As part of the Next Stage Review, A high quality workforce: NHS Next Stage review considers the future of the NHS workforce. The main findings are in the final report of the review. This document explains in more detail how each of the findings will be taken forward.

Our NHS, our future: the contribution of healthcare scientists provides examples of the potential contribution that scientists can make to the local Next Stage review process, to developing and setting up services within the primary care setting and to ensuring that the quality, service and safety of services are maintained. It fits in with the Modernising Scientific Careers agenda led by the Chief Scientific Officer, is a key work programme within the Department of Health designed to ensure flexibility, sustainability and modern career pathways for healthcare scientists, fit to address the needs of future NHS.

• The decision to establish a Neonatal Task Force is an important development, with the potential to improve the care for vulnerable babies.

• The reorganisation of neonatal services into clinical networks has had limited impact in reducing geographic variations in mortality rates.

• Whilst three-quarters of neonatal units have reviewed the types and intensity of care a unit should be able to provide safely, the resultant re-designation has yet to be implemented in full.

• There are currently no formal arrangements for performance managing neonatal networks.

• There are wide variations and mismatches in costs and charges between neonatal units for the different levels of care provided, and units’ understanding of costs is generally poor.

• There are serious shortages in the numbers of neonatal nurses with an average of nearly three vacancies per unit for nurses qualified in neonatal care.

• Only half of networks provide specialist neonatal transport services 24 hours a day, seven days a week.

• On average, in 2006–07, each neonatal unit had to close to new admissions once a week due to a lack of baby cots.

The report recommends:

• Department of Health should set the Task Force clear objectives and associated milestones for improving services, and monitor achievements against these milestones to ensure delivery of the
  objectives by the end of 2008–09.

• Prematurity and illness in newborn babies are associated with a complex range of factors, including
  social deprivation, ethnicity and maternal age. Primary Care Trusts need to improve their understanding of the changing demographics of their local population and model the impact on demand for neonatal services to target intervention and prevention strategies on key high risk groups.

• All networks should work with their relevant Primary Care Trusts to use the information from local strategic needs assessment to inform the designation of neonatal units, taking into account the standards recommended by the relevant professional groups. Primary Care Trusts should base their
  commissioning of neonatal services on units being able to demonstrate that they have the right levels of suitably qualified and experienced staff to provide the designated levels of care.

• In return for continued funding of networks, Strategic Health Authorities should agree a set of performance measures and review networks’ performance against these objectives. Strategic Health Authorities should also require the two areas without a formal managed network to establish them as a priority.

• Improving understanding of cost drivers is essential if the Department’s plan to introduce a ‘Payments by Results’ tariff is to be effective. In setting tariffs for neonatal care, the Department should ensure that the full costs, including the costs of meeting professional staffing standards and providing
  transport services, are taken into account.

• Strategic Health Authorities and the new Neonatal Task Force should develop a national action plan to address neonatal nurse shortages, including developing recruitment and retention initiatives based on good practice. In the meantime, Strategic Health Authorities should increase the number of neonatal training courses.

• Strategic Health Authorities working with networks need to develop local partnering arrangements so
  that all neonatal units have 24 hour access to appropriately staffed transport services.

• A third of neonatal units operated above the recommended occupancy rate of 70% and three of the 178 units operated above 100%. High occupancy rates could have major implications for patient safety due to increased risk of infection or inadequate staffing levels. The functionality of the National Cot Locator needs to be improved so that it identifies occupancy levels in order to meet the needs of networks and units wishing to transfer babies.

NHS East of England

Towards the best, together: A Clinical Vision for our NHS, now and for the next decade

NHS East Midlands

From Evidence to Excellence - our clinical vision for patient care

NHS South Central

Towards a healthier future: A ten year vision for healthcare across NHS South Central

NHS South East Coast

Healthier people, excellent care: A vision for the South East Coast

NHS South West

The Draft Strategic Framework For Improving Health In The South West 2008/09 To 2010/11

NHS North East

Our vision, our future, Our North East NHS: A strategic vision for transforming health and healthcare services within the North East of England

NHS West Midlands

Investing for Health: Step 2: Delivering our clinical vision for a world-class health service

NHS Yorkshire and Humber

Healthy Ambitions

• Results show a range of variations between black and minority ethnic (BME) groups and their white British counterparts. Where differences do exist, most are negative, indicating that BME groups are less likely to report a positive experience. But many areas show no difference and a few show a positive difference.

• Patients from the Asian and Chinese/Other groups were less likely to give positive responses.

• Results for Black patients were more mixed, although slightly less likely to give positive responses compared with the White British group.

• Patients from the White Irish group were more likely to give positive responses compared with the White British baseline, across many questions.

• BME groups tended to be less positive about questions relating to 'access and waiting' or to 'better information and more choice'.

• The largest number of differences were seen in the primary care and outpatient surveys. There were relatively few differences for results in the community mental health survey. This is consistent with previous HCC variations reports.

NHS Next Stage Review Leading Local Change sets the context for these local visions and the principles which will guide their implementation.

It recommends:

• Screening should be undertaken in all institutions and repeated at interval according to care setting, using accurate and reliable instruments
• Results of screening should be included in care plans.
• Nutrition advice and nutrition support teams should be routinely available.
• Strategies to detect, prevent, and treat malnutrition should be in place in all care settings, including the community, where most malnutrition originates.

One of the ambitions of free choice is to create incentives for hospitals to drive up quality standards as they compete for patients, but official data shows that:

• use of ‘Choose and Book’ — the computer system designed to facilitate choice — whilst increasing still falls short of the government’s target, with only 50 per cent of referrals from GP to hospital being made using the system
• although increasing numbers of patients say they remember being offered a choice of hospital by their GP since the policy began in 2006, the proportion is still only 45 per cent
• of those 45 per cent, only 27 per cent said their GP gave them a booklet containing comparative information on hospital performance to help them make a decision.

• Measurement of patient outcomes and use of that information to drive better commissioning of services should be made an explicit element of the Government’s vision of “world class commissioning”.

• Mortality and survival data should be collated and published for all condition/treatment areas at the same time as collection of other outcomes data is initiated. Data on casemix must be collected, so that the crude mortality/survival data can be adjusted for the casemix treated. Confidence intervals should be estimated and reported to permit comparisons to be made over time and between providers.

• For elective surgery, condition-specific measures should be collected beforeand after surgery simultaneously with the generic EQ-5D for all NHS patients undergoing common procedures.

• Measurement of mental health outcomes in secondary care should be reinvigorated with collection of HoNOS data being incentivised in addition to mental health providers being reminded of its mandatory nature as part of the Mental Health Minimum Data Set. Routine collection at annual intervals of the CORE-OM measure for all patients receiving community based mental health services be piloted in a range of NHS Trusts at the earliest practical opportunity in 2008/09.

• Research is required to identify a generic measure of health related quality of life that is suitable for application to mental health patients as well as recipients of other kinds of health care.

• The practicality and value of collecting and using measures of outcomes for COPD patients should be piloted by a range of commissioners and their secondary and primary care providers, commencing in 2008/09. The preferred disease specific measure is either the Chronic Respiratory Disease Questionnaire (CRDQ) or the St George’s Respiratory Questionnaire (SGRQ).

• For colorectal cancer patients, mortality data (1 year and 5 years after diagnosis) should continue to be monitored and assessed as an important but partial measure of health service productivity in this disease area given its relatively high rate of mortality. But at the same time instigation in 2008/09 of pilot programmes of routine use of the EORTC QLQ-CR38 instrument to measure outcomes in colorectal cancer patients simultaneously with the EQ-5D or an SF- series generic measure should be undertaken.

• Collection of data about the wider benefits from health services by addition of questions on patients’ experience of care to the patient questionnaires used to measure health outcomes. Aspects covered should include: access, care co-ordination, autonomy, choice, communication, confidentiality, dignity, quality of amenities and support for carers.Further research is needed into the relative values of the wider benefits referred to in recommendation 8 and by compassion with health outcomes.This should be commissioned during the course of 2008/9.

• Information on wider benefits is already collected in national patient surveys. Building on its ‘customer experience information’ project, the Department of Health should work with its counterparts in Northern Ireland, Scotland and Wales on a UK-wide stock-take of patient surveys in process and planned, and then use this as the basis for discussion with all the interested parties how to co-ordinate those surveys in future.

• After a short period of research to identify the most practical way of collecting such data, including working days lost, measurement of productivity effects should be commenced for patients being treated for mental health problems, diseases of the nervous system and diseases of the musculo-skeletal system should be identified.

• Modification of existing national surveys of a sample of the general population should be investigated as one way of collecting at a general level data relevant to the wider societal impacts of health care interventions, including impacts on carers.

• Health care professional bodies, including the Royal Colleges, should explicitly and actively support the collection and use by their members of patient outcome measures, including the provision of training in their collection and use for both existing and new clinicians.

• Training in understanding and using outcome measures should be provided to NHS commissioner and provider managers.

• Investment should be made in IT and appropriately trained staff to enable user-friendly information collection, collation and analysis of outcome measures.

• The NHS should, commencing as early as possible in 2008/09, pilot, monitor and evaluate explicit incentives to collect, collate, analyse, feedback and use patient outcome measures. Initially at least this would not be extended to rewarding providers for the measured levels of outcomes achieved, although that could be considered once experience with use of outcomes measures has accumulated.

• There should be an expectation that within 5 years (i.e. by the end of 2012/13) routine measures of patient outcomes comprising the impact of an NHS intervention in terms of patient survival, quality of life, and experience of care, are collected for the majority of NHS activity. Within 10 years it should be the exception rather than the rule to find an area of NHS activity that is not assessed and actively managed according to the outcomes achieved.

• The NHS should work with the ONS Centre for the Measurement of Government Activity to ensure that the health outcomes data used by the NHS can also used by ONS in its periodic assessments of NHS productivity and, subsequently, in the National Accounts.

• different age groups
• selected consultant specialties most likely to be involved in the care of children and young people
• emergency admission methods
• length of stay in hospital

This Audit Commission report finds that under PbR most hospitals have improved their financial management and now have a better understanding of how much it costs them to treat patients. The impact on the NHS in terms of efficiency and activity has been smaller than expected, however, and PbR seems to have contributed to positive trends rather than driven them.

The report sets out a number of priorities for future development of the policy that need to be addressed if PbR is to deliver further improvements:

For Primary Care Trusts

• Further develop commercial, legal and contracting skills, identifying gaps in line with the developing World Class Commissioning competencies, to improve their ability to operate in the PbR environment.

• Ensure that 2008/09 contracts contain appropriate incentives and penalties to support appropriate, high quality care, for example, readmissions targets, and that information requirements are clearly specified and enforceable. Progress against these targets should be reported regularly.

• Adopt a robust yet proportionate approach to monitoring and challenging provider activity and costs under contract, prioritising investment in practice level information systems so that practices can engage in the planning and monitoring of hospital activity.

• Actively monitor provider actions in response to the Audit Commission’s PbR data assurance audits, and use the findings from these audits to supplement existing information on potential data quality issues.

For Acute NHS Trusts

• Ensure that robust information and reporting systems are in place that meet all internal and external requirements within the minimum reporting deadline of 30 days following the end of the month, and that local information systems are in place to complement SUS as necessary.

• Embed and promote service-line management and reporting, paying particular attention to the use of surpluses and how this will be managed within the organisation.

• Understand the costing data they require to manage the business, and invest in improving internal costing systems, considering the business case for introducing patient level costing systems where appropriate.

• Prioritise the implementation of the OPCS-4.4 classification system for procedures, to improve coding internally and to support the introduction of HRG4.

• Engage in discussions with commissioners about changing patient pathways, demand management and use of local flexibilities, such as unbundling the tariff into its component parts.

For the Department of Health

• Identify and explicitly prioritise the changes that will be most effective in achieving policy objectives, and ensure that the development programme for addressing these priorities is realistic, properly resourced and communicated to stakeholders.

• Ensure that timely guidance, support and direction continues to be provided to both commissioners and providers in a balanced way, including more effective mechanisms for receiving and providing feedback, particularly in relation to contract and information issues.

• Review and address the perceived limitations of SUS in supporting PbR, ensuring there is a clear vision for NHS data and organisations’ responsibilities that is shared by NHS Connecting for Health and the Information Centre for Health and Social Care, and that the expectations of the NHS are consistent with this vision. Additional steps should be taken to ensure that guidance from these bodies is consistent.

• Invest in information systems to capture and report on community services and support the development of an appropriate payment mechanism.

• Monitor usage of the new standard contract and reinforce the move toward a consistent approach to contracting across the NHS, providing guidance as appropriate to ensure that balanced, fair contracts, that support nationally agreed principles, are negotiated.

• Use the tariff as a policy lever to drive desired behaviours, rather than purely as a reflection of average costs, signalling likely changes to the NHS well in advance.

• Explore the use of separate payment streams in addition to the tariff, for example to reward quality or to fund capital costs, where this is necessary to provide the right incentives to NHS bodies.

• Carefully monitor the implementation of HRG4 to ensure that the additional complexity of the payment classification is warranted and is not undermining policy objectives.

There is evidence that inpatient services are losing staff and resources to community
services, but that pressures on inpatient beds remain high. Over half of all wards are full or have more patients than beds, with staffing shortages and unpleasant ward environments undermining the therapeutic purpose of inpatient admission.

The report highlights the dangers inherent in devolved service commissioning for ensuring adequate levels of specialist provision, and note the vulnerability of mental health services as Trusts face financial crises.

The extension of patient ‘choice’ across health service provision should not be allowed further to disadvantage or ostracise patients who are unable to exercise choice because of their mental incapacity or because of legal powers of compulsion held over
their treatment.

Boundaries of current mental health law under stress, with discussion of about forty cases
in court, and a more general observation of legal powers being used in ways that may not have been intended by Parliament, often for pragmatic reasons where professionals are keen to intervene in what they perceive to be a person’s best interest or as measures of social order.

It also discusses aspects of the use of present mental health powers in relation to civil detention and police powers, including an extended discussion on the detention of mentally disordered offenders.We provide analysis of deaths of detained patients; seclusion incidents notified to the Commission; and Second Opinion activity during this period.

The report has a strong focus on measures to encourage and support the empowerment of all patients, including those without mental capacity to make certain decisions about their care.

It finally reviews the proposed future arrangements for monitoring detention of mentally disordered persons and suggest ways in which the forthcoming Mental Health Bill might be improved to ensure acceptability to mentally disordered persons and the effective protection of their rights.

Mental Health Act Commission Eleventh Biennial Report - Errata and Addendum

There is currently no legal framework for the Secretary of State to direct the Appointments Commission to suspend chairs and non-executive members or directors from office. The consultation documentation sets out proposals on the amendments that need to be made to the relevant legislation in order to allow for suspension of chairs and non-executive members or directors of PCTs and NHS trusts, and for temporary non-executive member(s) or director(s) to be appointed during the period of suspension. The consultation includes an impact assessment.

It is intended that the introduction of a suspension function for SHA chairs and non-executives will be covered by a separate consultation at a later date.

Physical Comfort of the Patient 

• Medication was assessed and non-essential medication was stopped in 93% of patients.

• Anticipatory prescribing was undertaken for pain relief in 91% of cases, for agitation in 84% of cases, for the prevention of respiratory tract secretions in 80% of cases, for nausea in 80% of cases and for breathlessness in 67% of cases.

• Inappropriate blood tests and antibiotics were discontinued in 87% and 91% respectively, and recording of ‘not for Cardio Pulmonary Resuscitation’ (where appropriate) documented in 93% of patients.

• In regard to ongoing care the presence or absence of symptoms could be recorded for patients during the last 24 hours of life. The status was not recorded for 18% - 19% of those assessments. Where the status was recorded patients were assessed as being symptom controlled in 95% for pain; 94% for agitation; 91% for respiratory tract secretions and 99% for nausea and vomiting of occasions.

Psychological and Spiritual Aspects of Care

On commencement of the LCP (Initial Assessment)

• Patient awareness of diagnosis and recognition of the dying phase was recorded as having been achieved in 57% and 45% of patients respectively. In one third of cases there was no documentation on the LCP suggesting a need for further education and training for healthcare staff.  Some hospitals, however, did achieve 100%.
• In over 80% of cases, carers were recorded as being aware of the diagnosis and dying phase, suggesting that healthcare staff find it easier to talk to carers
• The spiritual needs of patients and carers were recorded as being assessed in 34% and 53% (respectively) of appropriate cases

Communication with Patient,Carer and Healthcare Professionals

This is variable but carers were more likely to have had the care plan explained to them than the patient:

• At Initial Assessment, documentation confirmed that patients had the care plan communicated to them in over one third of cases, compared with 78% of carers.  It was recorded that 90% of those carers understood the care plan after it was explained to them.

• Communication with primary care (both on commencement of the LCP and after the death of the patient) was documented as having taken place in only about a third of cases, although there were pockets of good practice

Information Giving and Receiving

• Contact information about the most important person to contact in case the patient’s condition deteriorates was achieved at Initial Assessment in 79% of cases and Hospital information leaflets regarding facilities and access were given out in 59% of cases at that time
• Around the time of death or deteriorating condition of the patient (Initial Assessment), only half of families were recorded as having been given appropriate information about local and national procedures that may need to be followed.

Following Appropriate Procedures

• Following death, appropriate hospital procedures for laying out of bodies, storing of patient’s belongings and other activities were documented as having been followed in around half of cases.  However, the high level of care after death goals that are left blank at the point of delivery of care requires more investigation before firm conclusions can be made. 

Critical Care Medicine
Pediatric Critical Care Medicine
Intensive Care Medicine
American Journal of Respiratory and Critical Care Medicine
Intensive Care Medicine
Critical Care Nurse
Dimensions of Critical Care Nursing
American Journal of Critical Care
Australian Critical Care
Anesthesiology
Anesthesia and Analgesia
British Journal of Anaesthesia
Anaesthesia

Advanced warning the Fade Nativity is on the way...

Principles and rules for Cooperation and Competition are the subject of Annex D and recognise that competition and choice are powerful levers to drive up service quality, deliver better value and reduce inequalities but require enforceable rules guiding and governing behaviour within the healthcare system.  These rules ensure fair and transparent competition where this is needed to make the best use of resources and enable innovation, and provide essential safeguards for the interests of patients, taxpayers, and the reputation of the NHS.

There is also a new Standard NHS contract for acute services in Annex E.

In summary the 2008-09 Operating Framework sets out:

1. NHS priorities for the year ahead: freeing up the front line by moving towards local stretch targets, whilst delivering on national priorities. 2008/09 is the start of the next three-year planning round. In this context, the Operating framework sets out the priorities and planning framework for the NHS for the 2008/09 financial year, within the context of the 3 year CSR period 2008/09 – 2010/11;
2. Reform levers and enabling strategies: reform with a purpose – to improve services. The focus will be on developing world class commissioning as the key agent for change on behalf of patients and the public, using the full range of levers and incentives to transform services and improve outcomes;
3. Financial regime: setting out a framework that fully supports reform goals and incentivises transformational improvements in services within available resources. Key to this will be the need to sustain the surpluses the NHS is on track to deliver;
4. The business processes: ensuring a business-like and transparent approach to planning that supports locally led decisions whilst providing accountability. There is a strong emphasis on genuine partnership working at a local level with local government and other partners to ensure that local health and wellbeing needs are better understood and addressed in partnership.

Key findings are:

The health of the population is improving with significant increases in life expectancy, but there are major disparities around the country, particularly in poorer areas where there are often fewer GPs.

• Men are living over four years longer than they were 20 years ago, while women are living three years longer.
• Men from more deprived areas live for a decade less than those in wealthier areas. Looking at local authority areas, for example, Kensington and Chelsea has the highest life expectancy for both men and women, at 82.2 years and 86.2 years respectively. The lowest life expectancy for men is in Manchester at 72.5 years, and for women in Liverpool at 78.1 years.
• In poorer areas, where people tend to experience worse health, there are 18% fewer GPs than in the least deprived areas (54 per 100,000 people compared to 66).

Patients are positive about hospital services overall but some organisations perform poorly. Beneath the headline figures there are concerns about aspects of care such as dignity and privacy.

• National analysis of the Commission's survey of 80,000 inpatients at acute hospital trusts shows that 89.2% (149) were ranked "satisfactory" on patient experience, 7.8% (13) were "below average" and 3% (5) were "poor". Eleven of those in the latter two groups were rated as "below average" or "poor" for the second year running. The survey also shows concern about specific issues such as help with eating - one in five patients who wanted help eating did not get it.
• Almost a third of the complaints about hospitals referred to the Commission for independent review relate to dignity and respect, nutrition and other aspects of basic personal care. They included: patients left in soiled bedding and clothing; no regular baths or showers or oral hygiene; inappropriate or inadequate clothing.

There have been dramatic improvements in waiting times but there are hidden waits for some services, which are not measured and therefore difficult to address.

• Government standards say no patient should wait longer than 26 weeks for a hospital appointment. In 2006/07, 83% of trusts met this, leaving some 350 patients with longer to wait than 26 weeks. This is a vast improvement on figures for 2000 when 264,000 patients waited this long.
• Waiting time targets do not apply fully to some services, making it difficult for problems to be addressed and patients needs to be met. Evidence suggests that a two-year wait for those referred for psychological therapies is not uncommon. People in some areas are still waiting between 12 and 24 months to have hearing aids fitted.

NHS trusts are performing better overall on quality of services, but the performance of primary care trusts (PCTs) has declined, with many not getting to grips with the needs of their communities so as to provide services to match.

• Overall, the quality of NHS services is improving with 46% of trusts rated ‘excellent' or ‘good' in 2006/07, compared to 40% in 2005/6. But for PCTS, only 26% were ‘excellent' or ‘good' in 2006/7 compared to 33% in 2005/6. Many PCTs went through a reorganisation over the period but this does not provide a complete explanation for the underperformance.
• The Commission says PCTs form the bedrock of healthcare. They control more than three-quarters of the budget, purchasing services from other providers, including hospitals. They are directly responsible for providing services handling more than 80% of NHS contact with patients, including those carried out by GPs and dentists.
• The report says that many PCTs do not fully understand the health needs of their local people, making it difficult for them to buy targeted services. For instance, last year 2.3 million people did not have their BMI index recorded as planned, with GPs not recording the data, which provides vital statistics on levels of obesity. The number of people diagnosed with heart failure is also considerably less (140,000) than expected, indicating that GPs may not be picking up on signs of serious illness. There is also a poor understanding of the sexual health of local populations at a time when sexually transmitted infections are rising rapidly.
• Where there is a known need, PCTs are not always providing the services required. Some 60,000 people with serious long-term conditions did not get the care from community matrons that was originally planned. Forty-one per cent of PCTs failed to purchase sufficient crisis services for people who are seriously mentally ill, resulting in 5,000 fewer people receiving the service than planned. Some 85% of PCTs did not have arrangements for providing education programmes for patients with diabetes in their area. And 2,000 GP practices did not fulfil their PCT's plans to establish registers for those people at risk of coronary heart disease, designed to help prevent these patients from becoming seriously ill.

There is progress towards a stronger culture of safety and grounds for cautious optimism in reducing healthcare-associated infection. But trust boards need to show stronger leadership.

• On safety more generally, there has been an encouraging increase in reporting of incidents. Reported figures show more than 229,000 known incidents causing low or moderate harm and more than 9,400 incidents causing severe harm or death.
• Only 58% of NHS trusts complied with all the government's nine core standards on safety, with infection control, decontamination of medical devices and medicines management the biggest areas of concern.
• Infection control is arguably of greatest public concern; latest figures suggest grounds for cautious optimism. Cases of MRSA fell from 7,096 in 2005/2006 to 6,381 in 2006/2007. There are early signs that increases in cases of Clostridium difficile are slowing. Between 2005 and 2006 the number of cases increased 7% to 55,620, compared to a 16% rise from 2004 to 2005.
• By the end of October 2007 the Commission had visited 87 trusts to check their performance in meeting the requirements of the hygiene code. Only one trust needed to be issued with an improvement notice, suggesting that organisations are taking the issue seriously. But there was a need for stronger leadership from trusts' boards to improve monitoring, isolation facilities, training, and compliance with policies and procedures.

New figures show that more independent healthcare providers meet core standards, mirroring a similar trend among NHS trusts. But there are concerns about compliance among independent providers of mental healthcare.

• The proportion of independent healthcare establishments that met the government's national minimum standards - including those that were not inspected as they were considered not to be at risk - was 63% in 2006/07 compared to 50% the year before. Five per cent of independent establishments failed five or more of the standards.
• Although NHS trusts must meet a different set of standards, the broad picture is similar. The number of trusts that were "fully met" on government core standards rose from 49% in 2005/06 to 55% in 2006/07. Six per cent of trusts were judged "not met" on core standards overall.
• In the independent sector, non-compliance was greatest on national minimum standards covering: monitoring of quality of treatment (C4); ensuring patients get care from appropriately recruited, trained and qualified staff (C9); and taking account of patients' views (C6).
• Independent mental health providers, which mostly look after NHS patients, performed worse than others in the sector. Non-compliance was greatest in relation to national minimum standards for: ensuring patients receive care from appropriately recruited, trained and qualified staff (C9); providing treatment in safe and appropriate premises (C17); and ensuring patients are resuscitated appropriately (C27).
  Independent providers of mental health services need to focus on ensuring patients are appropriately and safely restrained. In 2006/7, 17% of establishments failed a standard in this area compared with under 9% in 2005/2006.

The NHS often fails to meet the needs of children and young people and there are concerns about other groups requiring specialist care, such as people with mental health problems and with learning difficulties.

• Paediatric hospital services are generally good at looking after children, but other more general services are not. Some 70% of specialist inpatient services were rated "good" or "excellent" by the Commission, but 28% of emergency and day case services were "weak". Transition from children to adult services is not managed well in services for people with mental health problems, diabetes and disabilities, and those requiring palliative care services. Vulnerable children such as those with disabilities, those in care and young offenders face particular problems in getting appropriate care. One in 20 NHS trusts are not yet compliant with child protection standards.
• On specialist wards for people with mental health problems and people with learning difficulties, more than half of the inpatients were found to be in mixed-sex accommodation.
  Levels of violence in mental health services remain high, although there are signs of it being dealt with better. The report includes new data from an audit into violence in the sector, which found that almost one in 20 patients reported being assaulted. Forty-six per cent of nurses reported being physically assaulted, and 72% said they had been threatened or made to feel unsafe. On older people's mental health wards, almost two-thirds of nurses reported physical assault by patients.

There have been dramatic improvements in responding to the big killers - cancer, circulatory and respiratory disease - but five-year survival rates for cancer, and mortality rates for respiratory disease, are worse than in other comparable countries.

• The mortality rate for people under 75 diagnosed with cancer fell by almost 17% between 1996 and 2005, which suggests that some 60,000 fewer people died prematurely.
• Despite this improvement, the UK survival rates do not compare favourably with most of Europe. For instance, the survival rate for lung cancer in Holland and Spain is around double that in England, which stands at 6.5% for men and 7.6% of women.

A Self assessment checklist for trusts allows Trusts to check their progress in adopting NCEPOD's recommendations following the 2007 report 'Trauma: Who cares?'. This toolkit is for Trust use.

You can check out what the papers said on 21st November 2007 about the report on Fade the Blog.