the burden of treatment may help us begin to consider minimally disruptive medicine - forms of effective treatment and service provision that are designed to reduce the burden of treatment on users," she said.

"The treatment burden leads to poor adherence, wasted resources and poor outcomes.

"We are calling for minimally disruptive medicine that seeks to tailor treatment regimens to the realities of the daily lives of patients.

"Such an approach could greatly improve the care and quality of life for patients."

http://news.bbc.co.uk/1/hi/scotland/glasgow_and_west/8196928.stm

The Care Quality Commission has published its in-depth analysis of the performance of England's 391 NHS trusts across a range of categories over the past year.

NHS RATINGS 2008 To find out more Care Quality Commission information for England, enter your full postcode here: This search goes to an external site

The watchdog assessed the trusts on a series of criteria, focusing on their quality of service and use of resources.

Each trust was graded either excellent, good, fair or weak.

The services measured included patient access, safety and the way the services are run.

The ratings reflect how well the organisation met basic standards of care and how they performed against existing and new national targets.

The NHS is being praised for improving the services it provides.

The number of excellent performers has risen more than six-fold in the last two years. Meanwhile, just 5% are classed as weak.

The poorest performers will now be subject to monitoring by the Care Quality Commission.

Basically, this is a measure of how well trusts are managing their finances.

Again the figures show an improvement in recent years as the health service has turned its deficit into a healthy surplus.

Performance is generally up for each of the four types of trusts. However, primary care trusts, which oversee community services such as GPs, are still struggling to achieve excellent ratings.

This is probably because as largely management organisations they have more targets to hit.

READ THE FINDINGS IN FULL NHS health check 2007/08 [3MB] Most computers will open this document automatically, but you may need Adobe Reader Download the reader here

Hospitals, in particular, have upped their game on financial management in recent years. Two thirds are now excellent or good.

But the watchdog has flagged up the lack of rigour seen among ambulance trusts. These have recently been merged, which could partly explain the lack of any excellent performers. NHS chiefs will be expecting this to improve in future years.

http://news.bbc.co.uk/1/hi/health/7672260.stm

A patient lobby group is demanding an urgent review of basic hospital care after highlighting accounts of "appalling" NHS standards.

Relatives told the Patients Association how their loved ones, often elderly people, were left lying in faeces and urine and were not helped to eat.

The group's president Claire Rayner, an ex-nurse, called for "bad, cruel nurses" to be struck off.

The government said the cases were unacceptable but not representative.

The report focused on 16 stories from relatives of patients in England, which the association says are just a few of "hundreds and hundreds" of similar reports from across the UK.

It says self assessment allows too many health authorities to ignore problems that have been raised and is calling for regulator the Care Quality Commission to intervene.

Soiled bedding

The association insists accounts used in the report were reviewed critically before publication as it was aware complaints do "not necessarily reflect the reality".

But it stressed nearly all the accounts were concerned not about treatment but basic nursing and domiciliary care.

The Patients Association noted the latest inpatient survey found 43% rated the service they received as excellent, a significant increase from the previous year.

It is important to note this is not representative of the picture across the NHS. The NHS treats millions of people every day and the vast majority of patients experience good quality, safe and effective care Chris Beasley Government chief nursing officer

But it stressed the 2% who deemed the service poor had not changed between 2002 and 2008, and that while the proportions were small they still represented thousands of patients.

Earlier this year, a report from the Healthcare Commission - now replaced by the Care Quality Commission - detailed grave lapses in standards of care at the Mid Staffordshire NHS Trust.

Families described "Third World" conditions, with some patients drinking water from vases and lying for hours in soiled bedding.

"Whilst Mid Staffordshire may have been an anomaly in terms of scale the Patients Association knew the kinds of appalling treatment given there could be found across the NHS," said Katherine Murphy, the association's director.

"This report removes any doubt and makes this clear to all. Two of the accounts come from Stafford, and they sadly fail to stand out from the others."

She said the stories were often about the most vulnerable elderly.

"We hope this report also encourages other people to get in touch with us and tell their stories. We plan to continue publishing accounts until we can be confident that every patient is secured dignity in their care," she continued.

Two per cent is too many but we are concerned that this might undermine the public's confidence in the world-class care they can expect to receive from the NHS Dr Peter Carter Royal College of Nursing

Relatives described how they found their loved ones dehydrated or lying in faeces, blood and urine, and told of problems in getting help from nurses. They also told how patients were left with sandwiches or drinks in packaging which they could not open.

Ron Kirk said his father, Leslie, was admitted to hospital in October 2007, having suffered a stroke, but that his treatment at the hands of some nurses amounted to cruelty.

His father had been fitted with the wrong catheter, leaving him in pain, but nurses took away his bedside alarm because they thought he was "pressing it too often", Mr Kirk said.

Claire Rayner said: "I am sickened by what has happened to some part of my profession of which I was so proud. These bad, cruel nurses may be - probably are - a tiny proportion of the nursing work force, but even if they are only one or two per cent of the whole they should be identified and struck off the Register."

Good 'overshadowed'

Government chief nursing officer Chris Beasley said: "All patients deserve the highest quality of care from the NHS and the poor care received in these cases is simply unacceptable."

But she said this was not representative of the picture across the NHS.

"The NHS treats millions of people every day and the vast majority of patients experience good quality, safe and effective care - the Care Quality Commission's recent patient experience survey shows 93% of patients rate their overall care as good or excellent."

The CQC said the registration system it was introducing for trusts next year would ensure they met key quality standards.

"It is absolutely right to highlight that standards of hospital care can vary from very good to poor," said chairman Barbara Young.

"Many people are happy with the care they receive, but we also know that there are problems.

"Matters related to the dignity of care are of particular concern to patients and their families.

"And poor basic nursing is a recurring theme in organisations that perform badly.

"I am in no doubt that many hospitals need to raise their game in this area."

Dr Peter Carter, chief executive of the Royal College of Nursing (RCN), said it would not condone nurses who behave in ways "that are contrary to the principles and ethics of the profession".

But he added: "This report is based on the 2% of patients who feel that their care was unacceptable.

"Two per cent is too many but we are concerned that this might undermine the public's confidence in the world-class care they can expect to receive from the NHS.

"Furthermore it could also dampen the morale of the millions of staff who work tirelessly to help their patients."

http://news.bbc.co.uk/1/hi/health/8223710.stm

The Patients Association has exposed awful hospital neglect. Our cherished healthcare system needs a dose of regulation

http://www.statistics.gov.uk//StatBase/Prep/9684.asp

http://www.statistics.gov.uk/StatBase/ssdataset.asp?vlnk=6157&More=Y

More than 5,700 patients died or suffered serious harm due to errors and near misses in England, latest figures for a six-month period show.

The National Patient Safety Agency said there were 459,500 safety incidents from October 2008 to March 2009 - the highest rate since records began.

Patient accidents were the most common problem, followed by mistakes made during treatment and with medication.

Experts said the health service had to do more to eradicate errors.

The NPSA operates a voluntary reporting system whereby the onus is on hospitals, GPs and mental health units to record problems themselves.

Patients shouldn't have to face a postcode lottery on patient safety Katherine Murphy, of the Patients Association

It has meant that ever since the programme was launched in 2003 the number of mistakes being reported has been rising as more and more trusts join the scheme.

The last six months have been no different with the overall figure representing a 12% rise on the period before.

The NPSA now has 382 of the 392 trusts on board.

A breakdown of the latest figures show that in two thirds of cases - 303,016 - there was no harm to the patient, while a quarter - 122,246 result in low harm.

Another 28,521 - or 6% - resulted in moderate harm and 5,717 - 1% - in death or severe harm, which is classed as permanent injury or disability.

NPSA chief executive Martin Fletcher said the involvement of most trusts showed that the health service was willing to learn from its errors.

"This will help build an even stronger safety culture of reporting and learning to prevent harm to future patients."

Katherine Murphy, of the Patients Association, agreed the increasing involvement was encouraging.

But she added some of the levels of mistakes being made were too high.

"Patients shouldn't have to face a postcode lottery on patient safety."

And Peter Walsh, of Action Against Medical Accidents, said the reporting of safety incidents should be made mandatory, adding: "Not to do so would be a travesty."

http://news.bbc.co.uk/1/hi/health/8295417.stm

The NHS is turning to no win, no fee legal representation - despite being a persistent critic of the practice.

The health service has spent the last few years complaining the no win, no fee culture has led to a rise in costs incurred in medical negligence cases.

But the NHS Counter Fraud Service is now embracing the system after reaching an agreement with a law firm in a bid to recoup more money lost to fraud.

Patient groups accused the NHS of double standards.

They have a right to do it, but I find the attitude quite amusing when they have been so against it Joyce Robins, of Patient Concern

Half of the medical negligence cases the NHS deals with now are brought on a no win, no fee basis whereby lawyers get paid only if they win the case.

But in return for taking on such a risk, they increase their rates of pay and the practice has led to accusations they have tried to entice patients into legal action.

Nonetheless, the Fraud Service, which supports individual trusts in bringing action, believes the agreement with a law firm called Capsticks will help the service recoup money.

Under the terms of the scheme, Capsticks will provide expert advice and representation at a discounted rate.

About £6m a year is returned to the NHS following legal action against fraudsters - although the true value of the crime is much higher.

Fraud cases can run into hundreds of thousands of pounds with some of the biggest crimes involving companies with NHS contracts or health workers, such as GPs and dentists, incorrectly billing for work.

There are two routes open to the health service when tackling fraud - criminal and civil action - but both are fraught with difficulties.

In criminal cases a judge may not always order the return of funds and even when they do the case may have only been heard on a small sample of the fraud committed.

Civil action, because the evidence required is much lower, is in many ways a more attractive option.

But trusts have often been reluctant to start proceedings because of the time and resources needed.

As a result, there were just eight civil cases launched last year compared with 60 criminal proceedings.

Exploited

The Fraud Service believes the deal with Capsticks will make it easier to pursue civil action.

No cases have been brought yet as it was only finally signed off during the summer, but there is said to be a great deal of interest from trusts in the service.

Allan Carter, head of operations at the Fraud Service, said: "I don't think we would change our view on no win, no fee."

But he added there was no point ignoring a route that may, in the case of fraud, benefit the NHS.

NHS FRAUD Private contractors - The health service has contracts with private firms for a variety of services, including cleaning, catering and procurement, which are all open to abuse Dentists - There is scope in the dental contract for dentists to make out they are treating more NHS patients than they do Pharmacists - They bill the NHS for each prescription they hand out and while many patients do pay for their medicines the fees do not cover the true cost of the treatment so pharmacists claim that back from the NHS. Again there is scope to cheat the system GPs - Family doctors are now paid a bonus for hitting certain targets and while there is some independent assessment of whether these have been met, cases have begun to emerge where fraud is suspected

"We want to help get more funds back into the health service and I think this agreement will help us do that."

He also said that no win, no fee would probably represent only a minority of cases taken on under the deal with Capsticks.

As well as no win, no fee, Capsticks will also be operating under the more traditional hourly and fixed rates.

But despite the potential to recoup more money, there was some surprise at the move.

Joyce Robins, of Patient Concern, said: "They have a right to do it, but I find the attitude quite amusing when they have been so against it.

"I think there is a case of double standards here."

And Karen Jennings, head of health at Unison, said the NHS had been "exploited" by the no win, no fee culture.

But she added: "I can understand why they are looking to do this. With the introduction of the market in the NHS, there is going to be more and more scope for fraud."

http://news.bbc.co.uk/1/hi/health/8292897.stm

One in eight NHS trusts has been told it must urgently improve the care it provides, by a new regulator publishing ratings on England's 392 trusts.

The assessments by the Care Quality Commission show a drop in the number of hospitals meeting basic standards in areas such as hygiene and safety.

But it also said more services than ever could be rated good or excellent.

From April, the CQC will gain new powers to be able to shut any of the 47 underachieving trusts down.

Rigorous assessment

The new commission, which took over the watchdog duties of the old Healthcare Commission earlier this year, pointed out a number of successes in its report.

These included what it called the notable achievement of most patients in England receiving hospital treatment within 18 weeks.

NHS RATINGS 2009 To find out more Care Quality Commission information for England, enter your full postcode here: This search goes to an external site

The government said this was the most rigorous assessment the NHS had ever seen.

NHS Ratings Health Minister Mike O'Brien said the report showed improving standards across the health service.

"We have transformed the waiting experience for millions of patients and now have the shortest waits on record. MRSA and C. difficile infections have been significantly reduced and over three quarters of GP surgeries are providing extended opening hours, giving patients greater choice and more convenient access to GPs."

But shadow health secretary Andrew Lansley said the report showed the government was unable to "turn round poor performers".

"Many staff are doing a great job in keeping up high standards but we cannot allow that to obscure the fact that there has been poor performance in some very important areas in the NHS, such as maternity and stroke services.

"And it is unacceptable that the number of patients who have had their operations cancelled has risen so sharply."

PARTICULARLY POOR PERFORMERS Royal Cornwall Hospitals NHS Trust Great Western Ambulance Service NHS Trust Yorkshire Ambulance Service NHS Trust Maidstone and Tunbridge Wells NHS Trust Barking, Havering and Redbridge Hospitals NHS Trust What do you do with the Royal Cornwall?

The CQC looked at every type of NHS trusts, including acute, mental health, primary care and ambulance.

More than half of primary care trusts were rated good or excellent, with many patients reporting being able to get an appointment within two days and services such as chlamydia screening for young people improving.

There were, however, significant regional variations, with trusts in London performing particularly poorly on patient satisfaction with appointments and opening times.

Fewer mental health trusts were rated excellent or good, and some struggled to meet new criteria on collecting data about services. Ambulance services also failed to perform as well as last year, but the CQC nonetheless praised the general response to emergency calls.

But much of the focus is on hospitals: fewer acute and specialist trusts were rated excellent, with more receiving an unimpressive fair grading.

Based on a system of self-reporting, there was a significant drop in the number of acute trusts fully meeting basic standards such as those relating to hygiene, child protection and training: this was down to 59% of all trusts from 69% last year.

Many also failed to meet new performance targets, such as the collection of maternity data to help improve services, and stroke care.

The number of operations cancelled rose for the second year in a row - equating to 63,000 procedures called off at the last minute for non-clinical reasons.

However a higher proportion are now being rearranged within 28 days of the original appointment, and the figure also reflects the much higher number of people now receiving treatment.

Waiting times for treatment have fallen to 18 weeks or less this year, one of the achievements highlighted by the regulator.

It also noted that 98% of the 19 million patients who attended A&E waited less than four hours, while rates of the infections Clostridium difficile and MRSA had both fallen by about a third - despite hospitals themselves reporting failings in hygeine.

While a number of trusts were singled out for praise - including the Royal Marsden, which has scored excellent every year for both quality and finance - the CQC said the focus now had to be on those which had performed persistently poorly.

Twenty trusts scored weak for overall quality, while 27 others have now never scored higher than fair for either quality or finance in the four years since the ratings system was started.

'Nuclear option'

Some particularly poor performing acute trusts were highlighted: Barking, Havering and Redbridge hospitals received a double weak rating, while the Royal Cornwall Hospitals NHS Trust was deemed weak for the fourth year in a row.

Maidstone and Tunbridge Wells NHS Trust - which saw a deadly outbreak of clostridium difficile amid serious hygiene lapses between 2004 and 2006 - was rated weak for the third year in a row.

The CQC said it intended to work closely with these 47 trusts to sort out their problems ahead of April next year, when it will gain the power to intervene in every trust, from dealing out admonishments to potentially launching prosecutions and closing services down.

"But that would be the extreme nuclear option for any regulator," said CQC head Cynthia Bower.

"Trust are aware of what their issues are, so none of this is going to come as a surprise to them.

"There is an ongoing process of debate to sort these problems out by April, no-one is just waiting around."

The King's Fund chief executive Niall Dickson stressed that overall the report showed the NHS appeared to be performing well, but that it was unfortunate the ratings did not shed light on why some did well and some badly.

"Patients served by the hospitals and other services that consistently rank at the bottom have a right to know why these organisations are not providing the quality of services that is expected from them.

"We need to understand whether the problems are managerial or structural, and what is being done to help them raise their game."

Key areas of lung cancer care are still "woefully inadequate", a report by leading lung cancer experts says.

The UK Lung Cancer Care Coalition, an umbrella group composed of doctors, charities and private health firms, says UK care lags behind Europe.

It says too few patients are receiving treatment, such as chemotherapy or surgery, because of staff shortages.

The government says it already recognises that more needs to be done to improve lung cancer services.

Our review shows there are still huge variations and vast inequalities in care across the country Dame Gill Oliver, of UK Lung Cancer Care

Lung cancer kills about 34,000 people a year - more than breast, prostate, bladder and leukaemia versions of the disease combined.

Despite being labelled a "smoker's disease", one in eight people with lung cancer have never smoked.

The coalition draws on data from this year's official national audit as well as feedback from leading doctors.

The report says in some parts of the UK, as few as 10% of patients are receiving any form of treatment and nationally the figure is only 51%.

The coalition is calling for a target of 70% - recognising that for some patients further treatment is not advisable because the cancer has already spread too far.

It estimates this would save an extra 3,000 lives a year.

One of the major problems is a lack of access to surgeons - there are only 44 full-time positions for more than 240 separate teams.

The shortfall means that some patients who would be eligible for treatment are being turned down, the report adds.

'Vast inequalities'

Dame Gill Oliver , chairman of the coalition, says: "We are still letting lung cancer patients down.

"Our review shows there are still huge variations and vast inequalities in care across the country.

"We believe that whatever the cause of their disease patients deserve the best care and support."

Five-year lung cancer survival rates are still below 9% in the UK, compared with 12.3% across Europe on average.

But the coalition believes survival rates can be doubled by 2020 by making the disease a priority.

It says more money needs to be invested in diagnostic equipment and the workforce as well as encouraging GPs to refer at-risk patients for tests at an earlier stage.

A Department of Health spokesman said: "We know there is more to do on lung cancer.

"That is why we recently re-convened the Lung Cancer and Mesothelioma Advisory Group to look at many of the issues raised in this review, including access to surgery."

http://news.bbc.co.uk/1/hi/health/8334340.stm

An outbreak of the Clostridium difficile (C. diff) bug has killed two hospital patients and contributed to the deaths of three more.

The patients were among a total of eight elderly people who contracted the infection at Ninewells Hospital in Dundee over an 18 day period.

All of those affected had been in the hospital's ward 31, which generally cares for geriatric patients.

Seven of the patients had contracted the more dangerous 027 strain.

NHS Tayside said it carried out regular testing in order to detect C. diff outbreaks early.

Dr Gabby Phillips, lead infection control doctor for Ninewells Hospital, said the ward remained closed to new admissions.

The hospital has been dealing with the outbreak since September, over a 10 week period.

The deaths occurred between 19 October and 6 November.

'Appropriate measures'

Dr Phillips added: "We have comprehensive infection monitoring procedures throughout our hospitals and these are able to rapidly identify any emerging trends of infection which then trigger a rapid response from our infection control teams.

"These cases of C. diff infection were detected very early which meant we were then able to identify the 027 strain rapidly and reinforce all appropriate infection control measures.

"There have been no new cases identified in the ward for 10 days. I am confident that all appropriate procedures to deal with this infection were put in place immediately."

She added that the hospital had sought external advice over its policies and procedures, and had been "reassured that our surveillance systems are robust".

http://news.bbc.co.uk/1/hi/scotland/tayside_and_central/8352612.stm