Lo! The Care Quality Commission has spoken on quality. Look upon their works, ye 47 underachieving trusts, and despair.

Their lines for the media have all been about how trusts who had merely remained 'fair' would not be considered to have made sufficient progress; that the un-fab 47 (20 were weak on quality this past year; another 27 who have not risen above 'fair' in the past four years' assessments of quality and financial management) will be supported to achieve sucessful registration by April 2010 ... you've seen the stories.

For quality, the CQC rated 15% of trusts “excellent”, 47% “good”, 33% “fair” and 5% “weak” (last year, 26%, 35%, 34% and 6% respectively).

In financial management, 26% were rated “excellent”, 45% “good”, 26% “fair” and 3% “weak” (last year, 24%, 37%, 34% and 5% respectively).

Primary care trusts earned better results overall, with more than half rated "excellent" or "good" for the first time.

But there was a decrease in ratings awarded to acute hospital trusts, with fewer trusts rated "excellent" and more "fair".
One point worth noting for the CQC figures is that the increase in acute trusts reporting that they are failing to comply in several categories may well be down to more accurate (read honest) self-assessments this pats year. Like trusts who are high reporters of patient safety incidents,

Cakes and ALE?
We have to add this to the recent Audit Commission verdict on financial performance, the Auditor's Local Evaluation (ALE - top acronym, hurrah!) for provider trusts, and the less exciting (but at least new this year) Use Of Resources (UoR) for PCTs. UoR is of course part of the new Comprehensive Area Agreements (CAAs, inevitably), which are designed to ensure that all the local bits of public service provision and comissioning pretend to talk to each other on a regular basis.

The change of methodology, of course, means that the 2008-9 results can't be compared with previous years when PCTs were assessed under ALE. (I wish I was being, too.)

The Audit Commission found a fair amount of encouragement: only six provider trusts and one PCT failed to achieve in-year financial balance. The reasons for these are mostly historical ones.

93 per cent of NHS trusts (116) met or exceeded minimum standards (91 per cent in 2007/08); 69 per cent of NHS trusts (86) were assessed as performing well (level 3) or performing strongly (level 4) (49 per cent in 2007/08); „ 9 per cent of NHS trusts (11) were assessed as performing strongly (4 per cent in 2007/08); and only nine NHS trusts failed to meet the minimum standards (14 in 2007/08).

Overall, the ALE picture for providers was one of ongoing improvement. The UoR picture was more mixed: in managing finances, 70 PCTs (46 per cent) were performing at minimum requirements and 80 PCTs (53 per cent) were performing above minimum requirements. „„ In governing the business, 109 PCTs (72 per cent) were performing at minimum requirements and 42 PCTs (28 per cent) above minimum requirements.

In managing the resources, 121 PCTs (80 per cent) were performing at minimum requirements and 24 PCTs (16 per cent) were performing above minimum requirements.

„Only two PCTs scored below minimum standards for managing finances; one PCT scored below minimum standards for governing the business; and seven scored below minimum standards for managing resources theme.

No PCT performed excellently in any of the three themes.

From average to good and from failing to not failing
The line you will hear trotted out by David Nicholson and others is about the NHS moving "from good to world-class". All that gubbins is fine for fans of rhetoric and Jim Collins, but the NHS faces two important challenges: how to support the improvement from average performance to good performance in a substantial minority of trusts; and from failing to not failing in a tiny minority.

Another way to phrase this would be to distinguish improvement work from remedial work. The worst-performing trusts were very much those expected. The concern now is how quickly a meaningful plan to address the underperformance can be achieved. It is not easy. Would the solution in Cornwall be to close the hospital there? And how about London? Reform of provision in London has been bottled for years.

The cultural questions are more acute for those trusts who have not been improving: the CQC is right to focus its attentions on this group.

What is not yet clear is how these trusts are going to be monitored, supported and occasionally threatened. Someone must wield the carrot and the stick. The role is currently messily distributed between SHAs, the DH, Monitor and various safety regulators.

Farewell, the safe middle
But the key changes have to be internal ones, to trusts' own organisational psychologies. It is no longer good enough to follow the old NHS tradition of 'safely in the middle, neither a top performer nor a bottom performer'. The money to paper over the cracks (unfortunately few of which were actually filled with the Blair billions) is running out fast. That means that every level achieved should become the baseline, and that failing to improve should be only slightly less negative than slipping down a level.

This cannot be imposed from outside. It has got to be internalised.