Social Research Institute

Frontiers of performance in the NHS II “Stop looking up to the Department... and start looking out to your local populations and patients” David Nicholson NHS Chief Executive

About Ipsos MORI

Ipsos MORI is the sum total of two successful research companies, Ipsos UK and MORI, which joined together in October 2005 to create the second largest research company in the UK. We offer a full range of quantitative and qualitative research services, as well as extensive international research capacity.

The Ipsos MORI Social Research Institute works closely with national government, local public services and the not-for-profit sector. We help policy makers understand what works in terms of service delivery, and we provide robust evidence to bridge the gulf between the public and politicians — we also provide a host of background information for clients on key policy challenges.

The NHS and Public Health research team is a leading provider of research on attitudes of public service users, staff and other stakeholders. The team works extensively with the Department of Health and many Trusts and Strategic Health Authorities on a wide range of issues, from communications approaches to patient satisfaction, using the full range of research techniques.

2 Ipsos MORI: Frontiers of performance in the NHS II Contents Foreword 2 Executive Summary 4 Introduction 6 How is performance measured in the NHS? 6 Structure of the report 9

Part 1 – PCTs 11 1. What factors are associated with positive patient ratings of PCTs? 12 A. The effect of objective performance measures 12 B. Local population factors 16 C. Can we predict PCT patient ratings? 20

2. What performance levels should we expect? 24 A. Actual versus predicted ratings 24 B. Putting the patient ratings into context – who is performing well given their local conditions? 25 C. The best performers 26 D. Implications for PCTs 27

Part 2 – acute trusts 29 3. What factors are associated with inpatient ratings? 30 A. Perceptions of specific service dimensions and overall patient ratings 30 B. Local population factors 37 C. Can we predict inpatient ratings? 40

4. What performance levels should we expect? 44 A. Actual versus predicted ratings 44 B. Putting the patient ratings into context – who is performing well given their local conditions? 45 C. The best performers 46 D. Implications for acute trusts 48

Conclusions 51 What does this mean for you? 51

Appendices 53 Appendix A – Performance tables 54 Appendix B – Regression Analysis 90 Appendix C – Notes on the data 92

Ipsos MORI: Frontiers of performance in the NHS II 1 Foreword

When we launched the preview draft of this report in January 2008, we were delighted with the response we received. The reaction from primary care and acute trusts alike has been that this report has given them important insights into how their patients view them, and, more importantly, what drives those perceptions.

Perhaps the audience with the greatest interest in the report has been those health bodies faced with providing high quality services in some of the most challenging areas of the country. The report highlights the importance of “place” in shaping people’s views of the healthcare they receive: if you’re in a tough area, people are much less likely to give you the benefit of the doubt, and your satisfaction scores are likely to be lower than in the leafier, less deprived parts of the country. This is something many health bodies working in these tough areas have long suspected, and the report has proved an asset in starting to quantify this effect.

The flipside is also true. Trusts and PCTs in less deprived, less diverse areas have an easier ride: their patients tend to be far more positive about the healthcare they receive. So a good patient score in these areas may simply reflect a more positive target population, rather than anything about the services per se. The message here for health bodies with high patient satisfaction scores is: make sure you’re not being complacent.

Perhaps the key message from this is to reframe the question trusts and PCTs should be asking themselves. The question is not: how well are we doing? It’s: how well are we doing compared with what’s expected for this type of area? Refocusing the question in this way is key to helping health bodies consider more closely whether they need to raise their game. And as the following analyses show, asking the question in this way reveals some interesting shifts in who count as the better and poorer performers: the Newhams and Lambeths of this world are doing far better than their raw scores would suggest.

For acute trusts, the analysis goes beyond this, revealing which of the things practitioners do are most linked to improved patient satisfaction. Privacy, pain control and good communication are all important – but the real drivers of satisfaction are treating people with dignity, involving them in the decisions that affect them, and making sure the place is clean. The question for trusts now is: what does this look like in practice? What specifically do you need to do to engender a sense of dignity – and how does this vary for different groups of patients? How involved do patients have to be to really feel involved in their healthcare decisions? What things really count in patients judging whether the wards are clean? Understanding these issues will be invaluable for acute trusts looking to build a stronger reputation amongst their patients.

2 Ipsos MORI: Frontiers of performance in the NHS II Perhaps the one gap in this analysis is understanding what PCTs can do to increase patient satisfaction. It’s a gap because the data we’ve been able to access for this report does not provide a ready route into this question. Nevertheless, it’s a question that PCTs should be focusing on. The World Class Commissioning agenda is driving PCTs to far better understand their local communities – and as part of this, it will be important to understand what’s driving your reputation and how satisfied people are with you. Comparisons on measures such as this are likely to become far more visible, so the best trusts would do well to really delve into this question.

Historically, the NHS has not perhaps focused as much attention on social research as other sectors. We hope therefore that what follows demonstrates that it is worth paying attention to the research findings and what they mean. We hope too that you find this a useful contribution to the debate about how the NHS can best deliver the best patient care.

Jonathan Nicholls Research Director – NHS and Public Health May 2008

Ipsos MORI: Frontiers of performance in the NHS II 3 Executive summary

The NHS today increasingly talks about being “patient-centred”; its Chief Executive asks it to “stop looking up to the Department….and start looking out to your local populations and patients”. How well are those charged with delivery on the ground doing on this, and what factors affect patient perception?

In 2004, Ipsos MORI published our first Frontiers of Performance in the NHS, exploring what was driving patient perception, and identifying key local factors that had very significant effects on patient perception. This report brings this work up to date, and raises a number of key questions.

We explore those factors underlying the patient experience from a range of patient surveys – both individual aspects of the treatment and care received and more objective performance measures. We add to this with an examination of the geo-demographic factors that are associated with patient ratings – the nature of local population served by the Trusts in question – and ask what role local conditions play in determining patient ratings, as opposed to action by managers.

The Primary Care Sector

Our analysis shows again that objective performance measures, such as the standardised mortality ratios and expenditure per patient (reference costs), have little relationship with patient ratings of primary care services.

Instead, the nature of local communities has far more impact. Our analysis shows that PCT services in areas with high ethnic fractionalisation (the extent of different ethnicities in an area), high deprivation, those with a younger population and those situated in London nearly always receive lower ratings of satisfaction than those serving wealthier, older, more homogenous populations. We can predict patient ratings with some accuracy, simply by knowing the characteristics of the local population served by the PCT.

This means that when looking at patient perception of PCT services, it is important to take into account local factors: brilliance looks different in different places. Given the strong associations found, in some cases it will be misleading to consider just the raw scores of patient ratings in making judgements. Our analysis argues for a more comprehensive measurement of patient experience, taking all these factors into account.

Lessons can be learned from those PCTs that are able to overcome the challenges posed by their local conditions and achieve relatively high patient ratings, like Lambeth. In this report we have analysed patient experience data for all PCTs and using regression analysis techniques, identified those Trusts which perform best and worst – after taking into account local conditions.

The Acute Sector

In the acute sector we find that the nature of the place has much less impact, although as with PCTs, and indeed ratings of the NHS by non-patients, London faces particular challenges, as do trusts serving younger, more ethnically fractionalised populations.

4 Ipsos MORI: Frontiers of performance in the NHS II As in 2004, for acute trusts, a limited number of individual aspects of care are highly correlated with overall patient experience. It is vital to get these right. The analysis shows three areas as key drivers of overall inpatient ratings – treating patients with dignity and respect, involving them in decisions and the cleanliness of the hospital room or ward.

Breaking down the concept of “dignity and respect” highlights a close association with a number of other individual aspects of care. It confirms the importance of involvement in treatment decisions and cleanliness and also shows associations with the privacy of treatment and pain control. Understanding what these mean for specific staff behaviours, organisation and communications is key.

Key Findings

• Objective performance measures, such as standardised mortality ratio and reference costs, show a weak relationship with overall ratings of primary care satisfaction. • The analysis confirms what we found in 2004 - local population factors are associated with patient ratings, particularly in relation to primary care. PCTs in areas with high ethnic fractionalisation, high deprivation, those with a young population and those situated in London or the West Midlands are likely to receive lower ratings of satisfaction. • This means that it is possible to predict patient ratings with some accuracy, simply by knowing the characteristics of the local population served by the PCT. • A strong predictive model was produced, explaining 69% of the variation in patient ratings, containing ethnic fractionalisation, levels of deprivation and being situated in the East of England as key negative drivers of patient satisfaction. The number of GPs per population, the percentage of the population aged over 65, and four region indicators – North West, North East, Yorkshire and the Humber and East Midlands – all exert a positive influence. • The PCT model is broadly similar to that produced in 2004 but with the inclusion of four region indicators as positive drivers and exclusion of London and the South East as negative drivers. • For acute trusts, a weaker predictive model was produced, explaining 40% of the variation in patient ratings, containing the percentage of the population aged under 16 and being situated in London as negative drivers. • This model differs from that produced in 2004, where local factors were found to be more strongly associated with patient ratings. Our 2004 model contained ethnic fractionalisation, proportion of the population over 65 and two region indicators, South East and East of England, in addition to the drivers in the current model. • Individual aspects of care are highly correlated with overall ratings of inpatient care. Most important are treating patients with dignity and respect, involving patients in decisions and the cleanliness of the hospital. • There is a clear contrast between the two types of health bodies – for acute trusts ‘how patients are treated’ is more important, whereas for PCTs, ‘where patients are treated’ is more important in predicting patient satisfaction.

Jonathan Nicholls, Anna Quigley, Daniel Tse, Caroline Webb, Ben Page. London, April 2008.

Ipsos MORI: Frontiers of performance in the NHS II 5 Introduction How is performance measured in the NHS?

The current system for rating performance in the NHS was launched in March 2005 by the Healthcare Commission, the body responsible for assessing and reporting on the performance of both NHS and independent healthcare organisations. The annual health check scores NHS trusts on many aspects of their performance, including the quality of the services they provide to patients and the public as well as their management of finances and other resources such as property and staff. These scores are based on a range of information gathered throughout the year through various service reviews and inspections, as well as data collected by other organisations, such as the Commission for Social Care Inspection, the Mental Health Act Commission and the Criminal Records Bureau.

However, the recent emphasis on a patient-centred NHS means that the views of patients are becomingly increasingly important. The ‘Our NHS, our future’ interim report states that “effective change needs to be animated by the needs and preferences of patients, empowered to make their decisions count within the NHS”. The Healthcare Commission itself acknowledges that health services should be shaped by what matters most to patients and the public – its own survey programme of NHS patients, the results of which feed into the annual health check, is building up a national picture of people’s experience that will allow it to compare:

• patient satisfaction with different organisations

• changes in patient ratings over time

• variations in patient experience between different patient groups

This programme of work provides an assessment of patient satisfaction, but does not provide an explanation of what factors lead to patient satisfaction. A quick examination of patient ratings and Healthcare Commission ratings of performance shows us that there is no association between the two. A top-rated trust is not necessarily one that patients rate highly. Charts 1 and 2 demonstrate this.

6 Ipsos MORI: Frontiers of performance in the NHS II Healthcare Commission rating and overall PCT rating

1.0

0.9

0.8

0.7

Overall PCT score 0.6

0.5 0123 Healthcare Commission star rating

Source: PCT patient survey 2005/Healthcare Commission

Chart 1: Healthcare Commission star ratings and overall PCT patient ratings2

Healthcare Commission rating and ratings of overall inpatient care

1.0

0.9

0.8

0.7

Ratings of overall care 0.6

0.5 Weak Fair Good Excellent Healthcare Commission rating

Source: Inpatient survey 2006/Healthcare Commission

Chart 2: Healthcare Commission rating and ratings of inpatient care

2 The chart plots Healthcare Commission star rating against patient ratings derived from the 2005 PCT patient survey. These represent the most recently available patient findings for PCTs.

Ipsos MORI: Frontiers of performance in the NHS II 7 Therefore, further analysis is needed to understand what it is that actually leads to patient satisfaction. For example, what aspects of the patient experience are related to overall ratings of satisfaction? Are there any other issues that are important, for example, demographic factors relating to the locality of the health body? This report will look at this data in more detail, exploring the key drivers of patient satisfaction, both those relating to the patient experience and other situational factors.

MORI’s 2004 Frontiers of Performance in the NHS report3 highlighted the key factors that determine overall patient perceptions. The report showed that there were some very clear key drivers of patient perceptions that individual managers and clinicians could affect. For example, being treated with dignity and respect was key to a positive inpatient experience and other important factors included cleanliness of the wards and effective communication between staff and patients. There were others, however, that were effectively beyond the control of managers and the Department of Health. The report showed that the nature of the population served by individual trusts was important in relation to ratings of the patient experience. Trusts serving more ethnically diverse areas with relatively young populations were rated less positively by patients. The analysis provided an alternative picture of relative performance that suggested that some apparently under-performing trusts were actually doing very well given local conditions, whilst some top-rated trusts were benefiting from operating under relatively ‘easy’ circumstances.

The current report seeks to build on this work using updated data from the national patient surveys. The primary aim of this report is to consider the situation as it exists at the moment for health bodies within the NHS and to discuss the implications of the findings for NHS managers. The previous findings will be discussed where appropriate and any changes in findings will be discussed. However, some caution must be exercised in comparing results, as various factors could be affecting the results. Firstly, the constantly evolving NHS creates new challenges for health bodies on a regular basis. For example, reconfigurations of the service may mean that health bodies may not exist in the same form as they did at the time of the last report. Further, the patient surveys used as the dependent variable here employ a postal methodology. This means that non-response bias may affect results to differing extents at each point in time. In addition, some data used as independent variables in 2004 are not available to be used in the current analysis.

3 MORI (2004) Frontiers of Performance in the NHS

8 Ipsos MORI: Frontiers of performance in the NHS II Structure of the report

This report will examine a range of factors for association with patients’ ratings of their experiences. It will then look at patient ratings in light of the local context in which individual health bodies are operating to establish realistic parameters for ratings, based on local area factors. This allows us to compare the actual ratings of health bodies with what can realistically be expected, given their situation, to establish relative performance levels of individual organisations. The report is divided into two parts looking at PCTs and acute trusts separately:

Part one - PCTs Chapter one – What factors are associated with patient ratings of PCTs?

This chapter explores the forces that are associated with positive PCT patient experiences, focusing on:

• ‘objective’ performance indicators (e.g. number of GPs serving the population, Standardised Mortality Ratio)

• local population characteristics

Chapter two – What performance levels should we expect?

Having looked at the association between local conditions and patient ratings, this chapter compares actual patient ratings against what is realistic for individual PCTs to achieve and to identify which PCTs are actually performing well, given their local conditions.

Ipsos MORI: Frontiers of performance in the NHS II 9 Part two – Acute trusts Chapter three – What factors are associated with inpatient ratings?

Turning to look at acute trusts, this chapter explores the factors that are associated with positive inpatient experiences, in this case, specifically:

• patient perceptions of individual aspects of the care they receive

• local population characteristics

Chapter four – What performance levels should we expect?

Again, this analysis will allow us to compare actual patient ratings against what is realistic for individual trusts to achieve in the context of the local conditions under which they operate. Again, we will identify which trusts are actually performing well, given their local conditions.

Conclusions

Having reviewed the data, we finally go on to draw out some key messages about what this means for PCTs and NHS Trusts. In particular, we draw out the factors that tend to depress patient ratings, and highlight where NHS managers should focus their attention.

10 Ipsos MORI: Frontiers of performance in the NHS II Part 1 - PCTs 1. What factors are associated with positive patient ratings of PCTs?

This chapter explores the factors that may be related to how happy patients are with the care they receive from their PCT4, including:

• the role of ‘objective’ performance measures, such as mortality rates and numbers of GPs per head

• the characteristics of the local population served by individual PCTs

A. The effect of objective performance measures

As mentioned earlier, the annual health check combines data from a number of sources including patient perceptions, financial and managerial measures and clinical outcomes. In fact, the quality of the patient experience, as perceived by the patients themselves, does not always reflect these ‘objective’ measures of performance. Measures such as reference costs, or the numbers of GPs in the population, show a weak association with patient satisfaction. Using data from the 2005 PCT patient survey5, the results in this section suggest that how a trust is objectively measured as performing is relatively unimportant in shaping perceptions.

Reference costs

Reference costs are the average costs to the NHS of providing a defined service in any given financial year. The Reference Cost Index shows the average cost of an organisation’s aggregate activity, compared with the same activity delivered at the national average cost, so that an organisation scoring 125 has costs of 25% more than the national average.

4 The PCT patient survey does not contain an overall measure of satisfaction rating. For the purposes of the analysis, an overall score is derived from individual survey items. This means that we cannot look at the relative importance of these items. See Appendix C for the method used to derive overall PCT ratings from individual survey scores. 5 These represent the most recent available findings for PCTs. It contains data for pre-reconfigured PCTs.

12 Ipsos MORI: Frontiers of performance in the NHS II Our 2004 report showed that the average costs of providing health services, either at the hospital or PCT level, had very little or no bearing on what patients thought of the service they received6. The current analysis again shows only a small correlation between reference costs and overall PCT ratings, although this relationship is a statistically significant one – i.e. it could not have happened by chance. This implies that, as a general rule, those PCTs where costs are higher than average tend to attract lower patient ratings. However, a low R-Sq of 0.0534 means that only 5% of the total variation is accounted for by this factor in isolation from all factors. For example, chart 3 shows that adjusted reference costs are substantially higher in Halton PCT than in East Lincolnshire PCT but there is only 0.05 points difference (out of a total of 100 points) in overall ratings. Equally, South and East Dorset and Tower Hamlets PCTs have similar reference costs but very different overall scores, suggesting that other factors must be at play here.

While the association is only a weak one, the findings do raise a number of questions. For example, the fact that those PCTs scoring over 100 on the Reference Cost Index tend to receive lower patient ratings might suggest that more efficient PCTs operate more effectively and are better at keeping their patients happy. Or, it may mean that patients in these PCTs have more challenging needs which are more costly to treat and make it more difficult to achieve high patient ratings.

Reference costs and overall PCT ratings

0.90 S & E Dorset

East Lincolnshire 0.85 Halton

0.80

2 0.75 R = 0.0534 Overall score PCT 0.70 Tower Hamlets

0.65 50 75 100 125 150 175 200 Reference Cost Index

Source: PCT patient survey 2005/DH

Chart 3: PCT reference cost and overall PCT ratings

6 For example, the R-Sq achieved in relation to PCT ratings was 0.0125. R-Sq values range from zero to one, according to the strength of association between the two variables. It is interpreted as the percentage of variation explained. For example, if the R-Sq is zero, then the independent variable explains none of the variation in patient ratings. If the R-Sq was one, it would explain all of the variation.

Ipsos MORI: Frontiers of performance in the NHS II 13 GPs per 100,000 population

We know from the findings of the GP Patient Survey 2006/20077 that most patients who tried to get an appointment quickly report being able to do so – 84% were able to make an appointment within 48 hours. Yet improved access to a GP within 48 hours was also one of the areas thought most likely to improve the NHS locally in a survey of the general public.8

However, the current analysis shows that the availability of GPs in a PCT does not appear to be strongly related to patient ratings of satisfaction. The chart below shows an R-Sq of just 0.0577, representing a slightly weaker association than found in 2004 (R-Sq = 0.0978). The situation in South Wiltshire and Swale PCTs illustrates the lack of a strong relationship. South Wiltshire PCT has over double the number of GPs but receives only slightly higher overall ratings from its patients.

GPs per 100,000 population and overall PCT ratings

0.90

Hambledon & North Dorset Richmondshire S. Wiltshire 0.85 R2 = 0.0577

0.80

Central Derby 0.75 PCT

Overall PCT score PCT Overall Swale 0.70 Bradford City

Heart of Birmingham 0.65 40 50 60 70 80 90 100 110 120 GPs per 100,000 population

Source: PCT patient survey 2005/DH

Chart 4: GPs per 100,000 population and overall PCT ratings

7 The GP Patient Survey 2006/2007 National report conducted for the Department of Health by Ipsos MORI 8 NHS tracker for the Department of Health, Winter 2006, Ipsos MORI

14 Ipsos MORI: Frontiers of performance in the NHS II Standardised Mortality Ratio

Possibly the starkest measure of quality of healthcare provision is the Standardised Mortality Ratio. The SMR is a measure of mortality rates, taking into account the age and gender profile of the patient population. The findings do show a clear negative relationship between this objective measure and overall ratings. However, the strength of the relationship is tempered by both Kensington & Chelsea PCT and Westminster PCT, which both display low SMR yet still receive low ratings. The chart shows that although it is important, SMR still only explains 11% of the variation in patient ratings.

Again, there may be several factors explaining this finding. It may suggest that PCTs with high SMRs are in fact underperforming and this is reflected in patient ratings. Again though, it might also result from the more challenging needs of the patients in these PCTs, leading both to higher SMRs and lower patient ratings.

SMR and overall PCT ratings

0.90 Carlisle & District

North Dorset 0.85 North Sheffield

0.80

0.75 R2 = 0.1073 Kensington & Chelsea Bradford City Overall score PCT

0.70 Westminster

0.65 60 70 80 90 100 110 120 130 140 150 Standardised Mortality Ratio

Source: PCT patient survey 2005/DH

Chart 5: Standardised Mortality Ratio and overall PCT ratings

Ipsos MORI: Frontiers of performance in the NHS II 15 B. Local population factors

So, we have seen that objective measures of performance are only marginally associated with patient ratings. Now we turn to consider whether there are any other factors at play in determining ratings. Combining the patient survey data with local area statistics from the Census and the Index of Multiple Deprivation (IMD)9, it becomes evident that where people live is linked to their attitudes towards the healthcare they receive.

This is consistent with Healthcare Commission findings that people who are older or from an ethnic minority group report different experiences of the NHS to the rest of the population.10 Older patients were consistently more likely to report positive experiences of health services than younger patients. It was also found that patients from black and minority ethnic groups were more likely than white patients to report negative experiences. Specifically, this finding relates to the patient’s level of involvement in decisions about their care, as well as their experience of medical staff talking in front of them as if they were not there. Finally, Asian patients respond more negatively than white patients in general.

Ethnic Fractionalisation

The ethnic fractionalisation of the area is calculated by taking account of the range and proportion of local residents from different ethnic groups. Areas with a high proportion of ethnic minority residents that are predominantly all from the same ethnic group will have a lower fractionalisation score than an area that has a similar proportion of ethnic minorities drawn from a wide range of different groups.

The analysis shows that health bodies serving patients from a relatively ethnically diverse population are somewhat less likely to attract higher ratings from patients. A very strong association is observed between this factor and overall PCT satisfaction. This is borne out by the PCTs with EF scores above 0.2, where a very clear downward trend is observed as ethnic fractionalisation increases (e.g. Newham and Brent Teaching PCTs). Furthermore, the chart shows that almost 50% of the variation in patient satisfaction can be explained by ethnic fractionalisation in isolation from all other factors11. This is similar to the findings in 2004 where the R-Sq was 0.4877, confirming the continuing importance of this factor.

9 IMD is a weighted index, calculated according to ‘performance’ in six areas – income (25%), employment (25%), health deprivation and disability (15%), education, skills and training (15%), housing (10%) and geographical access to services (10%), created by the Office of the Deputy Prime Minister (now Communities and Local Government). 10 Variations in the experiences of patients using the NHS services in England, Healthcare Commission, November 2006 11 This regression analysis contains the assumption that all PCTs provide the same quality of service irrespective of the areas in which they are situated, which may not be true.

16 Ipsos MORI: Frontiers of performance in the NHS II Ethnic Fractionalisation and overall PCT ratings

0.90 Eden Valley Cambridge City 0.85 Lambeth

0.80 Newham

0.75 R2 = 0.4948

Overall score PCT 0.70 Basildon Barking & Dagenham Brent 0.65 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

Ethnic Fractionalisation

Source: PCT patient survey 2005/Ipsos MORI

Chart 6: Ethnic fractionalisation and overall PCT ratings

Age: Percentage of population who are under 16 As found in 2004, where the R-Sq was 0.1881, PCTs that serve areas with a relatively large number of dependent children (measured here by the population who are aged 0-15) attract lower ratings (chart 7). Cambridge City and Newham PCTs are good examples of this pattern.

Percentage of population under 16 years old and overall PCT ratings

0.90 North Dorset East Devon 0.85 Central Derby Blackburn with Darwen 0.80 Canbridge City

R2 = 0.2019 0.75

Heart of Birmingham Overall PCT score 0.70 Westminster Newham

Bradford City 0.65 10 15 20 25 30 % Population aged 0-15 years Source: PCT patient survey 2005/census mid-year estimates 2005

Chart 7: Percentage of population under 16 and overall PCT ratings

Ipsos MORI: Frontiers of performance in the NHS II 17 Age: Percentage of population who are 65 and over

A similar picture emerges when looking at the other end of the population. Those PCTs that serve areas with an older population are more likely to receive higher patient ratings. As noted in the 2004 report, where the R-Sq was 0.3757, this is a common finding in public sector research – older people are more likely to express satisfaction with a range of services for any given level of service quality. For example, Newham PCT serves a population which contains less than 10% who are over 65 and receives relatively low overall ratings. Conversely, East Devon PCT serves a population where over one quarter are over 65 and receives much higher overall ratings.

Percentage of population over 65 and overall PCT ratings

0.90 South East Oxfordshire R2 = 0.3222 Huntingdonshire 0.85

0.80 Newham East Devon

0.75 Havering Overall score PCT 0.70 Wednesbury & West Brom Barking & Bradford City Dagenham 0.65 5 10 15 20 25 30 % Population aged 65 years or older Source: PCT patient survey/Census mid-year estimates 2005

Chart 8: Percentage of population over 65 and overall PCT ratings

18 Ipsos MORI: Frontiers of performance in the NHS II Index of Multiple Deprivation (IMD)

It is also possible to show that the more deprived a local population is, the less satisfied with PCT services that population is likely to be. This is shown in chart 9 below, and is particularly demonstrated by South East Oxfordshire PCT at one end of the spectrum and North Manchester PCT at the other.

This factor is more strongly associated with primary care ratings in the current analysis compared to the 2004 analysis (R-Sq = 0.113). This difference can be accounted for by both an increased dispersion in PCT ratings and considerable changes within IMD scores between the 2000 IMD (used in 2004) and the 2005 data used here – representing real change in relative deprivations between PCT areas and methodological change in the measurement of deprivation.

IMD and overall PCT ratings

0.90

South East Oxfordshire Birkenhead & Wallasey 0.85

North Manchester 0.80

Wokingham 0.75 R2 = 0.2443

Overall score PCT Havering 0.70 Barking & Dagenham Bradford City

Heart of Birmingham 0.65 0102030405060 Index of Multiple Deprivation

Source: PCT patient survey 2005/ODPM

Chart 9: Index of Multiple Deprivation and overall PCT ratings

Ipsos MORI: Frontiers of performance in the NHS II 19 Regional variation

Finally, the following chart shows that there are also regional variations in patient perceptions, with ratings lowest in London and highest in the South West. We can clearly see the gap between PCT patient ratings in London and the rest of the country. This may be a function of those factors we have seen associated with patient ratings above. For example, the high levels of ethnic fractionalisation and deprivation seen in London may distinguish these PCTs from those situated in other areas of the country.

Overall PCT ratings - regional variations

South West North East South East Coast South Central East Midlands Yorkshire and the Humber North West East Of England West Midlands London

72 74 76 78 80 82 84 Overall PCT Rating

Source: PCT patient survey 2005/Ipsos MORI

Chart 10: Overall PCT ratings - regional variations

C. Can we predict PCT patient ratings?

The current analysis has demonstrated that objective performance measures show a weak relationship with overall ratings of inpatient and primary care satisfaction. On the other hand, PCT performance, at least in terms of patient ratings, appears to be affected by the nature of the population served. PCTs in areas with high ethnic fractionalisation, high deprivation, those with a young population and those situated in London or the West Midlands are likely to receive lower ratings of satisfaction.

Now we move on, using multivariate analysis, to examine the relative importance of local population and area characteristics in explaining the difference in patients’ ratings between health bodies. Once we have discovered the key drivers of PCT patient ratings, the results of this analysis can then be used to ‘predict’ patient satisfaction, based only on these exogenous factors. Therefore, once we know the type of population served by the health body, we can state with some accuracy what ratings can reasonably be expected.

20 Ipsos MORI: Frontiers of performance in the NHS II The variables that appeared in the bivariate analysis were considered, alongside a number of other demographic variables, in a multiple regression (see Appendix B for an explanation of regression analysis and a list of variables considered). The results found so far tell a similar story to those found in the first Frontiers report, although with some variation in actual figures. Therefore, in an attempt to understand any differences in the data between the two reports, the regression models produced in 2004 were replicated, within a number of different variable combinations attempted.

The ‘key drivers’ results presented below illustrate the relative importance of the various factors in driving overall ratings, scaled to 100. The higher the percentage, the stronger the association. Factors presented in dark blue illustrate a negative relationship; light blue demonstrates a positive relationship.

Key drivers of patient ratings

As mentioned above, a number of combinations were attempted and the most successful model is shown in the following chart. The model below displays an R-Sq of 69.3% suggesting a very good predictive model. Here we can see the model contains many of the factors we would expect given the results of the bivariate analysis. For example, ethnic fractionalisation and deprivation are clear negative drivers and the number of GPs per head and the percentage of the population over 65 are clear positive drivers. The analysis also shows the importance of the region within which the PCT is situated, despite the absence of London from the model. This is possibly due to the strength of ethnic fractionalisation and deprivation – key characteristics of London.

15% GPs per 100,000 population 24% 9% Ethnic Fractionalisation % Aged 65+ 9% 23% North West Deprivation (IMD) PCT Overall Rating 7% 2 North East 3% R = 69.3% East England 6% Yorkshire and the Humber 5% East Midlands

Chart 11: Key drivers of overall PCT ratings – local population factors

Ipsos MORI: Frontiers of performance in the NHS II 21 This model shows some similarities with that produced in 2004 – the only differences are found in the inclusion or exclusion of regions – other local population factors have remained consistent. In 2004, there were just two positive drivers – GPs per head of population, and the percentage of over 65s, both included here. The difference in the current model is the addition of the four region indicators. Negative drivers were ethnic fractionalisation, deprivation, and being situated in the East of England, all included here. In addition, two region indicators – London and the South East – were found to be negative drivers in 2004. The fact that the only differences in the overall shape of the two models relate to regional indicators could suggest that it is the characteristics of the local population in these regions that have changed since 2004.

This model can be used to predict the patient ratings that can be expected for individual PCTs, given prevailing local contextual factors. Simply by knowing these factors, it is possible to predict overall patient ratings quite accurately, as the following chart – which plots actual and predicted values – illustrates. The chart shows the points reasonably tightly clustered along the line, illustrating a strong predictive model.

Predicted versus actual Overall PCT Ratings

0.90

0.85

0.80 R2 = 0.701

0.75

0.70 Actual Overall PCT Rating Overall Actual

0.65 0.70 0.75 0.80 0.85 Predicted Overall PCT Rating

Source: PCT patient survey 2005/Ipsos MORI

Chart 12: Predicted versus actual overall PCT ratings

22 Ipsos MORI: Frontiers of performance in the NHS II Summary

• Objective performance measures show a weak relationship with overall ratings of inpatient and primary care satisfaction. • Local population factors are associated with patient ratings, particularly in relation to primary care. PCTs in areas with high ethnic fractionalisation, high deprivation, those with a young population and those situated in London or the West Midlands are likely to receive lower ratings of satisfaction. • A strong predictive model contained high ethnic fractionalisation, high levels of deprivation and being situated in the East of England as key negative drivers of patient satisfaction. The number of GPs per population, the percentage of the population aged over 65, and four region indicators (North West, North East, Yorkshire and the Humber and East Midlands) all exert a positive influence. • Where a PCT is situated is clearly important in relation to the patient ratings they achieve.

Ipsos MORI: Frontiers of performance in the NHS II 23 2. What performance levels should we expect?

We have discovered that we can quite accurately predict overall patient ratings once we know the nature of the local population (as shown in chart 12). In this chapter, we compare actual performance, as measured by patient ratings, against what can be expected given the contextual factors shown to infl uence patient satisfaction. By comparing actual versus predicted outcomes we can compile a list of PCTs performing better than might be expected, given their situation.

A. Actual versus predicted ratings

In order to do this, a performance index was calculated – a score of 100 means that a health body is performing to exactly the levels that might be expected given the local conditions contained in our predictive model. A score of more than 100 shows that a trust is performing better than might be expected and a score under 100 shows that a trust is under-performing given its local conditions.

In relation to primary care ratings, which have been shown to be sensitive to local conditions, we can clearly see from chart 13 that there are a couple of PCTs who are particularly under-performing (Havering PCT and Bradford City Teaching PCT)12.

Ranked Performance of Primary Care Trusts

3.00 2.00 1.00 0.00 -1.00 -2.00 -3.00 -4.00

-5.00 Bradford City Havering -6.00 Performance above/below 100 1 1 11 71 81 91 11 41 71 91 11 21 31 41 51 61 71 81 91 101 1 121 131 141 151 16 1 1 1 201 2 221 231 2 251 261 2 281 2 301 Rank

Source: Ipsos MORI

Chart 13: Ranked performance of PCTs (London PCTs marked in dark blue)

12 See Appendix A for a full list of PCTs

24 Ipsos MORI: Frontiers of performance in the NHS II B. Putting the patient ratings into context – who is performing well, given their local conditions?

This further analysis provides a richer understanding of the ratings obtained from patient surveys. For example, we can look at those health bodies that on first glance appear to be under-performing and ask whether their results have been affected by the local situation they find themselves in. How does a PCT compare with what can realistically be expected given its local conditions?

The table below looks at the bottom 20 rated PCTs (as rated by patients) and considers their position once local population factors are taken into account. We can see that in actual fact, once we take account of local conditions, there are several trusts which are performing at a high level. Westminster PCT, Haringey Teaching PCT and Newham PCT all achieve a performance index of over 100 (highlighted in blue). We can also see what this means in terms of ranking achieved by the PCTs. For example, Westminster PCT jumps over 100 places to 126th in the table, once local conditions are taken into account.

We can also see that in many cases, a number of PCTs are performing at levels substantially lower than might be expected (highlighted in grey). This means that these PCTs are still rated in the bottom 20 even once local conditions are taken into account.

Performance Patient rating index (taking local (raw score from Change conditions into Primary Care Trust survey) in rank account) Score Rank Rank Score Eastern Leicester PCT 0.748 284 × 249 98.76 Westminster PCT 0.747 285 × 126 100.46 Thurrock PCT 0.746 286 Ø 295 96.66 Redbridge PCT 0.745 287 × 218 99.31 Islington PCT 0.745 288 × 176 99.86 Wednesbury and West Bromwich PCT 0.742 289 Ø 294 96.82 Havering PCT 0.741 290 Ø 303 94.06 Ealing PCT 0.741 291 × 238 98.97 Haringey Teaching PCT 0.741 292 × 121 100.52 Waltham Forest PCT 0.741 293 × 178 99.84 Newham PCT 0.741 294 × 62 101.22 Basildon PCT 0.738 295 Ø 298 95.51 Hounslow PCT 0.736 296 Ø 286 97.62 City and Hackney Teaching PCT 0.734 297 × 209 99.41 Barking and Dagenham PCT 0.721 298 × 297 95.83 Tower Hamlets PCT 0.720 299 × 234 99.02 Brent Teaching PCT 0.719 300 × 293 96.86 Slough PCT 0.718 301 × 296 96.02 Heart Of Birmingham Teaching PCT 0.704 302 × 244 98.89 Bradford City Teaching PCT 0.698 303 × 302 94.66

Table 1: Bottom 20 rated PCTs on raw patient scores

Ipsos MORI: Frontiers of performance in the NHS II 25 C. The best performers

We have seen the importance of local conditions in predicting patient ratings, suggesting that it is difficult for PCTs to achieve high ratings if they are situated in an area with high levels of deprivation, ethnic fractionalisation and a young population. Therefore, this chapter now turns to consider those PCTs that are performing particularly well having taken account of local conditions and asks what lessons can be learned from them.

Lambeth PCT achieves a score for patient ratings of 0.780 – in the lower half of PCT scores obtained from the patient survey (ranked 245 out of 303). However, given its high levels of deprivation and ethnic fractionalisation, it is actually the best performing PCT in the country according to our performance index.

Performance Patient rating index (taking local (raw score from Change conditions into Primary Care Trust survey) in rank account) Score Rank Rank Score Lambeth PCT 0.780 245 × 1 102.90 South Cambridgeshire PCT 0.830 36 × 2 102.84 Cambridge City PCT 0.825 58 × 3 102.83 Exeter PCT 0.839 12 × 4 102.82 Norwich PCT 0.826 48 × 5 102.69 South Western Staffordshire PCT 0.836 17 × 6 102.66 Middlesbrough PCT 0.823 71 × 7 102.65 Huddersfield Central PCT 0.806 150 × 8 102.63 Vale Of Aylesbury PCT 0.832 29 × 9 102.57 East Leeds PCT 0.813 113 × 10 102.51 North Manchester PCT 0.780 243 × 11 102.43 Kensington and Chelsea PCT 0.775 262 × 12 102.34 Birkenhead and Wallasey PCT 0.835 22 × 13 102.34 Huntingdonshire PCT 0.833 27 × 14 102.29 Bedford PCT 0.808 141 × 15 102.27 Newcastle PCT 0.821 81 × 16 102.26 Airedale PCT 0.834 24 × 17 102.16 Durham Dales PCT 0.848 5 Ø 18 102.10 North Dorset PCT 0.854 2 Ø 19 102.10 Oldham PCT 0.804 160 × 20 102.07

Table 2: Top 20 performing PCTs once local conditions are taken into account

26 Ipsos MORI: Frontiers of performance in the NHS II D. Implications for PCTs

The analysis clearly shows that it is possible for PCTs to overcome negative impacts of the local conditions in which they operate. We have seen that some PCTs that look as if they are performing poorly are actually performing reasonably well despite particularly difficult circumstances. Further, the table above identifies those trusts that are performing particularly well given local conditions. However, the patient survey data does not tell us what it is that these PCTs are doing to overcome the local conditions. Further analysis exploring these issues would provide valuable lessons for all PCTs, but particularly those that are suffering from operating in the most difficult circumstances.

Of course the patient does not rate the PCT as a whole, instead they are asked to rate the service they received from their GP, dentist or other health professional at the surgery or health centre.13 PCT scores reported in this analysis are therefore an aggregate of the individual scores received. Although scores relating to individual GP surgeries are not available, we know from the GP Patient Survey that there can be considerable variation from one surgery to another. For example, within Lambeth PCT, satisfaction with telephone access ranges from 57% to 94% with an average of 86%14. Therefore, for PCTs to take effective action, it is necessary for them to consider the ratings for individual surgeries rather than for the PCT as a whole. This data can then be considered in light of the local conditions.

13 These are the topics covered in the 2005 primary care patient survey 14 The GP Patient Survey 2006/2007 National report conducted for the Department of Health by Ipsos MORI

Ipsos MORI: Frontiers of performance in the NHS II 27 Summary

• A number of PCTs which look like they are underperforming are actually doing well given their local conditions, e.g. Newham PCT, Haringey Teaching PCT and Westminster PCT.

• Lambeth PCT is the best performing PCT once the local conditions in our model are taken into account.

28 Ipsos MORI: Frontiers of performance in the NHS II Part 2 - Acute trusts 3. What factors are associated with inpatient ratings?

We turn now to consider the situation for acute trusts. This chapter will explore those factors that may be related to how happy patients are with the care they receive whilst they are an inpatient, specifi cally looking at:

• Patient perceptions of specifi c aspects of care

• Local population characteristics

A. Perceptions of specific service dimensions and overall patient ratings

Using data from the 2006 inpatient survey, the relationship between specific aspects of the patient experience can be shown to be very closely associated with patients’ overall assessment of the care received. The charts presented in this section illustrate these relationships, by plotting overall inpatient ratings of the quality of care received against individual aspects of inpatient care, for example, privacy, communication, cleanliness and pain control.

The importance of dignity, respect and privacy

The importance of treating patients with dignity and respect has recently been highlighted by the Healthcare Commission, particularly in regard to older patients. A number of standards are used by the Healthcare Commission to assess whether NHS trusts are treating people with dignity and respect and to ensure that nutritional needs and the need for privacy are being met. Findings from the most recent NHS Inpatient Survey indicate that a high proportion of older inpatients are being treated with dignity and respect while in hospital, and many NHS trusts have declared compliance with standards relating to dignity in the Healthcare Commission’s annual health check. However, the Healthcare Commission decided to focus on ‘dignity’ as a key theme in the annual health check for 2006/2007 and to undertake a targeted inspection programme to assess the extent to which NHS trusts are meeting the standards relating to dignity in care for hospital inpatients. They found no major breaches of national standards, but reported that there was still a considerable need for improvement in many areas and made a number of recommendations.

30 Ipsos MORI: Frontiers of performance in the NHS II The chart below clearly shows how important being treated with dignity and respect is for patients. The higher the ratings a trust receives from its patients for treating them with dignity and respect, the higher ratings of overall patient satisfaction it receives. The chart shows an R-Sq of 0.877, which represents a very strong association between these two variables, illustrated by the proximity of the points to the line. This is similar to the situation in 2004 where this factor was found to be the most closely associated with overall patient ratings, with an R-Sq of 0.9009.

This relationship is particularly demonstrated by the trusts identified on chart 14. For example, the Newcastle upon Tyne Hospitals NHS Foundation Trust and Norfolk and Norwich University Hospital NHS Trust are both rated highly by patients in relation to dignity and respect and overall. We can also see that trusts that receive poor ratings for this one aspect of care are also more likely to receive poor overall ratings (e.g. Mayday Healthcare NHS Trust, Newham University Hospital NHS Trust and North Middlesex University Hospital NHS Trust).

Treated with dignity and respect and ratings of overall inpatient care

Newcastle 2 0.85 upon Tyne R = 0.877

South Manchester 0.80 Norfolk & Norwich UCLH Peterborough & 0.75 Stamford

0.70 Newham Barnet & Chase Farm

Ratingsoverall of care 0.65 N. Middlesex

Mayday 0.60 0.75 0.80 0.85 0.90 0.95 Treated with dignity and respect Source: NHS inpatient survey 2006

Chart 14: Treating patients with dignity and respect and overall ratings of inpatient care

Similarly, being given privacy during treatment discussions and examinations is also strongly related to overall satisfaction, though less so than being treated with dignity and respect. The chart below shows an R-Sq of 0.5689 for examination privacy, slightly lower to that found in 2004 where the R-Sq was 0.6726. Again, we can see the Newcastle Upon Tyne Hospitals NHS Foundation Trust and Newham University Hospital NHS Trust illustrating this pattern. There is a similar level of association between privacy during treatment discussions (R-Sq = 0.5901, chart not shown).

Ipsos MORI: Frontiers of performance in the NHS II 31 Satisfaction with examination privacy and ratings of overall inpatient care

0.85 Newcastle 2 Upon Tyne R = 0.5689 Royal Liverpool & Broadgreen 0.80

Royal West Lancashire 0.75 Sussex

Newham 0.70

Ratingsoverall of care 0.65 Queen Mary’s Ealing Sidcup 0.60 0.87 0.89 0.91 0.93 0.95 0.97 Satisfaction with examination privacy Source: NHS inpatient survey 2006

Chart 15: Satisfaction with examination privacy and overall ratings of inpatient care

Patients want to be involved in their treatment

Communication between patients and staff and involvement in treatment decisions are consistently found to be strongly and positively related to overall satisfaction.

Again, the Newcastle Upon Tyne Hospitals NHS Foundation Trust is a good illustration of the positive link between communication and overall ratings (chart 16).

Effectiveness of communication with doctors and ratings of overall inpatient care

Newcastle 0.85 Royal Cornwall Upon Tyne

Dartford & 0.80 Gravesham R2 = 0.5742

0.75

0.70 Mayday

Ratingsoverall of care 0.65 Queen Mary’s Sidcup Lewisham

0.60 0.70 0.75 0.80 0.85 0.90 Doctors answered questions in an understandable way Source: NHS inpatient survey 2006

Chart 16: Effectiveness of communication with doctors and overall ratings of inpatient care

32 Ipsos MORI: Frontiers of performance in the NHS II The findings suggest that involvement in decision-making is particularly important to patients, explaining 75% of the total variation in overall ratings (see chart 17). The relationship between satisfaction with involvement in decision-making and overall ratings is demonstrated by North Middlesex University Hospital NHS Trust and Ealing Hospital NHS Trust at one end and Norfolk and Norwich University Hospital NHS Trust at the other. The strength of this association has increased since 2004 where the R-Sq was 0.5393. This suggests that there is increasing appetite for patient involvement, reflecting the policy move towards this in the wider health service.

Satisfaction with involvement in decision-making and ratings of overall inpatient care

R2 = 0.7466 0.85 Aintree

0.80 East Kent Norfolk & Norwich 0.75 Coventry & Warks Northampton

0.70 N. Middlesex Tameside & Glossop

Ratingsoverall of care 0.65

Ealing 0.60 0.55 0.60 0.65 0.70 0.75 0.80 Satisfaction with involvement in decision-making Source: NHS inpatient survey 2006

Chart 17: Satisfaction with involvement in decision-making and overall ratings of inpatient care

Ipsos MORI: Frontiers of performance in the NHS II 33 Pain control is also important

The analysis also shows that physical comfort whilst in hospital is important to patients, although to a lesser extent than the personal treatment they receive from staff. Chart 18 shows a strong positive correlation, with an R-Sq of 0.6575, similar to that found in 2004 (R-Sq = 0.6932). Hinchingbrooke Healthcare NHS Trust is a clear example of this positive relationship.

Satisfaction with pain control and ratings of overall inpatient care

2 0.85 Hinchingbrooke R = 0.6575

0.80 Central Manchester

0.75 Walsall Newham Salisbury 0.70

Ratingsoverall of care 0.65 Ealing

0.60 0.70 0.75 0.80 0.85 0.90 Satisfaction with pain control

Source: NHS inpatient survey 2006

Chart 18: Satisfaction with pain control and overall ratings of inpatient care

Cleanliness matters too

The cleanliness of hospital premises has received substantial public attention in recent years and the current findings confirm the importance of this aspect of healthcare to patients. They clearly show that patients’ perception of their surroundings, particularly their cleanliness, is almost as important as the treatment they receive. For example, the chart below shows a strong positive correlation between ratings of how clean the room or ward is and overall satisfaction. Poole Hospital NHS Trust and Homerton University Hospital NHS Foundation Trust illustrate this relationship.

34 Ipsos MORI: Frontiers of performance in the NHS II Cleanliness of hospital room or ward and ratings of overall inpatient care

0.85 Plymouth Newcastle 2 upon Tyne R = 0.5352

0.80 Poole

Homerton 0.75

UCLH 0.70 West Middlesex

Ratings of overallRatings of care 0.65

Newham 0.60 0.70 0.75 0.80 0.85 0.90 Cleanliness of hospital room or ward Source: NHS inpatient survey 2006

Chart 19: Cleanliness of hospital room or ward and overall ratings of inpatient care

Thus we can see that perceptions of cleanliness are associated with ratings of overall care but an examination of MRSA rates shows that these perceptions are not always accurate. As chart 20 shows, there is only a weak correlation between MRSA rates and ratings of cleanliness of hospital bathrooms/toilets. Perceptions at Homerton University Hospital Trust are particularly inaccurate – it has the lowest rating for toilet and bathroom cleanliness by some distance but actually has the lowest incidence of MRSA.

However, the correlation is statistically significant. Rotherham General Hospitals NHS Trust and University Hospital Birmingham NHS Foundation Trust are good examples of the relationship.

MRSA rate and rating of toilet/bathroom cleanliness

0.90 Rotherham

0.85

0.80

0.75 R = -0.219

0.70

0.65 Birmingham 0.60 Homerton

Rating of toilet/bathroom cleanlinessRating of 0.55 0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 0.45 MRSA rate (per 1000 bed days) Source: Healthcare Commission/Inpatient survey 2006

Chart 20: MRSA rate (per 1000 bed days) and ratings of cleanliness of toilet/bathroom

Ipsos MORI: Frontiers of performance in the NHS II 35 But what service aspects are most important to patients?

So, we know that trusts where patients feel that they have been treated with dignity and respect, felt their privacy was respected, felt they were involved in their treatment, had their pain managed well and thought the hospital looked clean were more likely to receive higher overall ratings. The analysis above shows that people who are generally satisfied with their experience as an inpatient are also likely to have positive views about most aspects of their care. However, these bivariate relationships do not tell us which aspects of care are most important to patients. Using multivariate analysis techniques, it is possible to identify the relative importance of these various factors15. This will lead to a better understanding of which particular aspects of care providers should focus on to improve the overall patient experience16.

As previously, the results presented in the chart below show the relative importance of specific service aspects, scaled to 100, all positive in this case. The higher the percentage, the stronger the association. The model demonstrates a very high R-Sq of 90.9%. This figure means that 91% of the variation in overall ratings of quality of care can be explained by just these three factors. The results corroborate those illustrated in the two-way scatterplots above – i.e. being treated with dignity and respect is the strongest predictor of overall satisfaction. Involvement in decisions and cleanliness of the hospital are also confirmed as important factors underlying a positive patient experience.

59% Dignity & respect

28%

Ratings of overall inpatient care Involved in decisions

R2 = 90.9% 13% Cleanliness of room & ward

Chart 21: Key drivers of inpatient ratings

15 This analysis only allows for discussion of the relative importance of those factors included in the NHS inpatient survey. There may be other factors affecting patient experience that are not adequately measured by this survey 16 See Appendix B for an explanation of regression analysis

36 Ipsos MORI: Frontiers of performance in the NHS II As mentioned earlier, caution should be exercised when comparing results with the previous Frontiers report. However, it is worth noting that although this model differs from that produced in 2004, dignity and respect has remained the key driver of positive patient ratings. In 2004, it featured as the most important driver (37%) in a model explaining 94% of the variation in patient ratings. While the other individual aspects differed slightly, cleanliness also featured (cleanliness of toilets, 15%), as did measures of involvement in treatment (purpose of medicines explained, 13%; and communicated side-effects, 8%)17.

B. Local population factors

So, we know that individual aspects of care, particularly dignity and respect, involvement in treatment decisions and cleanliness are important in relation to overall patient satisfaction. We have also seen consistent ratings of individual aspects of care e.g. the Newcastle Upon Tyne Hospitals NHS Foundation Trust received high ratings across all individual aspects and Newham received low ratings across all individual aspects of inpatient care. In Part 1 one of this report we saw that PCT patient ratings are affected by local population factors, so now we turn to consider whether the same is true for acute trusts. Again, combining the patient survey data with local area statistics from the Census and the Index of Multiple Deprivation (IMD) will allow us to look at these associations.18

Chart 22 below also shows a relationship between inpatient satisfaction ratings and ethnic fractionalisation (R-Sq = 0.2747), but this relationship is weaker than that found for PCTs or in 2004 (R-Sq = 0.5237).

Ethnic fractionalisation and ratings of overall inpatient care

0.85 Hinchingbrooke

R2 = 0.2747 0.80

0.75

North Cumbria 0.70

Homerton 0.65 Ratingsoverall of care Barking, Havering & Redbridge Newham Ealing 0.60 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 Ethnic Fractionalisation Source: NHS Inpatient survey 2006/Ipsos MORI

Chart 22: Ethnic fractionalisation and overall ratings of inpatient care

17 Other factors were pain control (13%), A&E organisation (7%) and privacy to discuss treatment (6%) 18 See Appendix C for an explanation of the calculation of acute trust boundaries

Ipsos MORI: Frontiers of performance in the NHS II 37 This is typical of the results in this section which all show a weaker relationship with overall patient ratings than found for PCTs, suggesting that the difference may be due to the differences in the nature of health provision between primary and secondary care. For example, acute trusts can be said to be less rooted in the community in which they are situated than PCT services. Therefore, acute trust ratings may be less sensitive to factors linked to the community.

Age: Percentage of population who are under 16

Chart 23 shows that trusts that serve areas with a relatively large number of dependent children attract lower ratings. Again, this association is weaker than that found for PCT ratings.

Percentage of population under 16 years old and ratings of overall inpatient care

0.85 Newcastle Upon Tyne Airedale Chelsea & Westminster

0.80 Good Hope

St Mary’s 0.75

0.70 UCLH Royal Free R2= 0.1301

0.65 Newham Ratingsoverall of care Ealing

0.60 14 16 18 20 22 24 % Population aged 0-15 Source: NHS inpatient survey 2006/Census mid-year estimates 2005

Chart 23: Percentage of population under 16 and overall ratings of inpatient care

Age: Percentage of the population who are over 65

Considering those areas with an older population, we can again see a weak association with overall ratings of care. For example, Poole is situated in an area with a relatively older population and attracts higher ratings than somewhere like Homerton University Hospital NHS Foundation Trust (see chart 24).

38 Ipsos MORI: Frontiers of performance in the NHS II Percentage of population over 65 years old and ratings of overall inpatient care

0.85 Norfolk & UH South Norwich Manchester R2 = 0.2155 Guy’s and St. 0.80 Thomas’

Bart’s and Poole The London 0.75 Royal Bournemouth & Christchurch 0.70 Ratings of overall care 0.65 Queen Mary’s, Newham Sidcup Ealing 0.60 8 1012141618202224 % Population aged 65 years or older Source: NHS Inpatient survey 2006/Census mid-year estimates 2005

Chart 24: Percentage of population over 65 years and overall ratings of inpatient care

Index of Multiple Deprivation (IMD)

We saw a strong association between deprivation and PCT patient ratings. However a similar relationship was not found for inpatients. Therefore, an acute trust in an area of deprivation cannot be expected to receive lower patient ratings than the equivalent trust in a more affluent area simply because of this fact.

Index of Multiple Deprivation and ratings of overall inpatient care

Newcastle 0.85 upon Tyne Frimley Park Aintree Royal Liverpool & Broadgreen 0.80

0.75 R2 = 0.0005 Royal 0.70 Surrey Homerton

0.65 Newham Ratings of overall care Ashford & St. Peter’s North Middlesex 0.60 5 101520253035404550 Index of Multiple Deprivation

Source: NHS Inpatient survey 2006/ODPM

Chart 25: Index of Multiple Deprivation and overall ratings of inpatient care

Ipsos MORI: Frontiers of performance in the NHS II 39 Regional variation

When looking at regional variation, we can see that ratings differ by region, particularly as regards those trusts situated in London. The overall pattern is similar to that seen in relation to PCT ratings, with the notable exception of South East Coast, which drops significantly in the overall ratings.

Ratings of overall patient care - regional variations

South West North East Yorkshire and the Humber East of England South Central North West West Midlands East Midlands South East Coast London 68 70 72 74 76 78 80 Ratings of overall care

Source: NHS Inpatient survey 2006/Ipsos MORI

Chart 26: Ratings of overall inpatient care – regional variations

C. Can we predict inpatient ratings?

This chapter has demonstrated that some local population factors – age, region and ethnic fractionalisation – show some association with inpatient ratings. Part 1 of this report demonstrated that using multiple regression, it is possible to produce a strong predictive model for PCT patient ratings, using just local population factors. Again, multivariate analysis was conducted to examine the relative importance of the local population and area characteristics in explaining differences in patient ratings. In relation to acute trusts, the analysis produced a model containing just two negative drivers – London and the proportion of the population under 16.19 This is perhaps not surprising given the findings of the bivariate analysis, where these two factors were found to be the most strongly associated with patient ratings. As the proportion of the population over 65 is likely to be strongly correlated with the proportion of the population under 16, this accounts for the absence of this factor here.

19 See Appendix B for a list of factors included in the analysis

40 Ipsos MORI: Frontiers of performance in the NHS II The R-Sq is substantially lower than that obtained for the PCT model, and that produced in 2004, where the model contained a larger number of factors, including ethnic fractionalisation, proportion of the population over 65 and two region indicators – South East and East of England – in addition to the drivers in the current model. This is perhaps due to changes in the population and patient profile of particular areas or it could be a reflection of changes in healthcare since 2004 and the impact of choice. This is a point to consider for the future and is an encouraging finding for trust managers, bearing in mind the importance of individual aspects of care, seen in the previous chapter. It appears that for acute trusts, the local situation is less important than perceptions of the individual treatment received by patients.

However, despite this, it is still important to note the potential role that local population factors can play in determining patient ratings, as the model accounts for 40% of the variance in scores.

58% London

Overall rating of inpatient care

42% R2= 40.3% % Aged under 16

Chart 27: Key drivers of overall ratings of inpatient care – local population factors

Ipsos MORI: Frontiers of performance in the NHS II 41 Again, we can use this model to predict the ratings that can be expected for acute trusts, given their local conditions. Chart 28 plots predicted versus actual ratings using this model and demonstrates a weaker predictive model than that obtained for PCTs. This reinforces the importance of individual aspects of care in relation to inpatient ratings. Whereas for primary care ratings, the analysis shows that where patients are treated is important, for acute trusts, how patients feel they have been treated is more important.

Predicted versus actual ratings of overall inpatient care

0.85

0.80

0.75 R2 = 0.4114

0.70

0.65 Actual ratings of overall care overall ratings of Actual 0.60 0.65 0.70 0.75 0.80 Predicted ratings of overall care

Source: NHS Inpatient survey 2006

Chart 28: Predicted versus actual overall ratings of inpatient care

42 Ipsos MORI: Frontiers of performance in the NHS II Summary

• Individual aspects of care are highly correlated with overall ratings of inpatient care. Most important are treating patients with respect and dignity, involving patients in decisions and the cleanliness of the hospital.

• Local population factors are less important, but are still associated with patient ratings.

• The percentage of the population aged under 16 and being situated in London are negative drivers in predicting inpatient ratings.

• There is a clear contrast between the two types of health bodies – for acute trusts how patients feel they are treated is more important whereas for PCTs, where patients are treated is more important in predicting patient satisfaction.

Ipsos MORI: Frontiers of performance in the NHS II 43 4. What performance levels should we expect?

Although local population factors are less important in relation to inpatient ratings than PCT patient ratings, it is still possible to predict overall inpatient ratings with relative accuracy once we know the nature of the local population (as shown in chart 28). In this chapter, we can again compare actual performance, as measured by patient ratings, against what can be expected, given the contextual factors shown to infl uence patient satisfaction. By comparing actual versus predicted outcomes, we can compile a list of trusts performing better than might be expected, given their situation.

A. Actual versus predicted ratings

Again, a performance index was created, based on the factors contained in our predictive model – a score of 100 means that a health body is performing to exactly the levels that might be expected given the local conditions contained in our predictive model. A score of more than 100 shows that a trust is performing better than might be expected and a score under 100 shows that a trust is under-performing given its local conditions.

The following chart quickly shows the pattern of results for acute trusts.20 We can see that relative performance is evenly spread above and below 100 with one trust achieving more than 8 points above what can be expected (Bromley Hospitals NHS Trust) and three achieving more than 8 points less than can be expected (Trafford Healthcare NHS Trust, Ealing Hospital NHS Trust and Surrey and Sussex Healthcare NHS Trust).

Ranked Performance of Acute Trusts

10 8 Bromley 6 4 2 0 -2 -4 -6 Trafford -8 Ealing Surrey & Sussex Performance above/below 100 -10 1 11 21 31 41 51 61 71 81 91 101 111 121 131 141 151

Rank

Source: Ipsos MORI

Chart 29: Ranked performance of acute trusts (London trusts marked in dark blue)

20 See Appendix A for a full list of health bodies

44 Ipsos MORI: Frontiers of performance in the NHS II B. Putting the patient ratings into context – who is performing well given their local conditions?

Again, we can use this analysis to provide a deeper understanding of the raw scores obtained from the patient survey ratings. We have considered the bottom 20 rated acute trusts, but it is important to remember that local population factors are less important here, so these trusts are less likely to be suffering from the impact of local conditions. Nevertheless, we can see that there are three trusts (indicated in blue) that look as if they are under-performing but are actually performing well, given their local conditions. Again, we can see that there are several trusts who are performing at levels substantially lower than might be expected (highlighted in grey). These trusts find themselves in the bottom 20 even once local conditions are taken into account.

Performance Patient rating index (taking local (raw score from Change conditions into Acute trust patient survey) in rank account) Score Rank Rank Score The Hillingdon Hospital NHS Trust 0.713 132 × 40 101.7 Maidstone And Tunbridge Wells NHS 0.709 133 Ø 141 95.3 Trust Kingston Hospital NHS Trust 0.708 134 × 101 98.9 Queen Elizabeth Hospital NHS Trust 0.707 135 × 48 101.4 Homerton University Hospital NHS 0.706 136 × 45 101.6 Foundation Trust George Eliot Hospital NHS Trust 0.705 137 Ø 146 94.0 West Middlesex University Hospital NHS 0.705 138 × 98 99.1 Trust Tameside And Glossop Acute Services 0.701 139 Ø 140 95.5 NHS Trust Luton And Dunstable Hospital NHS 0.700 140 Ø 144 95.0 Foundation Trust Trafford Healthcare NHS Trust 0.689 141 Ø 149 91.4 Walsall Hospitals NHS Trust 0.686 142 Ø 147 93.7 North West London Hospitals NHS 0.682 143 × 113 97.9 Trust Barking, Havering And Redbridge 0.677 144 × 93 99.3 Hospitals NHS Trust Surrey And Sussex Healthcare NHS 0.675 145 Ø 151 91.2 Trust The Lewisham Hospital NHS Trust 0.673 146 × 137 96.0 Queen Mary’s Sidcup NHS Trust 0.669 147 × 130 96.7 Newham University Hospital NHS 0.664 148 × 107 98.6 Trust Mayday Healthcare NHS Trust 0.652 149 × 145 94.8 North Middlesex University Hospital 0.630 150 × 148 93.6 NHS Trust Ealing Hospital NHS Trust 0.622 151 × 150 91.3

Table 3: Bottom 20 rated acute trusts on raw patient scores

Ipsos MORI: Frontiers of performance in the NHS II 45 C. The best performers

As we have seen, local conditions play less of a role in relation to inpatient scores so Bromley Hospitals NHS Trust, at the top of our table, already achieved a relatively high patient rating score of 0.786, and was ranked at 35 based on this rating. Further, the Newcastle Upon Tyne Hospitals NHS Foundation Trust was the highest scoring trust and still is performing well given its local conditions.

Performance Patient rating index (taking local (raw score from Change conditions into Acute trust patient survey) in rank account) Score Rank Rank Score Bromley Hospitals NHS Trust 0.786 35 × 1 108.5 The Newcastle Upon Tyne Hospitals 0.845 1 Ø 2 106.4 NHS Foundation Trust Airedale NHS Trust 0.805 13 × 3 106.2 Guy’s And St Thomas’ NHS Foundation 0.784 41 × 4 106.0 Trust Hinchingbrooke Health Care NHS Trust 0.824 4 Ø 5 105.5 University Hospital of South Manchester 0.826 3 Ø 6 105.0 NHS Foundation Trust Norfolk And Norwich University Hospital 0.838 2 Ø 7 105.0 NHS Trust King’s College Hospital NHS Foundation 0.773 60 × 8 104.9 Trust Whipps Cross University Hospital NHS 0.730 119 × 9 104.8 Trust Aintree University Hospitals NHS 0.813 8 Ø 10 104.6 Foundation Trust Bolton Hospitals NHS Trust 0.802 17 × 11 104.5 Peterborough And Stamford Hospitals 0.805 14 × 12 104.4 NHS Foundation Trust Basingstoke and North Hampshire NHS 0.800 18 × 13 104.2 Foundation Trust Plymouth Hospitals NHS Trust 0.823 5 Ø 14 104.0 Sheffield Teaching Hospitals NHS 0.811 9 Ø 15 103.6 Foundation Trust Royal Cornwall Hospitals NHS Trust 0.820 6 Ø 16 103.6 County Durham And Darlington NHS 0.796 24 × 17 103.3 Foundation Trust Wirral Hospital NHS Trust 0.807 12 Ø 18 103.2 University Hospital Birmingham NHS 0.766 72 × 19 103.2 Foundation Trust Dartford And Gravesham NHS Trust 0.782 46 × 20 103.1

Table 4: Top 20 performing acute trusts once local conditions are taken into account

46 Ipsos MORI: Frontiers of performance in the NHS II So what is it that these top performing acute trusts are doing? We have already seen that how patients feel they are treated is more important for acute trusts than where they are situated. In the table below we can see the top five performers tend to achieve high scores for those factors we have seen are associated with positive patient ratings - dignity and respect, cleanliness and involving their patients in decision-making. These scores tend to be lower among the bottom five performers.

Performance Dignity & Involved in Rank Trust Name Cleanliness Index respect decisions 1 Bromley Hospitals NHS Trust 108.5 0.904 0.686 0.824 The Newcastle Upon Tyne 2 Hospitals NHS Foundation 106.4 0.925 0.791 0.853 Trust 3 Airedale NHS Trust 106.2 0.899 0.730 0.867 Guy’s And St Thomas’ NHS 4 106.0 0.782 0.732 0.902 Foundation Trust Hinchingbrooke Health Care 5 105.5 0.835 0.779 0.919 NHS Trust

Table 5: Top 5 performers – individual aspects of care

Performance Dignity & Involved in Rank Trust Name Cleanliness Index respect decisions 147 Walsall Hospitals NHS Trust 93.7 0.822 0.599 0.746 North Middlesex University 148 93.6 0.713 0.583 0.713 Hospital NHS Trust Trafford Healthcare NHS 149 91.4 0.820 0.630 0.778 Trust 150 Ealing Hospital NHS Trust 91.3 0.788 0.593 0.709 Surrey and Sussex 151 91.2 0.819 0.619 0.776 Healthcare NHS Trust

Table 6: Bottom 5 performers – individual aspects of care

Ipsos MORI: Frontiers of performance in the NHS II 47 D. Implications for acute trusts

The information in these tables confirms that dignity and respect, involving patients in treatment decisions and the perceived cleanliness of the hospital are the three areas that are important in relation to patient ratings. Key driver analysis showed the relative importance of these areas and now these tables confirm that trusts that are rated highly on these issues are also rated highly overall. While our analysis does not necessarily imply a causal relationship, it does suggest that trust managers would be wise to concentrate on these issues, given their importance to their patients.

The analysis shows that treating patients with dignity and respect is particularly important, but what does this mean? While the cleanliness of a hospital and involving patients in their treatment are relatively straightforward concepts and suggest clear actions to be undertaken, it is less clear what trusts can do to make patients feel as if they have been treated with dignity and respect. However, the Healthcare Commission has focused on this issue recently and has provided recommendations for action to improve the care and overall experience, particularly of older people, in this regard.21

Although it acknowledges that the concept is difficult to define, it suggests that many patients find it easier to explain where their dignity has been compromised. For example, this includes being talked about as if they were not there, being left in soiled clothes, not being given adequate assistance at meal times and being treated in mixed sex wards. Its list of common complaints of where patients’ dignity has been compromised covers many of the individual aspects of care that we have already looked at e.g. cleanliness of the environment, privacy of treatment, involvement in treatment decisions and pain management. While the concept may mean different things to different people, our analysis shows that these last two issues are particularly closely associated with dignity and respect, as shown in the following charts. We have already seen that these aspects of care are closely associated with overall patient ratings, and this further analysis suggests that the ratings of dignity and respect may be measuring a combination of these factors.

21 Healthcare Commission, Caring for Dignity, 2007

48 Ipsos MORI: Frontiers of performance in the NHS II Satisfaction with involvement in treatment decisions and dignity and respect

0.95

0.90

0.85

0.80 Dignity and Respect Dignity 0.75

0.70 0.55 0.60 0.65 0.70 0.75 0.80 Patient felt involved in decisions about treatment Source: NHS Inpatient survey 2006

Chart 30: Satisfaction with involvement in treatment decisions and treating patients with dignity and respect

Satisfaction with pain control and dignity and respect

0.95

0.90

0.85

0.80

Dignity and Respect Dignity 0.75

0.70 0.70 0.75 0.80 0.85 0.90 0.95 Satisfaction with pain control

Source: NHS Inpatient survey 2006

Chart 31: Satisfaction with pain control and treating patients with dignity and respect

Ipsos MORI: Frontiers of performance in the NHS II 49 Summary

• A number of acute trusts which look like they are underperforming are actually doing well, given their local conditions, e.g. the Hillingdon Hospital NHS Trust and Homerton University Hospital NHS Foundation Trust.

• Bromley Hospitals NHS Trust is the best performing trust once the local conditions in our models are taken into account.

• Top performing trusts all score highly on treating patients with dignity and respect, involving them in treatment decisions and the cleanliness of the hospital room or ward.

50 Ipsos MORI: Frontiers of performance in the NHS II Conclusions What does this mean for you?

The analysis provides food for thought for all interested spectators of the NHS, but what does it mean for those managers who are tasked with improving the patient experience? It’s clear that the implications depend on your sector. For acute trusts, it’s about how you treat your patients, whereas for PCTs, it’s more to do with where you’re situated.

As in 2004, we found that the nature of the local community will often limit the potential of PCTs to achieve high ratings of patient satisfaction. This confirms the validity of these factors as real issues. If you serve an area with high levels of deprivation, high ethnic fractionalisation and large numbers of younger residents, you are likely to find it more difficult to achieve high patient ratings. For example, Newham PCT is amongst the lowest rated PCTs in the country and is operating in just such an area, with high levels for each of these factors.

So what are the reasons behind this? There are any number of possibilities to consider. Is it about more complex health needs in these communities? Is it about getting the right staff and resources into these areas? Is it about the challenges of delivering a service when faced with multiple languages and cultural expectations? Is it that these groups are more demanding of the service they receive? Or is it even an artefact of the survey measures themselves?

Of course, it’s likely to be a combination of many of these things. And what we do know from our work in places like Newham, Tower Hamlets and Birmingham is that different cultural groups do indeed expect different things from the health service – which will inevitably challenge healthcare providers in those areas, and potentially hit their overall patient satisfaction scores.

But what we also know is that some PCTs are able to overcome the particular challenges posed by their local situation. For example, Newham PCT is actually performing well once local factors are taken into account. Lambeth PCT is another good example: even though its raw patient scores are poor, it actually achieved the highest performance index of any PCT in the country. For PCTs whose Frontiers scores suggest they are underperforming, these are the PCTs to look towards to see what they’re doing to meet the needs of their populations: there are almost certainly useful lessons to learn.

If you work in an acute trust, the situation is not quite as difficult. As we found in 2004, there are factors you can concentrate on that are linked to patient satisfaction. Involving patients in their treatment, the cleanliness of the hospital and, most importantly, treating patients with dignity and respect, are all issues that are key to a positive inpatient experience. This is not to say that local population factors do not play a role: they will still influence the patient ratings achievable by trusts. But by identifying key things you need to deliver, the analysis gives acute trusts an agenda for where they might most usefully focus their efforts.

Whether you work in a PCT or an acute trust, the first step is to look at your scores in the tables at the end of this report, to understand what you are faced with and how you are dealing with it. The next step is to ask yourselves how this analysis can be taken forward to

Ipsos MORI: Frontiers of performance in the NHS II 51 your benefit and the benefit of your patients.

For example, patient satisfaction is lower amongst younger patients, those from ethnic minority groups and those in more deprived areas. Therefore, if you serve these communities you may want to forge greater links with these groups. The analysis suggests there may be value in investigating the beliefs, attitudes and experiences of these patients to gain a better understanding of their needs. We know that many trusts are already doing this, not least from our own work with them. The challenge is for health bodies to learn from each other on these issues and build links with these groups so that they are better able to understand and meet their needs.

For acute trusts, further investigation is also needed to fully understand the nature of the relationship between factors like cleanliness, involving patients and respect and dignity and the levels of satisfaction patients express. The relationships highlighted in this report are essentially correlational. The questions that therefore arise are: to what extent do these factors cause patient satisfaction; and what specifically are the critical elements within these factors that matter?

These pose some challenging research questions, but the current ‘deep clean’ of NHS hospitals provides a good opportunity to test its impact on perceptions of cleanliness and overall ratings. And to understand the importance of dignity and respect in relation to overall patient ratings, the Healthcare Commission’s work in this area appears timely and appropriate. Acute trusts would be wise to look carefully at these issues, dissecting what they mean for their own patients, how this varies across different patient groups, and how they can turn this into a strategy for improving patient experience.

52 Ipsos MORI: Frontiers of performance in the NHS II APPENDICES APPENDIX A – Performance tables PCTs in alphabetical order

Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population 169 283 Adur, Arun and South East 98.01 0.098 16.065 66.688 23.881 Worthing PCT Coast 24 17 Airedale PCT Yorkshire and 102.16 0.200 20.138 69.282 17.477 the Humber 18 36 Amber Valley PCT East 101.70 0.042 18.994 64.059 16.717 Midlands 254 275 Ashfield PCT East 98.15 0.037 28.502 48.804 16.001 Midlands 148 190 Ashford PCT South East 99.66 0.097 13.487 61.713 16.150 Coast 218 242 Ashton, Leigh and North West 98.93 0.048 29.307 54.128 14.411 Wigan PCT 298 297 Barking and London 95.83 0.342 31.315 49.842 14.710 Dagenham PCT 274 250 Barnet PCT London 98.69 0.617 17.529 70.978 14.463 201 168 Barnsley PCT Yorkshire and 99.93 0.037 33.001 55.826 16.192 the Humber 295 298 Basildon PCT East Of 95.51 0.109 27.963 59.264 14.078 England 99 58 Bassetlaw PCT East 101.29 0.054 25.655 55.096 16.243 Midlands 100 219 Bath and North East South West 99.31 0.116 12.223 75.414 17.841 Somerset PCT 38 104 Bebington and West North West 100.73 0.064 15.834 54.957 20.379 Wirral PCT 139 15 Bedford PCT East Of 102.27 0.342 17.543 65.350 14.859 England 103 79 Bedfordshire East Of 101.00 0.116 9.968 64.162 13.530 Heartlands PCT England 46 128 Bexhill and Rother South East 100.40 0.089 16.084 59.145 28.338 PCT Coast 215 180 Bexley Care Trust London 99.83 0.225 15.006 53.107 15.808 237 285 Billericay, Brentwood East Of 97.79 0.119 9.055 60.013 17.140 and Wickford PCT England 22 13 Birkenhead and North West 102.34 0.072 39.137 80.559 16.672 Wallasey PCT 222 56 Blackburn With North West 101.31 0.401 32.343 58.476 13.319 Darwen PCT 197 207 Blackpool PCT North West 99.42 0.068 33.882 55.977 19.579 134 144 Blackwater Valley and South Central 100.19 0.125 7.406 60.425 12.139 Hart PCT 121 41 Bolton PCT North West 101.53 0.235 29.381 64.438 14.917 102 177 Bournemouth South West 99.85 0.135 23.383 80.656 20.120 Teaching PCT 152 49 Bracknell Forest PCT South Central 101.47 0.178 8.606 47.644 10.823 303 302 Bradford City Yorkshire and 94.66 0.649 51.504 84.977 10.503 Teaching PCT the Humber

54 Ipsos MORI: Frontiers of performance in the NHS II Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population 168 142 Bradford South and Yorkshire and 100.23 0.244 31.785 79.012 14.318 West PCT the Humber 300 293 Brent Teaching PCT London 96.86 0.845 25.715 74.053 11.477 186 112 Brighton and Hove South East 100.61 0.222 25.672 67.445 16.323 City PCT Coast 189 140 Bristol North PCT South West 100.25 0.267 27.449 79.185 15.529 162 169 Bristol South and West South West 99.92 0.169 27.800 84.576 14.125 PCT 67 115 Broadland PCT East Of 100.56 0.051 9.646 64.408 19.274 England 217 263 Bromley PCT London 98.45 0.250 13.157 67.235 16.854 77 95 Broxtowe and East 100.84 0.112 18.139 63.268 16.034 Hucknall PCT Midlands 181 99 Burnley, Pendle and North West 100.79 0.206 28.224 54.306 15.023 Rossendale PCT 161 146 Burntwood, Lichfield West 100.13 0.069 15.850 58.716 13.390 and Tamworth PCT Midlands 151 105 Bury PCT North West 100.71 0.175 23.510 54.500 14.758 117 50 Calderdale PCT Yorkshire and 101.45 0.172 25.632 59.399 15.593 the Humber 58 3 Cambridge City PCT East Of 102.83 0.373 14.308 81.464 13.192 England 276 47 Camden PCT London 101.48 0.685 34.611 68.995 10.715 220 197 Cannock Chase PCT West 99.49 0.049 18.911 49.747 13.671 Midlands 52 43 Canterbury and South East 101.51 0.128 16.479 65.058 18.680 Coastal PCT Coast 11 39 Carlisle and District North West 101.59 0.040 22.197 67.413 18.000 PCT 277 301 Castle Point and East Of 95.34 0.065 10.809 56.463 17.249 Rochford PCT England 111 212 Central Cheshire PCT North West 99.36 0.062 16.213 60.996 15.380 10 34 Central Cornwall PCT South West 101.75 0.064 21.583 78.245 20.363 223 205 Central Derby PCT East 99.43 0.547 37.932 107.248 13.299 Midlands 213 54 Central Liverpool PCT North West 101.32 0.208 51.547 70.548 14.253 281 148 Central Manchester North West 100.11 0.616 48.699 79.223 10.756 PCT 34 76 Central Suffolk PCT East Of 101.03 0.054 10.136 69.800 18.208 England 157 235 Charnwood and North East 99.01 0.146 13.695 61.505 15.353 West Leicestershire Midlands PCT 112 97 Chelmsford PCT East Of 100.83 0.119 9.035 58.812 15.539 England 114 245 Cheltenham and South West 98.89 0.106 12.843 77.476 17.654 Tewkesbury PCT 62 51 Cherwell Vale PCT South Central 101.40 0.117 10.782 64.061 14.548 (North Oxfordshire PCT partnership) 74 256 Cheshire West PCT North West 98.56 0.084 15.515 79.607 17.634

Ipsos MORI: Frontiers of performance in the NHS II 55 Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population 44 106 Chesterfield PCT East 100.71 0.065 27.072 78.017 17.676 Midlands 59 73 Chiltern and South South Central 101.14 0.204 6.690 65.365 16.718 Bucks PCT 123 203 Chorley and South North West 99.44 0.070 15.527 58.235 14.884 Ribble PCT 297 209 City and Hackney London 99.41 0.755 43.859 81.594 9.473 Teaching PCT 170 139 Colchester PCT East Of 100.25 0.135 14.522 61.645 14.755 England 16 143 Cotswold and Vale South West 100.22 0.074 9.630 81.343 18.623 PCT 263 160 Coventry Teaching West 100.01 0.378 28.226 61.465 15.275 PCT Midlands 7 65 Craven, Harrogate Yorkshire and 101.17 0.090 11.292 73.420 18.151 and Rural District PCT the Humber 280 300 Crawley PCT South East 95.35 0.282 14.728 74.085 14.696 Coast 268 145 Croydon PCT London 100.18 0.578 19.793 65.364 12.886 202 248 Dacorum PCT East Of 98.82 0.159 9.471 67.164 15.103 England 130 254 Darlington PCT North East 98.62 0.066 24.611 71.589 17.024 235 194 Dartford, Gravesham South East 99.57 0.177 16.585 50.206 15.063 and Swanley PCT Coast 40 64 Daventry and South East 101.19 0.079 9.043 57.279 13.287 Northamptonshire Midlands PCT 101 85 Derbyshire Dales and East 100.95 0.073 14.095 46.244 15.248 South Derbyshire PCT Midlands 163 260 Derwentside PCT North East 98.53 0.027 28.268 64.878 17.335 209 267 Doncaster Central Yorkshire and 98.36 0.141 35.680 80.414 17.726 PCT the Humber 153 77 Doncaster East PCT Yorkshire and 101.02 0.049 25.444 45.041 15.709 the Humber 206 150 Doncaster West PCT Yorkshire and 100.10 0.041 35.219 54.034 16.165 the Humber 207 69 Dudley Beacon and West 101.16 0.190 28.193 53.192 16.857 Castle PCT Midlands 145 133 Dudley South PCT West 100.34 0.116 18.520 61.715 16.548 Midlands 83 199 Durham and Chester- North East 99.47 0.068 19.641 71.563 14.823 Le-Street PCT 5 18 Durham Dales PCT North East 102.10 0.030 27.953 74.720 18.116 291 238 Ealing PCT London 98.97 0.753 23.484 63.622 11.523 195 200 Easington PCT North East 99.46 0.024 41.762 64.319 17.044 174 202 East Cambridgeshire East Of 99.46 0.093 15.936 63.085 17.904 and Fenland PCT England 3 55 East Devon PCT South West 101.31 0.049 12.723 73.687 27.241 95 171 East Elmbridge and South East 99.91 0.214 6.636 69.088 17.558 Mid Surrey PCT Coast 54 113 East Hampshire PCT South Central 100.59 0.066 16.102 71.613 18.355

56 Ipsos MORI: Frontiers of performance in the NHS II Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population 122 107 East Kent Coastal PCT South East 100.69 0.087 22.501 58.915 20.418 Coast 113 10 East Leeds PCT Yorkshire and 102.51 0.190 35.024 60.927 15.611 the Humber 136 222 East Lincolnshire PCT East 99.26 0.051 21.325 55.309 21.475 Midlands 75 28 East Staffordshire PCT West 101.88 0.138 17.479 63.468 15.734 Midlands 147 220 East Surrey PCT South East 99.30 0.159 9.048 66.199 16.000 Coast 76 132 East Yorkshire PCT Yorkshire and 100.34 0.054 12.365 53.982 17.629 the Humber 56 122 Eastbourne Downs South East 100.51 0.114 17.213 62.547 26.244 PCT Coast 269 94 Eastern Birmingham West 100.84 0.420 41.966 67.939 16.132 PCT Midlands 39 216 Eastern Cheshire PCT North West 99.33 0.082 10.952 72.265 17.821 259 213 Eastern Hull PCT Yorkshire and 99.36 0.036 40.423 49.328 14.789 the Humber 284 249 Eastern Leicester PCT East 98.76 0.643 28.720 59.493 13.167 Midlands 104 53 Eastern Wakefield PCT Yorkshire and 101.35 0.037 34.228 64.747 15.694 the Humber 109 158 Eastleigh and Test South Central 100.02 0.090 8.247 61.564 14.954 Valley South PCT 1 108 Eden Valley PCT North West 100.67 0.035 15.261 86.693 19.162 105 227 Ellesmere Port and North West 99.13 0.060 19.821 69.453 16.282 Neston PCT 278 166 Enfield PCT London 99.95 0.601 23.054 56.320 13.783 204 179 Epping Forest PCT East Of 99.83 0.166 13.408 56.572 16.867 England 176 277 Erewash PCT East 98.12 0.068 19.257 68.279 15.828 Midlands 12 4 Exeter PCT South West 102.82 0.095 20.179 71.842 16.633 185 253 Fareham and Gosport South Central 98.65 0.066 11.309 58.680 16.904 PCT 65 157 Fylde PCT North West 100.04 0.070 13.045 48.426 22.779 87 103 Gateshead PCT North East 100.73 0.061 33.190 66.848 17.339 179 232 Gedling PCT East 99.07 0.117 16.538 53.959 16.915 Midlands 154 71 Great Yarmouth PCT East Of 101.15 0.058 27.639 57.286 19.645 England 92 25 Greater Derby PCT East 101.91 0.162 21.784 49.816 17.270 Midlands 271 116 Greenwich Teaching London 100.56 0.491 31.462 61.803 12.954 PCT 50 134 Guildford and South East 100.30 0.164 7.155 74.686 16.820 Waverley PCT Coast 246 270 Halton PCT North West 98.30 0.047 34.278 58.946 13.539 8 35 Hambleton and Yorkshire and 101.72 0.050 11.408 61.350 16.585 Richmondshire PCT the Humber

Ipsos MORI: Frontiers of performance in the NHS II 57 Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population 279 87 Hammersmith and London 100.90 0.632 27.485 57.823 10.495 Fulham PCT 292 121 Haringey Teaching London 100.52 0.747 38.022 66.822 9.780 PCT 264 278 Harlow PCT East Of 98.09 0.158 21.359 65.640 14.701 England 270 175 Harrow PCT London 99.87 0.694 13.504 65.900 14.471 232 273 Hartlepool PCT North East 98.22 0.039 37.695 64.436 16.227 133 26 Hastings and St South East 101.90 0.114 31.701 60.285 18.010 Leonards PCT Coast 290 303 Havering PCT London 94.06 0.152 14.779 53.932 17.692 302 244 Heart Of Birmingham West 98.89 0.816 52.052 65.267 9.957 Teaching PCT Midlands 30 98 Herefordshire PCT West 100.80 0.048 15.661 73.281 19.204 Midlands 239 228 Hertsmere PCT East Of 99.13 0.254 12.022 57.509 16.283 England 192 137 Heywood and North West 100.27 0.096 35.219 59.134 15.415 Middleton PCT 9 93 High Peak and Dales East 100.85 0.052 13.407 72.586 18.064 PCT Midlands 216 33 Hillingdon PCT London 101.75 0.461 17.644 54.674 13.897 135 210 Hinckley and East 99.40 0.066 10.345 51.600 15.149 Bosworth PCT Midlands 63 100 Horsham and South East 100.79 0.103 6.572 61.017 16.460 Chanctonbury PCT Coast 296 286 Hounslow PCT London 97.62 0.650 23.075 66.350 11.476 150 8 Huddersfield Central Yorkshire and 102.63 0.361 29.817 56.587 15.772 PCT the Humber 27 14 Huntingdonshire PCT East Of 102.29 0.131 10.166 72.751 12.988 England 178 187 Hyndburn and Ribble North West 99.72 0.147 22.258 53.395 15.995 Valley PCT 137 83 Ipswich PCT East Of 100.98 0.160 20.554 67.921 16.760 England 125 173 Isle Of Wight PCT South Central 99.89 0.063 21.097 60.708 22.378 288 176 Islington PCT London 99.86 0.650 42.365 77.750 10.232 80 118 Kennet and North South West 100.54 0.077 9.051 63.802 15.061 Wiltshire PCT 262 12 Kensington and London 102.34 0.679 22.029 54.527 12.217 Chelsea PCT 255 280 Kingston PCT London 98.05 0.416 11.613 74.497 13.366 240 198 Knowsley PCT North West 99.47 0.053 46.265 62.252 14.819 245 1 Lambeth PCT London 102.90 0.714 34.233 79.516 9.248 119 233 Langbaurgh PCT North East 99.03 0.036 26.388 68.979 16.990 183 290 Leeds North East PCT Yorkshire and 97.14 0.332 19.422 98.870 17.613 the Humber 98 59 Leeds North West PCT Yorkshire and 101.26 0.234 20.967 67.600 14.449 the Humber 252 257 Leeds West PCT Yorkshire and 98.56 0.133 28.627 54.616 15.123 the Humber

58 Ipsos MORI: Frontiers of performance in the NHS II Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population 248 224 Leicester City West East 99.18 0.304 37.822 76.852 14.060 PCT Midlands 267 38 Lewisham PCT London 101.59 0.646 28.562 70.718 10.992 127 274 Lincolnshire South East 98.18 0.063 12.483 69.778 16.676 West Teaching PCT Midlands 265 22 Luton Teaching PCT East Of 102.00 0.561 23.286 56.248 12.002 England 66 42 Maidstone Weald PCT South East 101.51 0.091 11.131 59.675 14.928 Coast 225 259 Maldon and South East Of 98.53 0.070 9.305 55.357 14.029 Chelmsford PCT England 166 72 Mansfield District PCT East 101.15 0.060 32.538 49.481 16.361 Midlands 266 258 Medway PCT South East 98.53 0.146 17.605 50.712 12.734 Coast 70 164 Melton, Rutland and East 100.00 0.093 8.528 59.386 16.679 Harborough PCT Midlands 47 129 Mendip PCT South West 100.40 0.070 14.353 76.176 17.189 6 57 Mid Devon PCT South West 101.31 0.048 17.260 89.753 18.969 71 7 Middlesbrough PCT North East 102.65 0.124 40.631 66.446 15.196 142 243 Mid-Hampshire PCT South Central 98.92 0.093 8.192 65.260 16.316 116 231 Mid-Sussex PCT South East 99.08 0.122 6.453 68.972 16.593 Coast 250 229 Milton Keynes PCT South Central 99.11 0.242 15.454 59.252 10.389 61 189 Morecambe Bay PCT North West 99.70 0.064 21.378 72.639 18.619 72 230 New Forest PCT South Central 99.10 0.062 10.375 70.458 22.611 172 266 Newark and Sherwood East 98.37 0.060 19.706 64.057 17.324 PCT Midlands 49 84 Newbury and South Central 100.97 0.101 8.556 68.746 13.911 Community PCT 81 16 Newcastle PCT North East 102.26 0.177 34.553 63.681 15.940 171 161 Newcastle-Under- West 100.00 0.077 20.025 56.254 17.395 Lyme PCT Midlands 294 62 Newham PCT London 101.22 0.830 40.521 69.447 8.947 97 152 North and East South West 100.07 0.047 20.636 68.228 19.892 Cornwall PCT 149 63 North Birmingham West 101.21 0.243 22.885 64.109 17.583 PCT Midlands 32 78 North Bradford PCT Yorkshire and 101.01 0.199 25.700 90.383 16.243 the Humber 26 89 North Devon PCT South West 100.89 0.047 20.916 79.251 20.264 2 19 North Dorset PCT South West 102.10 0.073 11.534 77.894 21.139 224 271 North East Yorkshire and 98.28 0.049 29.364 62.340 16.509 Lincolnshire PCT the Humber 51 70 North East Oxfordshire South Central 101.15 0.145 8.005 69.631 13.288 PCT (North Oxfordshire PCT Partnership) 118 138 North Eastern East 100.26 0.038 23.730 56.901 17.647 Derbyshire PCT Midlands

Ipsos MORI: Frontiers of performance in the NHS II 59 Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population 53 30 North Hampshire PCT South Central 101.84 0.115 8.783 59.671 12.983 258 284 North Hertfordshire East Of 97.95 0.192 12.839 60.485 15.191 and Stevenage PCT England 231 66 North Kirklees PCT Yorkshire and 101.17 0.329 28.756 51.040 13.778 the Humber 126 167 North Lincolnshire Yorkshire and 99.95 0.078 21.182 59.998 16.861 PCT the Humber 273 264 North Liverpool PCT North West 98.44 0.067 55.272 66.573 14.605 243 11 North Manchester PCT North West 102.43 0.342 58.437 62.400 14.817 96 214 North Norfolk PCT East Of 99.35 0.044 16.919 67.879 25.426 England 228 46 North Peterborough East Of 101.48 0.318 26.370 60.544 14.256 PCT England 124 31 North Sheffield PCT Yorkshire and 101.79 0.239 38.259 76.478 15.519 the Humber 106 281 North Somerset PCT South West 98.04 0.064 14.113 85.595 19.295 234 127 North Stoke PCT West 100.42 0.104 37.256 58.375 17.424 Midlands 182 225 North Surrey PCT South East 99.16 0.221 9.167 62.616 16.695 Coast 138 186 North Tees PCT North East 99.73 0.074 26.387 62.138 14.850 35 101 North Tyneside PCT North East 100.75 0.060 25.985 70.196 17.888 241 241 North Warwickshire West 98.93 0.101 19.362 49.175 14.899 PCT Midlands 233 262 Northampton PCT East 98.46 0.220 19.366 63.492 13.892 Midlands 156 172 Northamptonshire East 99.91 0.136 17.545 55.745 14.863 Heartlands PCT Midlands 94 272 Northumberland Care North East 98.22 0.038 21.892 78.052 17.591 Trust 48 5 Norwich PCT East Of 102.69 0.126 28.754 77.601 16.812 England 221 40 Nottingham City PCT East 101.58 0.339 41.364 64.946 14.416 Midlands 283 255 Oldbury and West 98.60 0.535 35.814 70.157 16.038 Smethwick PCT Midlands 160 20 Oldham PCT North West 102.07 0.282 30.726 54.294 14.282 167 81 Oxford City PCT South Central 101.00 0.376 17.947 73.592 13.857 120 90 Plymouth Teaching South West 100.88 0.068 26.165 68.663 15.983 PCT 90 149 Poole PCT South West 100.11 0.087 14.678 64.449 20.658 236 184 Portsmouth City South Central 99.79 0.155 24.874 56.435 15.358 Teaching PCT 212 183 Preston PCT North West 99.80 0.282 26.996 61.806 14.663 214 170 Reading PCT South Central 99.92 0.295 15.574 64.990 12.434 287 218 Redbridge PCT London 99.31 0.701 17.767 49.304 13.434 180 208 Redditch and West 99.41 0.111 14.919 62.416 14.727 Bromsgrove PCT Midlands 198 155 Richmond and London 100.06 0.370 9.684 66.035 13.738 Twickenham PCT 177 27 Rochdale PCT North West 101.90 0.330 32.964 59.856 13.693

60 Ipsos MORI: Frontiers of performance in the NHS II Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population 219 239 Rotherham PCT Yorkshire and 98.97 0.079 28.241 56.869 15.577 the Humber 282 289 Rowley Regis and West 97.38 0.223 35.122 62.800 15.596 Tipton PCT Midlands 173 196 Royston, Buntingford East Of 99.50 0.131 5.407 61.004 12.744 and Bishop’s Stortford England PCT 84 60 Rugby PCT West 101.25 0.168 13.582 65.504 16.066 Midlands 14 74 Rushcliffe PCT East 101.08 0.130 8.969 68.639 16.212 Midlands 229 237 Salford PCT North West 98.98 0.140 38.299 68.383 16.252 37 182 Scarborough, Whitby Yorkshire and 99.80 0.045 20.534 75.502 21.091 and Ryedale PCT the Humber 132 226 Sedgefield PCT North East 99.14 0.026 29.064 68.305 16.369 33 141 Selby and York PCT Yorkshire and 100.24 0.075 13.818 73.012 16.292 the Humber 129 282 Sheffield South West Yorkshire and 98.03 0.236 13.930 86.348 17.522 PCT the Humber 158 217 Sheffield West PCT Yorkshire and 99.32 0.167 21.798 71.299 14.808 the Humber 159 159 Shepway PCT South East 100.01 0.105 20.743 57.367 20.109 Coast 146 247 Shropshire County West 98.83 0.053 15.403 68.507 18.079 PCT Midlands 301 296 Slough PCT South Central 96.02 0.622 20.885 57.007 11.672 187 223 Solihull PCT West 99.24 0.166 16.527 66.207 16.832 Midlands 45 111 Somerset Coast PCT South West 100.62 0.048 18.635 70.822 20.941 43 251 South and East Dorset South West 98.68 0.063 10.799 75.394 26.929 PCT 184 21 South Birmingham West 102.01 0.373 31.281 71.519 15.430 PCT Midlands 36 2 South Cambridgeshire East Of 102.84 0.127 6.336 53.069 14.896 PCT England 230 265 South East East Of 98.42 0.154 11.081 64.047 14.546 Hertfordshire PCT England 4 24 South East South Central 101.94 0.120 7.239 84.116 16.314 Oxfordshire PCT 257 287 South East Sheffield Yorkshire and 97.55 0.175 35.285 74.071 17.130 PCT the Humber 194 276 South Gloucestershire South West 98.13 0.081 9.813 66.911 14.381 PCT 64 147 South Hams and West South West 100.12 0.057 14.446 68.930 20.565 Devon PCT 15 151 South Huddersfield Yorkshire and 100.09 0.070 14.664 86.792 14.546 PCT the Humber 191 114 South Leeds PCT Yorkshire and 100.57 0.132 33.025 61.542 14.488 the Humber 93 131 South Leicestershire East 100.35 0.204 8.873 58.228 15.780 PCT Midlands

Ipsos MORI: Frontiers of performance in the NHS II 61 Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population 226 185 South Liverpool PCT North West 99.76 0.123 40.018 55.471 18.349 208 45 South Manchester North West 101.49 0.303 40.904 62.906 14.416 PCT 115 37 South Peterborough East Of 101.64 0.131 15.587 60.664 14.229 PCT England 140 110 South Sefton PCT North West 100.62 0.057 31.955 56.264 16.962 23 75 South Somerset PCT South West 101.08 0.052 13.743 69.876 19.710 244 215 South Stoke PCT West 99.34 0.137 31.824 62.790 15.386 Midlands 68 52 South Tyneside PCT North East 101.39 0.068 33.082 64.104 17.833 82 88 South Warwickshire West 100.89 0.155 10.759 63.628 17.206 PCT Midlands 28 162 South West Dorset South West 100.00 0.061 17.332 82.144 22.001 PCT 41 91 South West Kent PCT South East 100.86 0.116 9.013 67.835 17.439 Coast 86 123 South West South Central 100.51 0.102 7.128 62.571 14.423 Oxfordshire PCT 17 6 South Western West 102.66 0.080 11.966 56.971 16.888 Staffordshire PCT Midlands 42 268 South Wiltshire PCT South West 98.35 0.070 11.695 98.975 18.063 91 165 South Worcestershire West 99.99 0.080 13.892 68.814 17.325 PCT Midlands 196 174 Southampton City PCT South Central 99.87 0.211 23.761 73.884 14.546 249 269 Southend On Sea PCT East Of 98.35 0.136 21.661 58.999 19.183 England 73 86 Southern Norfolk PCT East Of 100.91 0.072 12.281 64.321 18.676 England 25 135 Southport and Formby North West 100.30 0.077 17.677 66.580 21.770 PCT 272 29 Southwark PCT London 101.88 0.687 35.401 71.408 10.355 78 23 St Albans and East Of 101.97 0.243 7.725 64.400 14.907 Harpenden PCT England 210 252 St Helens PCT North West 98.65 0.045 32.122 62.402 15.596 107 82 Staffordshire West 100.99 0.033 17.629 54.999 16.597 Moorlands PCT Midlands 227 291 Stockport PCT North West 97.02 0.137 18.062 64.624 16.522 55 125 Suffolk Coastal PCT East Of 100.48 0.080 11.968 69.374 21.002 England 110 130 Suffolk West PCT East Of 100.38 0.176 11.327 71.334 16.455 England 175 188 Sunderland Teaching North East 99.71 0.057 34.223 60.277 15.589 PCT 164 191 Surrey Heath and South East 99.65 0.218 6.513 62.270 14.016 Woking PCT Coast 19 124 Sussex Downs and South East 100.50 0.100 10.142 79.529 18.604 Weald PCT Coast 211 109 Sutton and Merton London 100.63 0.450 13.942 64.709 13.715 PCT 261 236 Swale PCT South East 99.01 0.078 22.190 43.741 14.572 Coast 251 288 Swindon PCT South West 97.38 0.164 16.856 70.500 13.722

62 Ipsos MORI: Frontiers of performance in the NHS II Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population 203 136 Tameside and North West 100.29 0.131 28.084 50.099 14.711 Glossop PCT 13 48 Taunton Deane PCT South West 101.48 0.066 16.277 74.918 19.185 60 154 Teignbridge PCT South West 100.06 0.054 17.610 71.122 22.196 238 206 Telford and Wrekin West 99.43 0.134 21.799 58.787 12.396 PCT Midlands 205 240 Tendring PCT East Of 98.96 0.063 23.255 55.114 26.171 England 286 295 Thurrock PCT East Of 96.66 0.138 21.213 49.105 13.051 England 21 44 Torbay PCT South West 101.50 0.062 23.705 73.793 22.636 299 234 Tower Hamlets PCT London 99.02 0.697 45.862 66.611 9.362 253 221 Trafford North PCT North West 99.29 0.328 27.737 53.914 15.560 20 32 Trafford South PCT North West 101.77 0.172 14.411 62.137 16.737 31 68 Uttlesford PCT East Of 101.16 0.094 6.771 73.391 15.236 England 29 9 Vale Of Aylesbury South Central 102.57 0.176 7.987 61.936 13.346 PCT 128 201 Wakefield West PCT Yorkshire and 99.46 0.098 23.076 73.920 15.120 the Humber 275 246 Walsall Teaching PCT West 98.84 0.270 29.276 51.290 16.178 Midlands 293 178 Waltham Forest PCT London 99.84 0.751 30.255 64.713 9.814 260 102 Wandsworth PCT London 100.75 0.563 20.959 67.876 10.430 190 261 Warrington PCT North West 98.48 0.076 19.337 61.116 14.151 141 61 Watford and Three East Of 101.24 0.304 11.885 67.128 14.907 Rivers PCT England 144 192 Waveney PCT East Of 99.62 0.052 21.132 66.068 21.593 England 289 294 Wednesbury and West West 96.82 0.364 35.291 65.291 17.581 Bromwich PCT Midlands 193 153 Welwyn Hatfield PCT East Of 100.07 0.210 12.612 58.715 17.157 England 89 193 West Cumbria PCT North West 99.61 0.032 25.762 72.893 16.903 143 163 West Gloucestershire South West 100.00 0.120 17.313 66.617 16.070 PCT 199 156 West Hull PCT Yorkshire and 100.04 0.103 41.860 73.365 15.821 the Humber 155 211 West Lancashire PCT North West 99.36 0.057 21.104 55.718 15.616 79 92 West Lincolnshire PCT East 100.86 0.065 19.622 57.932 17.188 Midlands 88 117 West Norfolk PCT East Of 100.55 0.080 18.668 68.380 21.678 England 69 119 West Of Cornwall PCT South West 100.53 0.059 26.618 81.327 19.981 247 299 West Wiltshire PCT South West 95.46 0.077 11.959 75.750 17.214 57 96 Western Sussex PCT South East 100.83 0.084 12.820 55.265 23.403 Coast 285 126 Westminster PCT London 100.46 0.712 31.171 58.519 12.362 188 195 Windsor, Ascot and South Central 99.56 0.284 8.074 63.427 15.080 Maidenhead PCT

Ipsos MORI: Frontiers of performance in the NHS II 63 Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population 242 279 Witham, Braintree and East Of 98.08 0.081 13.522 56.675 14.753 Halstead Care Trust England 131 120 Wokingham PCT South Central 100.53 0.192 5.107 59.246 11.926 256 67 Wolverhampton City West 101.17 0.414 31.788 55.090 16.901 PCT Midlands 165 80 Wycombe PCT South Central 101.00 0.327 10.647 60.124 13.507 108 204 Wyre Forest PCT West 99.44 0.072 17.193 76.750 16.754 Midlands 200 292 Wyre PCT North West 97.00 0.047 17.795 57.324 22.175 85 181 Yorkshire Wolds and Yorkshire and 99.80 0.040 18.798 62.746 19.343 Coast PCT the Humber

64 Ipsos MORI: Frontiers of performance in the NHS II PCTs in rank order

Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population 245 1 Lambeth PCT London 102.90 0.714 34.233 79.516 9.248 South Cambridgeshire East Of 36 2 102.84 0.127 6.336 53.069 14.896 PCT England East Of 58 3 Cambridge City PCT 102.83 0.373 14.308 81.464 13.192 England

12 4 Exeter PCT South West 102.82 0.095 20.179 71.842 16.633

East Of 48 5 Norwich PCT 102.69 0.126 28.754 77.601 16.812 England South Western West 17 6 102.66 0.080 11.966 56.971 16.888 Staffordshire PCT Midlands 71 7 Middlesbrough PCT North East 102.65 0.124 40.631 66.446 15.196 Huddersfield Central Yorkshire and 150 8 102.63 0.361 29.817 56.587 15.772 PCT the Humber Vale Of Aylesbury 29 9 South Central 102.57 0.176 7.987 61.936 13.346 PCT Yorkshire and 113 10 East Leeds PCT 102.51 0.190 35.024 60.927 15.611 the Humber North Manchester 243 11 North West 102.43 0.342 58.437 62.400 14.817 PCT Kensington and 262 12 London 102.34 0.679 22.029 54.527 12.217 Chelsea PCT Birkenhead and 22 13 North West 102.34 0.072 39.137 80.559 16.672 Wallasey PCT East Of 27 14 Huntingdonshire PCT 102.29 0.131 10.166 72.751 12.988 England East Of 139 15 Bedford PCT 102.27 0.342 17.543 65.350 14.859 England 81 16 Newcastle PCT North East 102.26 0.177 34.553 63.681 15.940 Yorkshire and 24 17 Airedale PCT 102.16 0.200 20.138 69.282 17.477 the Humber 5 18 Durham Dales PCT North East 102.10 0.030 27.953 74.720 18.116 2 19 North Dorset PCT South West 102.10 0.073 11.534 77.894 21.139 160 20 Oldham PCT North West 102.07 0.282 30.726 54.294 14.282 South Birmingham West 184 21 102.01 0.373 31.281 71.519 15.430 PCT Midlands East Of 265 22 Luton Teaching PCT 102.00 0.561 23.286 56.248 12.002 England St Albans and East Of 78 23 101.97 0.243 7.725 64.400 14.907 Harpenden PCT England South East 424 South Central 101.94 0.120 7.239 84.116 16.314 Oxfordshire PCT East 92 25 Greater Derby PCT 101.91 0.162 21.784 49.816 17.270 Midlands Hastings and St South East 133 26 101.90 0.114 31.701 60.285 18.010 Leonards PCT Coast 177 27 Rochdale PCT North West 101.90 0.330 32.964 59.856 13.693

Ipsos MORI: Frontiers of performance in the NHS II 65 Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population West 75 28 East Staffordshire PCT 101.88 0.138 17.479 63.468 15.734 Midlands 272 29 Southwark PCT London 101.88 0.687 35.401 71.408 10.355 53 30 North Hampshire PCT South Central 101.84 0.115 8.783 59.671 12.983 Yorkshire and 124 31 North Sheffield PCT 101.79 0.239 38.259 76.478 15.519 the Humber 20 32 Trafford South PCT North West 101.77 0.172 14.411 62.137 16.737 216 33 Hillingdon PCT London 101.75 0.461 17.644 54.674 13.897 10 34 Central Cornwall PCT South West 101.75 0.064 21.583 78.245 20.363 Hambleton and Yorkshire and 835 101.72 0.050 11.408 61.350 16.585 Richmondshire PCT the Humber East 18 36 Amber Valley PCT 101.70 0.042 18.994 64.059 16.717 Midlands South Peterborough East Of 115 37 101.64 0.131 15.587 60.664 14.229 PCT England 267 38 Lewisham PCT London 101.59 0.646 28.562 70.718 10.992 Carlisle and District 11 39 North West 101.59 0.040 22.197 67.413 18.000 PCT East 221 40 Nottingham City PCT 101.58 0.339 41.364 64.946 14.416 Midlands 121 41 Bolton PCT North West 101.53 0.235 29.381 64.438 14.917 South East 66 42 Maidstone Weald PCT 101.51 0.091 11.131 59.675 14.928 Coast Canterbury and South East 52 43 101.51 0.128 16.479 65.058 18.680 Coastal PCT Coast 21 44 Torbay PCT South West 101.50 0.062 23.705 73.793 22.636 South Manchester 208 45 North West 101.49 0.303 40.904 62.906 14.416 PCT North Peterborough East Of 228 46 101.48 0.318 26.370 60.544 14.256 PCT England 276 47 Camden PCT London 101.48 0.685 34.611 68.995 10.715 13 48 Taunton Deane PCT South West 101.48 0.066 16.277 74.918 19.185 152 49 Bracknell Forest PCT South Central 101.47 0.178 8.606 47.644 10.823 Yorkshire and 117 50 Calderdale PCT 101.45 0.172 25.632 59.399 15.593 the Humber Cherwell Vale PCT 62 51 (North Oxfordshire South Central 101.40 0.117 10.782 64.061 14.548 PCT partnership) 68 52 South Tyneside PCT North East 101.39 0.068 33.082 64.104 17.833 Eastern Wakefield Yorkshire and 104 53 101.35 0.037 34.228 64.747 15.694 PCT the Humber 213 54 Central Liverpool PCT North West 101.32 0.208 51.547 70.548 14.253 3 55 East Devon PCT South West 101.31 0.049 12.723 73.687 27.241 Blackburn With 222 56 North West 101.31 0.401 32.343 58.476 13.319 Darwen PCT 6 57 Mid Devon PCT South West 101.31 0.048 17.260 89.753 18.969 East 99 58 Bassetlaw PCT 101.29 0.054 25.655 55.096 16.243 Midlands

66 Ipsos MORI: Frontiers of performance in the NHS II Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population Leeds North West Yorkshire and 98 59 101.26 0.234 20.967 67.600 14.449 PCT the Humber West 84 60 Rugby PCT 101.25 0.168 13.582 65.504 16.066 Midlands Watford and Three East Of 141 61 101.24 0.304 11.885 67.128 14.907 Rivers PCT England 294 62 Newham PCT London 101.22 0.830 40.521 69.447 8.947 North Birmingham West 149 63 101.21 0.243 22.885 64.109 17.583 PCT Midlands Daventry and South East 40 64 Northamptonshire 101.19 0.079 9.043 57.279 13.287 Midlands PCT Craven, Harrogate Yorkshire and 765 101.17 0.090 11.292 73.420 18.151 and Rural District PCT the Humber Yorkshire and 231 66 North Kirklees PCT 101.17 0.329 28.756 51.040 13.778 the Humber Wolverhampton City West 256 67 101.17 0.414 31.788 55.090 16.901 PCT Midlands East Of 31 68 Uttlesford PCT 101.16 0.094 6.771 73.391 15.236 England Dudley Beacon and West 207 69 101.16 0.190 28.193 53.192 16.857 Castle PCT Midlands North East Oxfordshire PCT 51 70 South Central 101.15 0.145 8.005 69.631 13.288 (North Oxfordshire PCT Partnership) East Of 154 71 Great Yarmouth PCT 101.15 0.058 27.639 57.286 19.645 England East 166 72 Mansfield District PCT 101.15 0.060 32.538 49.481 16.361 Midlands Chiltern and South 59 73 South Central 101.14 0.204 6.690 65.365 16.718 Bucks PCT East 14 74 Rushcliffe PCT 101.08 0.130 8.969 68.639 16.212 Midlands 23 75 South Somerset PCT South West 101.08 0.052 13.743 69.876 19.710 East Of 34 76 Central Suffolk PCT 101.03 0.054 10.136 69.800 18.208 England Yorkshire and 153 77 Doncaster East PCT 101.02 0.049 25.444 45.041 15.709 the Humber Yorkshire and 32 78 North Bradford PCT 101.01 0.199 25.700 90.383 16.243 the Humber Bedfordshire East Of 103 79 101.00 0.116 9.968 64.162 13.530 Heartlands PCT England 165 80 Wycombe PCT South Central 101.00 0.327 10.647 60.124 13.507 167 81 Oxford City PCT South Central 101.00 0.376 17.947 73.592 13.857 Staffordshire West 107 82 100.99 0.033 17.629 54.999 16.597 Moorlands PCT Midlands East Of 137 83 Ipswich PCT 100.98 0.160 20.554 67.921 16.760 England Newbury and 49 84 South Central 100.97 0.101 8.556 68.746 13.911 Community PCT

Ipsos MORI: Frontiers of performance in the NHS II 67 Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population Derbyshire Dales and East 101 85 100.95 0.073 14.095 46.244 15.248 South Derbyshire PCT Midlands East Of 73 86 Southern Norfolk PCT 100.91 0.072 12.281 64.321 18.676 England Hammersmith and 279 87 London 100.90 0.632 27.485 57.823 10.495 Fulham PCT South Warwickshire West 82 88 100.89 0.155 10.759 63.628 17.206 PCT Midlands 26 89 North Devon PCT South West 100.89 0.047 20.916 79.251 20.264 Plymouth Teaching 120 90 South West 100.88 0.068 26.165 68.663 15.983 PCT South East 41 91 South West Kent PCT 100.86 0.116 9.013 67.835 17.439 Coast East 79 92 West Lincolnshire PCT 100.86 0.065 19.622 57.932 17.188 Midlands High Peak and Dales East 993 100.85 0.052 13.407 72.586 18.064 PCT Midlands Eastern Birmingham West 269 94 100.84 0.420 41.966 67.939 16.132 PCT Midlands Broxtowe and East 77 95 100.84 0.112 18.139 63.268 16.034 Hucknall PCT Midlands South East 57 96 Western Sussex PCT 100.83 0.084 12.820 55.265 23.403 Coast East Of 112 97 Chelmsford PCT 100.83 0.119 9.035 58.812 15.539 England West 30 98 Herefordshire PCT 100.80 0.048 15.661 73.281 19.204 Midlands Burnley, Pendle and 181 99 North West 100.79 0.206 28.224 54.306 15.023 Rossendale PCT Horsham and South East 63 100 100.79 0.103 6.572 61.017 16.460 Chanctonbury PCT Coast 35 101 North Tyneside PCT North East 100.75 0.060 25.985 70.196 17.888 260 102 Wandsworth PCT London 100.75 0.563 20.959 67.876 10.430 87 103 Gateshead PCT North East 100.73 0.061 33.190 66.848 17.339 Bebington and West 38 104 North West 100.73 0.064 15.834 54.957 20.379 Wirral PCT 151 105 Bury PCT North West 100.71 0.175 23.510 54.500 14.758 East 44 106 Chesterfield PCT 100.71 0.065 27.072 78.017 17.676 Midlands South East 122 107 East Kent Coastal PCT 100.69 0.087 22.501 58.915 20.418 Coast 1 108 Eden Valley PCT North West 100.67 0.035 15.261 86.693 19.162 Sutton and Merton 211 109 London 100.63 0.450 13.942 64.709 13.715 PCT 140 110 South Sefton PCT North West 100.62 0.057 31.955 56.264 16.962 45 111 Somerset Coast PCT South West 100.62 0.048 18.635 70.822 20.941 Brighton and Hove South East 186 112 100.61 0.222 25.672 67.445 16.323 City PCT Coast 54 113 East Hampshire PCT South Central 100.59 0.066 16.102 71.613 18.355 Yorkshire and 191 114 South Leeds PCT 100.57 0.132 33.025 61.542 14.488 the Humber

68 Ipsos MORI: Frontiers of performance in the NHS II Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population East Of 67 115 Broadland PCT 100.56 0.051 9.646 64.408 19.274 England Greenwich Teaching 271 116 London 100.56 0.491 31.462 61.803 12.954 PCT East Of 88 117 West Norfolk PCT 100.55 0.080 18.668 68.380 21.678 England Kennet and North 80 118 South West 100.54 0.077 9.051 63.802 15.061 Wiltshire PCT 69 119 West Of Cornwall PCT South West 100.53 0.059 26.618 81.327 19.981 131 120 Wokingham PCT South Central 100.53 0.192 5.107 59.246 11.926 Haringey Teaching 292 121 London 100.52 0.747 38.022 66.822 9.780 PCT Eastbourne Downs South East 56 122 100.51 0.114 17.213 62.547 26.244 PCT Coast South West 86 123 South Central 100.51 0.102 7.128 62.571 14.423 Oxfordshire PCT Sussex Downs and South East 19 124 100.50 0.100 10.142 79.529 18.604 Weald PCT Coast East Of 55 125 Suffolk Coastal PCT 100.48 0.080 11.968 69.374 21.002 England 285 126 Westminster PCT London 100.46 0.712 31.171 58.519 12.362 West 234 127 North Stoke PCT 100.42 0.104 37.256 58.375 17.424 Midlands Bexhill and Rother South East 46 128 100.40 0.089 16.084 59.145 28.338 PCT Coast 47 129 Mendip PCT South West 100.40 0.070 14.353 76.176 17.189 East Of 110 130 Suffolk West PCT 100.38 0.176 11.327 71.334 16.455 England South Leicestershire East 93 131 100.35 0.204 8.873 58.228 15.780 PCT Midlands Yorkshire and 76 132 East Yorkshire PCT 100.34 0.054 12.365 53.982 17.629 the Humber West 145 133 Dudley South PCT 100.34 0.116 18.520 61.715 16.548 Midlands Guildford and South East 50 134 100.30 0.164 7.155 74.686 16.820 Waverley PCT Coast Southport and Formby 25 135 North West 100.30 0.077 17.677 66.580 21.770 PCT Tameside and 203 136 North West 100.29 0.131 28.084 50.099 14.711 Glossop PCT Heywood and 192 137 North West 100.27 0.096 35.219 59.134 15.415 Middleton PCT North Eastern East 118 138 100.26 0.038 23.730 56.901 17.647 Derbyshire PCT Midlands East Of 170 139 Colchester PCT 100.25 0.135 14.522 61.645 14.755 England 189 140 Bristol North PCT South West 100.25 0.267 27.449 79.185 15.529 Yorkshire and 33 141 Selby and York PCT 100.24 0.075 13.818 73.012 16.292 the Humber Bradford South and Yorkshire and 168 142 100.23 0.244 31.785 79.012 14.318 West PCT the Humber

Ipsos MORI: Frontiers of performance in the NHS II 69 Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population Cotswold and Vale 16 143 South West 100.22 0.074 9.630 81.343 18.623 PCT Blackwater Valley and 134 144 South Central 100.19 0.125 7.406 60.425 12.139 Hart PCT 268 145 Croydon PCT London 100.18 0.578 19.793 65.364 12.886 Burntwood, Lichfield West 161 146 100.13 0.069 15.850 58.716 13.390 and Tamworth PCT Midlands South Hams and West 64 147 South West 100.12 0.057 14.446 68.930 20.565 Devon PCT Central Manchester 281 148 North West 100.11 0.616 48.699 79.223 10.756 PCT 90 149 Poole PCT South West 100.11 0.087 14.678 64.449 20.658 Yorkshire and 206 150 Doncaster West PCT 100.10 0.041 35.219 54.034 16.165 the Humber South Huddersfield Yorkshire and 15 151 100.09 0.070 14.664 86.792 14.546 PCT the Humber North and East 97 152 South West 100.07 0.047 20.636 68.228 19.892 Cornwall PCT East Of 193 153 Welwyn Hatfield PCT 100.07 0.210 12.612 58.715 17.157 England 60 154 Teignbridge PCT South West 100.06 0.054 17.610 71.122 22.196 Richmond and 198 155 London 100.06 0.370 9.684 66.035 13.738 Twickenham PCT Yorkshire and 199 156 West Hull PCT 100.04 0.103 41.860 73.365 15.821 the Humber 65 157 Fylde PCT North West 100.04 0.070 13.045 48.426 22.779 Eastleigh and Test 109 158 South Central 100.02 0.090 8.247 61.564 14.954 Valley South PCT South East 263 159 Shepway PCT 100.01 0.105 20.743 57.367 20.109 Coast Coventry Teaching West 159 160 100.01 0.378 28.226 61.465 15.275 PCT Midlands Newcastle-Under- West 171 161 100.00 0.077 20.025 56.254 17.395 Lyme PCT Midlands South West Dorset 28 162 South West 100.00 0.061 17.332 82.144 22.001 PCT West Gloucestershire 143 163 South West 100.00 0.120 17.313 66.617 16.070 PCT Melton, Rutland and East 70 164 100.00 0.093 8.528 59.386 16.679 Harborough PCT Midlands South Worcestershire West 91 165 99.99 0.080 13.892 68.814 17.325 PCT Midlands 278 166 Enfield PCT London 99.95 0.601 23.054 56.320 13.783 North Lincolnshire Yorkshire and 126 167 99.95 0.078 21.182 59.998 16.861 PCT the Humber Yorkshire and 201 168 Barnsley PCT 99.93 0.037 33.001 55.826 16.192 the Humber Bristol South and West 162 169 South West 99.92 0.169 27.800 84.576 14.125 PCT 214 170 Reading PCT South Central 99.92 0.295 15.574 64.990 12.434

70 Ipsos MORI: Frontiers of performance in the NHS II Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population East Elmbridge and South East 95 171 99.91 0.214 6.636 69.088 17.558 Mid Surrey PCT Coast Northamptonshire East 156 172 99.91 0.136 17.545 55.745 14.863 Heartlands PCT Midlands 125 173 Isle Of Wight PCT South Central 99.89 0.063 21.097 60.708 22.378 196 174 Southampton City PCT South Central 99.87 0.211 23.761 73.884 14.546 270 175 Harrow PCT London 99.87 0.694 13.504 65.900 14.471 288 176 Islington PCT London 99.86 0.650 42.365 77.750 10.232 Bournemouth 102 177 South West 99.85 0.135 23.383 80.656 20.120 Teaching PCT 293 178 Waltham Forest PCT London 99.84 0.751 30.255 64.713 9.814 East Of 204 179 Epping Forest PCT 99.83 0.166 13.408 56.572 16.867 England 215 180 Bexley Care Trust London 99.83 0.225 15.006 53.107 15.808 Yorkshire Wolds and Yorkshire and 85 181 99.80 0.040 18.798 62.746 19.343 Coast PCT the Humber Scarborough, Whitby Yorkshire and 37 182 99.80 0.045 20.534 75.502 21.091 and Ryedale PCT the Humber 212 183 Preston PCT North West 99.80 0.282 26.996 61.806 14.663 Portsmouth City 236 184 South Central 99.79 0.155 24.874 56.435 15.358 Teaching PCT 226 185 South Liverpool PCT North West 99.76 0.123 40.018 55.471 18.349 138 186 North Tees PCT North East 99.73 0.074 26.387 62.138 14.850 Hyndburn and Ribble 178 187 North West 99.72 0.147 22.258 53.395 15.995 Valley PCT Sunderland Teaching 175 188 North East 99.71 0.057 34.223 60.277 15.589 PCT 61 189 Morecambe Bay PCT North West 99.70 0.064 21.378 72.639 18.619 South East 148 190 Ashford PCT 99.66 0.097 13.487 61.713 16.150 Coast Surrey Heath and South East 164 191 99.65 0.218 6.513 62.270 14.016 Woking PCT Coast East Of 144 192 Waveney PCT 99.62 0.052 21.132 66.068 21.593 England 89 193 West Cumbria PCT North West 99.61 0.032 25.762 72.893 16.903 Dartford, Gravesham South East 235 194 99.57 0.177 16.585 50.206 15.063 and Swanley PCT Coast Windsor, Ascot and 188 195 South Central 99.56 0.284 8.074 63.427 15.080 Maidenhead PCT Royston, Buntingford East Of 173 196 and Bishop’s Stortford 99.50 0.131 5.407 61.004 12.744 England PCT West 220 197 Cannock Chase PCT 99.49 0.049 18.911 49.747 13.671 Midlands 240 198 Knowsley PCT North West 99.47 0.053 46.265 62.252 14.819 Durham and Chester- 83 199 North East 99.47 0.068 19.641 71.563 14.823 Le-Street PCT 195 200 Easington PCT North East 99.46 0.024 41.762 64.319 17.044 Yorkshire and 128 201 Wakefield West PCT 99.46 0.098 23.076 73.920 15.120 the Humber

Ipsos MORI: Frontiers of performance in the NHS II 71 Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population East Cambridgeshire East Of 174 202 99.46 0.093 15.936 63.085 17.904 and Fenland PCT England Chorley and South 123 203 North West 99.44 0.070 15.527 58.235 14.884 Ribble PCT West 108 204 Wyre Forest PCT 99.44 0.072 17.193 76.750 16.754 Midlands East 223 205 Central Derby PCT 99.43 0.547 37.932 107.248 13.299 Midlands Telford and Wrekin West 238 206 99.43 0.134 21.799 58.787 12.396 PCT Midlands 197 207 Blackpool PCT North West 99.42 0.068 33.882 55.977 19.579 Redditch and West 180 208 99.41 0.111 14.919 62.416 14.727 Bromsgrove PCT Midlands City and Hackney 297 209 London 99.41 0.755 43.859 81.594 9.473 Teaching PCT Hinckley and East 135 210 99.40 0.066 10.345 51.600 15.149 Bosworth PCT Midlands 111 211 West Lancashire PCT North West 99.36 0.057 21.104 55.718 15.616 155 212 Central Cheshire PCT North West 99.36 0.062 16.213 60.996 15.380 Yorkshire and 259 213 Eastern Hull PCT 99.36 0.036 40.423 49.328 14.789 the Humber East Of 96 214 North Norfolk PCT 99.35 0.044 16.919 67.879 25.426 England West 244 215 South Stoke PCT 99.34 0.137 31.824 62.790 15.386 Midlands 39 216 Eastern Cheshire PCT North West 99.33 0.082 10.952 72.265 17.821 Yorkshire and 158 217 Sheffield West PCT 99.32 0.167 21.798 71.299 14.808 the Humber 100 218 Redbridge PCT London 99.31 0.701 17.767 49.304 13.434 Bath and North East 287 219 South West 99.31 0.116 12.223 75.414 17.841 Somerset PCT South East 147 220 East Surrey PCT 99.30 0.159 9.048 66.199 16.000 Coast 253 221 Trafford North PCT North West 99.29 0.328 27.737 53.914 15.560 East 136 222 East Lincolnshire PCT 99.26 0.051 21.325 55.309 21.475 Midlands West 187 223 Solihull PCT 99.24 0.166 16.527 66.207 16.832 Midlands Leicester City West East 248 224 99.18 0.304 37.822 76.852 14.060 PCT Midlands South East 182 225 North Surrey PCT 99.16 0.221 9.167 62.616 16.695 Coast 132 226 Sedgefield PCT North East 99.14 0.026 29.064 68.305 16.369 Ellesmere Port and 105 227 North West 99.13 0.060 19.821 69.453 16.282 Neston PCT East Of 239 228 Hertsmere PCT 99.13 0.254 12.022 57.509 16.283 England 250 229 Milton Keynes PCT South Central 99.11 0.242 15.454 59.252 10.389 72 230 New Forest PCT South Central 99.10 0.062 10.375 70.458 22.611 South East 116 231 Mid-Sussex PCT 99.08 0.122 6.453 68.972 16.593 Coast

72 Ipsos MORI: Frontiers of performance in the NHS II Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population East 179 232 Gedling PCT 99.07 0.117 16.538 53.959 16.915 Midlands 119 233 Langbaurgh PCT North East 99.03 0.036 26.388 68.979 16.990 299 234 Tower Hamlets PCT London 99.02 0.697 45.862 66.611 9.362 Charnwood and North East 157 235 West Leicestershire 99.01 0.146 13.695 61.505 15.353 Midlands PCT South East 261 236 Swale PCT 99.01 0.078 22.190 43.741 14.572 Coast 229 237 Salford PCT North West 98.98 0.140 38.299 68.383 16.252 291 238 Ealing PCT London 98.97 0.753 23.484 63.622 11.523 Yorkshire and 219 239 Rotherham PCT 98.97 0.079 28.241 56.869 15.577 the Humber East Of 205 240 Tendring PCT 98.96 0.063 23.255 55.114 26.171 England North Warwickshire West 218 241 98.93 0.101 19.362 49.175 14.899 PCT Midlands Ashton, Leigh and 241 242 North West 98.93 0.048 29.307 54.128 14.411 Wigan PCT 142 243 Mid-Hampshire PCT South Central 98.92 0.093 8.192 65.260 16.316 Heart Of Birmingham West 302 244 98.89 0.816 52.052 65.267 9.957 Teaching PCT Midlands Cheltenham and 114 245 South West 98.89 0.106 12.843 77.476 17.654 Tewkesbury PCT West 275 246 Walsall Teaching PCT 98.84 0.270 29.276 51.290 16.178 Midlands Shropshire County West 146 247 98.83 0.053 15.403 68.507 18.079 PCT Midlands East Of 202 248 Dacorum PCT 98.82 0.159 9.471 67.164 15.103 England East 284 249 Eastern Leicester PCT 98.76 0.643 28.720 59.493 13.167 Midlands 274 250 Barnet PCT London 98.69 0.617 17.529 70.978 14.463 South and East Dorset 43 251 South West 98.68 0.063 10.799 75.394 26.929 PCT 210 252 St Helens PCT North West 98.65 0.045 32.122 62.402 15.596 Fareham and Gosport 185 253 South Central 98.65 0.066 11.309 58.680 16.904 PCT 130 254 Darlington PCT North East 98.62 0.066 24.611 71.589 17.024 Oldbury and West 283 255 98.60 0.535 35.814 70.157 16.038 Smethwick PCT Midlands 74 256 Cheshire West PCT North West 98.56 0.084 15.515 79.607 17.634 Yorkshire and 252 257 Leeds West PCT 98.56 0.133 28.627 54.616 15.123 the Humber South East 266 258 Medway PCT 98.53 0.146 17.605 50.712 12.734 Coast Maldon and South East Of 225 259 98.53 0.070 9.305 55.357 14.029 Chelmsford PCT England 163 260 Derwentside PCT North East 98.53 0.027 28.268 64.878 17.335 190 261 Warrington PCT North West 98.48 0.076 19.337 61.116 14.151

Ipsos MORI: Frontiers of performance in the NHS II 73 Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population East 233 262 Northampton PCT 98.46 0.220 19.366 63.492 13.892 Midlands 217 263 Bromley PCT London 98.45 0.250 13.157 67.235 16.854 273 264 North Liverpool PCT North West 98.44 0.067 55.272 66.573 14.605 South East East Of 230 265 98.42 0.154 11.081 64.047 14.546 Hertfordshire PCT England Newark and East 172 266 98.37 0.060 19.706 64.057 17.324 Sherwood PCT Midlands Doncaster Central Yorkshire and 209 267 98.36 0.141 35.680 80.414 17.726 PCT the Humber 42 268 South Wiltshire PCT South West 98.35 0.070 11.695 98.975 18.063 East Of 249 269 Southend On Sea PCT 98.35 0.136 21.661 58.999 19.183 England 246 270 Halton PCT North West 98.30 0.047 34.278 58.946 13.539 North East Yorkshire and 224 271 98.28 0.049 29.364 62.340 16.509 Lincolnshire PCT the Humber Northumberland Care 94 272 North East 98.22 0.038 21.892 78.052 17.591 Trust 232 273 Hartlepool PCT North East 98.22 0.039 37.695 64.436 16.227 Lincolnshire South East 127 274 98.18 0.063 12.483 69.778 16.676 West Teaching PCT Midlands East 254 275 Ashfield PCT 98.15 0.037 28.502 48.804 16.001 Midlands South Gloucestershire 194 276 South West 98.13 0.081 9.813 66.911 14.381 PCT East 176 277 Erewash PCT 98.12 0.068 19.257 68.279 15.828 Midlands East Of 264 278 Harlow PCT 98.09 0.158 21.359 65.640 14.701 England Witham, Braintree and East Of 242 279 98.08 0.081 13.522 56.675 14.753 Halstead Care Trust England 255 280 Kingston PCT London 98.05 0.416 11.613 74.497 13.366 106 281 North Somerset PCT South West 98.04 0.064 14.113 85.595 19.295 Sheffield South West Yorkshire and 129 282 98.03 0.236 13.930 86.348 17.522 PCT the Humber Adur, Arun and South East 169 283 98.01 0.098 16.065 66.688 23.881 Worthing PCT Coast North Hertfordshire East Of 258 284 97.95 0.192 12.839 60.485 15.191 and Stevenage PCT England Billericay, Brentwood East Of 237 285 97.79 0.119 9.055 60.013 17.140 and Wickford PCT England 296 286 Hounslow PCT London 97.62 0.650 23.075 66.350 11.476 South East Sheffield Yorkshire and 257 287 97.55 0.175 35.285 74.071 17.130 PCT the Humber 251 288 Swindon PCT South West 97.38 0.164 16.856 70.500 13.722 Rowley Regis and West 282 289 97.38 0.223 35.122 62.800 15.596 Tipton PCT Midlands Yorkshire and 183 290 Leeds North East PCT 97.14 0.332 19.422 98.870 17.613 the Humber

74 Ipsos MORI: Frontiers of performance in the NHS II Raw GPs per PI Performance Age Score Primary Care Trust Region EF IMD 100K Rank Index 65+ Rank Population 227 291 Stockport PCT North West 97.02 0.137 18.062 64.624 16.522 200 292 Wyre PCT North West 97.00 0.047 17.795 57.324 22.175 300 293 Brent Teaching PCT London 96.86 0.845 25.715 74.053 11.477 Wednesbury and West West 289 294 96.82 0.364 35.291 65.291 17.581 Bromwich PCT Midlands East Of 286 295 Thurrock PCT 96.66 0.138 21.213 49.105 13.051 England 301 296 Slough PCT South Central 96.02 0.622 20.885 57.007 11.672 Barking and 298 297 London 95.83 0.342 31.315 49.842 14.710 Dagenham PCT East Of 295 298 Basildon PCT 95.51 0.109 27.963 59.264 14.078 England 247 299 West Wiltshire PCT South West 95.46 0.077 11.959 75.750 17.214 South East 280 300 Crawley PCT 95.35 0.282 14.728 74.085 14.696 Coast Castle Point and East Of 277 301 95.34 0.065 10.809 56.463 17.249 Rochford PCT England Bradford City Yorkshire and 303 302 94.66 0.649 51.504 84.977 10.503 Teaching PCT the Humber 290 303 Havering PCT London 94.06 0.152 14.779 53.932 17.692

Ipsos MORI: Frontiers of performance in the NHS II 75 Acute trusts in alphabetical order

Raw PI Performance Score Trust Name Region EF Under 16 Over 65 IMD Rank Index Rank Aintree University 810Hospitals NHS North West 104.6 0.1133 19.21 15.37 46.53 Foundation Trust Yorkshire and 14 3 Airedale NHS Trust 106.2 0.3271 21.55 14.68 28.31 the Humber Ashford And St Peter’s South East 128 135 96.3 0.2783 19.64 14.97 10.02 Hospitals NHS Trust Coast Barking, Havering And 144 93 Redbridge Hospitals London 99.3 0.4509 21.85 13.94 22.29 NHS Trust Barnet And Chase 131 67 Farm Hospitals NHS London 100.7 0.5993 19.55 14.34 16.09 Trust Barnsley Hospital Yorkshire and 92 100 99.0 0.0630 19.38 15.98 29.98 NHS Foundation Trust the Humber Barts And The London 113 35 London 102.4 0.7353 19.23 8.79 42.12 NHS Trust Basildon And Thurrock University East of 98 94 99.3 0.1241 19.87 16.31 16.02 Hospitals NHS England Foundation Trust Basingstoke and 18 13 North Hampshire NHS South Central 104.2 0.1790 20.02 13.21 9.29 Foundation Trust Bedford Hospital NHS East of 73 56 101.1 0.2257 20.39 13.66 13.82 Trust England Blackpool, Fylde And 57 90 Wyre Hospitals NHS North West 99.4 0.1202 17.87 19.43 22.53 Trust Bolton Hospitals NHS 17 11 North West 104.5 0.1617 20.15 15.18 29.20 Trust Bradford Teaching Yorkshire and 125 105 Hospitals NHS 98.6 0.3392 21.74 13.96 31.02 the Humber Foundation Trust Brighton And Sussex 28 61 University Hospitals South Central 100.9 0.1540 17.45 18.40 18.12 NHS Trust Bromley Hospitals 36 1 London 108.5 0.3169 20.15 15.77 16.58 NHS Trust Buckinghamshire 124 120 South Central 97.4 0.2936 20.39 15.75 10.39 Hospitals NHS Trust Burton Hospitals NHS West 70 68 100.7 0.1583 19.72 15.73 20.25 Trust Midlands Calderdale And Yorkshire and 53 29 Huddersfield NHS 102.8 0.2683 20.89 14.61 26.95 the Humber Foundation Trust Cambridge University East of 21 28 Hospitals NHS 102.8 0.1751 18.77 14.53 9.81 England Foundation Trust

76 Ipsos MORI: Frontiers of performance in the NHS II Raw PI Performance Score Trust Name Region EF Under 16 Over 65 IMD Rank Index Rank Central Manchester And Manchester 42 57 North West 101.1 0.3757 18.57 12.96 41.00 Children’s University Hospitals NHS Trust Chelsea And 79 76 Westminster Hospital London 100.2 0.6354 14.48 10.47 23.76 NHS Foundation Trust Chesterfield Royal East 91 115 Hospital NHS 97.8 0.0887 18.17 17.71 26.12 Midlands Foundation Trust City Hospitals 99 118 Sunderland NHS North East 97.7 0.0562 18.39 17.26 34.86 Foundation Trust Countess Of Chester 111 138 Hospital NHS North West 96.0 0.1027 18.30 16.95 28.50 Foundation Trust County Durham 25 17 And Darlington NHS North East 103.3 0.0761 19.54 16.17 27.76 Foundation Trust Dartford And South East 48 20 103.1 0.1991 20.72 15.20 18.29 Gravesham NHS Trust Coast Derby Hospitals NHS East 78 80 99.9 0.1600 19.51 15.81 21.34 Foundation Trust Midlands Doncaster And Yorkshire and 51 43 Bassetlaw Hospitals 101.7 0.0651 19.73 16.54 31.22 the Humber NHS Foundation Trust Dudley Group Of West 117 127 97.1 0.2650 19.73 17.29 27.91 Hospitals NHS Trust Midlands Ealing Hospital NHS 151 150 London 91.3 0.7176 19.38 11.28 21.53 Trust East And North East of 97 77 Hertfordshire NHS 100.2 0.2939 20.71 14.43 13.83 England Trust East Cheshire NHS 45 54 North West 101.2 0.1221 18.83 17.45 18.36 Trust East Kent Hospitals South East 55 63 100.9 0.1036 19.17 18.27 19.20 NHS Trust Coast East Lancashire 95 65 North West 100.8 0.2257 21.24 14.77 25.20 Hospitals NHS Trust East Sussex Hospitals 37 46 South Central 101.5 0.1009 18.82 20.96 16.60 NHS Trust Epsom And St Helier 110 36 University Hospitals London 102.4 0.5339 19.12 12.59 16.10 NHS Trust Essex Rivers East of 75 97 99.2 0.1047 18.58 18.07 17.27 Healthcare NHS Trust England Frimley Park Hospital South East 38 31 102.7 0.1808 20.05 13.74 7.15 NHS Foundation Trust Coast Gateshead Health 67 99 North East 99.0 0.1057 18.07 15.75 34.39 NHS Foundation Trust George Eliot Hospital West 138 146 94.0 0.2347 19.37 15.00 22.08 NHS Trust Midlands Gloucestershire 24 37 Hospitals NHS South West 102.3 0.1010 18.62 18.29 13.08 Foundation Trust

Ipsos MORI: Frontiers of performance in the NHS II 77 Raw PI Performance Score Trust Name Region EF Under 16 Over 65 IMD Rank Index Rank Good Hope Hospital West 116 92 99.4 0.4674 21.94 14.93 33.30 NHS Trust Midlands Guy’s And St Thomas’ 43 4 London 106.0 0.7341 17.91 9.18 38.77 NHS Foundation Trust Hammersmith 100 62 London 100.9 0.7333 16.31 10.47 28.95 Hospitals NHS Trust Harrogate And District Yorkshire and 20 49 101.4 0.2109 17.43 15.70 21.72 NHS Foundation Trust the Humber Heart Of England West 88 24 102.9 0.5839 23.09 13.48 39.64 NHS Foundation Trust Midlands Heatherwood And 120 122 Wexham Park South Central 97.4 0.4332 20.26 14.01 15.02 Hospitals NHS Trust Hereford Hospitals West 112 132 96.5 0.0857 18.81 18.21 16.11 NHS Trust Midlands Hillingdon Hospital 132 40 London 101.7 0.6360 20.68 12.54 20.35 NHS Trust Hinchingbrooke East of 45 105.5 0.2099 18.99 14.15 13.58 Health Care NHS Trust England Homerton University 136 45 Hospital NHS London 101.6 0.7649 21.23 8.86 43.06 Foundation Trust Hull And East Yorkshire and 56 73 Yorkshire Hospitals 100.5 0.0652 18.85 16.49 27.94 the Humber NHS Trust Ipswich Hospital NHS East of 19 33 102.5 0.1060 18.44 19.14 16.56 Trust England James Paget East of 60 104 University Hospitals 98.6 0.0689 17.30 19.80 19.30 England NHS Foundation Trust Kettering General East 74 69 100.7 0.1533 19.97 14.91 15.68 Hospital NHS Trust Midlands King’s College 61 8 Hospital NHS London 104.9 0.6992 17.92 9.11 33.80 Foundation Trust Kingston Hospital 134 101 London 98.9 0.4104 18.47 12.79 11.33 NHS Trust Lancashire Teaching 114 121 Hospitals NHS North West 97.4 0.1991 19.88 15.90 21.31 Foundation Trust Leeds Teaching Yorkshire and 58 89 99.5 0.2206 17.98 14.36 29.93 Hospitals NHS Trust the Humber Lewisham Hospital 146 137 London 96.0 0.5934 19.04 10.87 29.12 NHS Trust Luton And Dunstable East of 140 144 Hospital NHS 95.0 0.2921 20.85 14.29 13.30 England Foundation Trust Maidstone And South East 133 141 Tunbridge Wells NHS 95.3 0.1177 20.30 15.04 13.79 Coast Trust Mayday Healthcare 149 145 London 94.8 0.5939 19.90 11.75 21.56 NHS Trust South East 129 133 Medway NHS Trust 96.5 0.1330 20.63 14.63 16.79 Coast

78 Ipsos MORI: Frontiers of performance in the NHS II Raw PI Performance Score Trust Name Region EF Under 16 Over 65 IMD Rank Index Rank Mid Cheshire 126 142 North West 95.2 0.0807 18.64 16.96 19.80 Hospitals NHS Trust Mid Essex Hospital South East 31 21 103.1 0.1013 19.75 15.70 12.06 Services NHS Trust Coast Mid Staffordshire West 80 96 General Hospitals 99.2 0.0889 18.94 16.59 20.31 Midlands NHS Trust Mid Yorkshire Yorkshire and 121 125 97.2 0.1649 20.12 14.78 30.76 Hospitals NHS Trust the Humber Milton Keynes General 62 34 South Central 102.5 0.2442 21.08 12.67 14.00 Hospital NHS Trust Newcastle Upon 12Tyne Hospitals NHS North East 106.4 0.1112 17.81 16.33 33.12 Foundation Trust Newham University 148 107 London 98.6 0.7625 22.37 8.96 37.22 Hospital NHS Trust Norfolk And Norwich East of 27University Hospital 105.0 0.0686 17.15 19.78 16.26 England NHS Trust North Bristol NHS 29 53 South West 101.3 0.1687 17.91 14.46 20.68 Trust North Cheshire 65 66 North West 100.8 0.0578 19.77 15.14 27.73 Hospitals NHS Trust North Cumbria Acute 49 82 North West 99.9 0.0469 17.70 18.84 21.91 Hospitals NHS Trust North Middlesex 150 148 University Hospital London 93.6 0.6849 20.90 11.03 30.95 NHS Trust North Tees And 64 60 North East 100.9 0.0689 19.78 16.45 35.26 Hartlepool NHS Trust North West London 143 113 London 97.9 0.7468 19.95 13.06 19.21 Hospitals NHS Trust Northampton General East 123 126 97.1 0.1760 20.11 13.71 15.35 Hospital NHS Trust Midlands Northern Devon 44 85 South West 99.7 0.0616 17.37 19.77 18.74 Healthcare NHS Trust Northern Lincolnshire Yorkshire and 68 83 And Goole Hospitals 99.8 0.0575 18.83 16.81 29.69 the Humber NHS Trust Northumbria 63 103 Healthcare NHS North East 98.7 0.0851 17.60 16.88 29.53 Foundation Trust Nottingham University East 47 81 99.9 0.2213 17.67 14.81 27.87 Hospitals NHS Trust Midlands Oxford Radcliffe 39 41 South Central 101.7 0.1969 19.08 14.30 10.55 Hospitals NHS Trust Pennine Acute 59 42 North West 101.7 0.3442 20.14 13.65 42.99 Hospitals NHS Trust Peterborough And East of 15 12 Stamford Hospitals 104.4 0.1356 19.78 16.25 16.30 England NHS Foundation Trust Plymouth Hospitals 514 South West 104.0 0.0593 17.66 18.90 20.90 NHS Trust

Ipsos MORI: Frontiers of performance in the NHS II 79 Raw PI Performance Score Trust Name Region EF Under 16 Over 65 IMD Rank Index Rank Poole Hospital NHS 13 55 South West 101.2 0.0889 16.65 23.09 14.85 Trust Portsmouth Hospitals 40 70 South Central 100.7 0.0916 18.12 17.44 16.89 NHS Trust Princess Alexandra South East 122 124 97.2 0.2508 20.17 15.13 15.61 Hospital NHS Trust Coast Queen Elizabeth East of 86 116 Hospital King’s Lynn 97.7 0.1014 17.93 20.44 17.65 England NHS Trust Queen Elizabeth 135 48 London 101.4 0.5671 20.94 11.22 29.90 Hospital NHS Trust Queen Mary’s Sidcup 147 130 London 96.7 0.2884 20.09 15.90 17.77 NHS Trust Rotherham NHS Yorkshire and 83 91 99.4 0.1636 19.25 15.71 32.80 Foundation Trust the Humber Royal Berkshire NHS 77 74 South Central 100.4 0.2191 19.90 13.27 9.23 Foundation Trust Royal Bournemouth And Christchurch 30 87 South West 99.6 0.0887 16.39 23.45 14.88 Hospitals NHS Foundation Trust Royal Cornwall 616 South West 103.6 0.0617 17.55 19.30 25.02 Hospitals NHS Trust Royal Devon 726And Exeter NHS South West 102.9 0.0635 16.86 21.29 18.45 Foundation Trust Royal Free Hampstead 118 106 London 98.6 0.6999 15.80 10.14 33.10 NHS Trust Royal Liverpool And 41 52 Broadgreen University North West 101.3 0.1309 18.80 15.27 47.07 Hospitals NHS Trust Royal Surrey County South East 82 84 99.8 0.1823 19.58 15.35 7.05 Hospital NHS Trust Coast Royal United Hospital 106 134 South West 96.4 0.1474 18.19 15.79 19.35 Bath NHS Trust Royal West Sussex 932 South Central 102.6 0.0996 17.45 20.10 17.73 NHS Trust Royal Wolverhampton West 46 25 102.9 0.3082 20.57 16.63 30.91 Hospitals NHS Trust Midlands Salford Royal NHS 50 72 North West 100.6 0.3098 18.70 13.96 36.77 Foundation Trust Salisbury NHS 87 117 South West 97.7 0.1171 17.92 17.73 12.97 Foundation Trust Sandwell And West West 76 22 Birmingham Hospitals 103.0 0.6704 22.37 12.84 40.49 Midlands NHS Trust Scarborough And Yorkshire and 81 114 North East Yorkshire 97.9 0.0534 17.60 18.80 20.44 the Humber Health Care NHS Trust Sheffield Teaching Yorkshire and 10 15 Hospitals NHS 103.6 0.1900 18.43 15.94 29.56 the Humber Foundation Trust Sherwood Forest East 101 112 Hospitals NHS 97.9 0.0668 18.90 16.42 28.72 Midlands Foundation Trust

80 Ipsos MORI: Frontiers of performance in the NHS II Raw PI Performance Score Trust Name Region EF Under 16 Over 65 IMD Rank Index Rank Shrewsbury And West 71 86 Telford Hospital NHS 99.6 0.0990 18.73 17.86 16.36 Midlands Trust South Devon 22 71 Healthcare NHS South West 100.7 0.0641 16.86 20.56 18.02 Foundation Trust South Tees Hospitals 34 30 North East 102.8 0.0747 19.82 16.10 31.52 NHS Trust South Tyneside NHS 52 78 North East 100.1 0.0734 18.25 17.08 33.85 Foundation Trust South Warwickshire West 35 50 General Hospitals 101.4 0.2702 18.66 16.22 18.78 Midlands NHS Trust Southampton 115 139 University Hospitals South Central 95.6 0.1288 18.20 15.86 13.78 NHS Trust Southend University East of 54 44 Hospital NHS 101.6 0.0942 19.77 16.72 17.36 England Foundation Trust Southport And 96 111 Ormskirk Hospital North West 98.0 0.0627 18.48 18.72 25.42 NHS Trust St George’s 94 38 London 102.3 0.6055 17.24 10.40 21.17 Healthcare NHS Trust St Helens And 27 23 Knowsley Hospitals North West 103.0 0.0797 19.34 15.77 39.16 NHS Trust 102 102 St Mary’s NHS Trust London 98.7 0.7103 14.51 10.65 29.88 Stockport NHS 104 123 North West 97.2 0.2319 18.74 15.03 27.80 Foundation Trust Surrey And Sussex South East 145 151 91.2 0.2310 19.57 16.04 9.90 Healthcare NHS Trust Coast Swindon And 84 75 Marlborough NHS South West 100.3 0.1086 20.25 15.42 11.01 Trust Tameside And 139 140 Glossop Acute North West 95.5 0.2259 21.23 14.47 35.43 Services NHS Trust Taunton And Somerset 11 27 South West 102.9 0.0547 18.01 21.55 16.52 NHS Trust Trafford Healthcare 141 149 North West 91.4 0.2556 18.38 14.40 31.97 NHS Trust United Bristol 16 39 South West 102.2 0.1693 17.78 14.73 20.83 Healthcare NHS Trust United Lincolnshire East 107 131 96.6 0.0596 18.45 18.18 18.97 Hospitals NHS Trust Midlands University College 90 88 London Hospitals London 99.5 0.6891 14.41 10.20 33.73 NHS Foundation Trust University Hospital West 72 19 Birmingham NHS 103.2 0.6348 22.40 12.90 39.28 Midlands Foundation Trust University Hospital Of West 32 51 North Staffordshire 101.3 0.0845 18.13 17.20 23.30 Midlands NHS Trust

Ipsos MORI: Frontiers of performance in the NHS II 81 Raw PI Performance Score Trust Name Region EF Under 16 Over 65 IMD Rank Index Rank University Hospital 36of South Manchester North West 105.0 0.3203 18.33 14.40 28.12 NHS Foundation Trust University Hospitals Coventry And West 108 129 97.0 0.2580 19.18 15.65 21.40 Warwickshire NHS Midlands Trust University Hospitals East 130 143 Of Leicester NHS 95.1 0.3766 19.42 14.54 19.83 Midlands Trust University Hospitals of 23 58 Morecambe Bay NHS North West 101.1 0.0562 17.31 20.01 18.88 Trust Walsall Hospitals NHS West 142 147 93.7 0.3440 20.94 16.31 32.39 Trust Midlands West Dorset General 33 59 South West 100.9 0.0700 17.77 21.29 14.81 Hospitals NHS Trust West Hertfordshire East of 109 108 98.3 0.2928 20.57 15.02 11.73 Hospitals NHS Trust England West Middlesex 137 98 University Hospital London 99.1 0.6408 18.97 11.51 19.42 NHS Trust West Suffolk Hospitals East of 69 79 100.0 0.1400 19.03 16.96 13.06 NHS Trust England Weston Area Health 105 136 South West 96.1 0.1170 17.68 16.88 19.81 NHS Trust Whipps Cross 119 9 University Hospital London 104.8 0.7534 22.03 10.15 33.48 NHS Trust Whittington Hospital 127 95 London 99.3 0.6779 17.15 9.76 34.89 NHS Trust Winchester And 89 110 Eastleigh Healthcare South Central 98.0 0.1305 18.36 15.39 13.66 NHS Trust Wirral Hospital NHS 12 18 North West 103.2 0.1244 18.44 16.46 39.95 Trust Worcestershire Acute West 103 119 97.5 0.0875 18.87 17.22 15.25 Hospitals NHS Trust Midlands Worthing And South East 85 128 Southlands Hospitals 97.1 0.1479 17.22 19.11 18.92 Coast NHS Trust Wrightington, Wigan 66 64 North West 100.8 0.0968 19.81 15.31 28.07 And Leigh NHS Trust Yeovil District Hospital 93 109 South West 98.3 0.0595 18.67 20.38 14.79 NHS Foundation Trust York Hospitals NHS Yorkshire and 26 47 101.5 0.0810 17.81 16.98 15.47 Trust the Humber

82 Ipsos MORI: Frontiers of performance in the NHS II Acute trusts in rank order

Raw Ethnic PI Performance Score Trust Name Region Fraction- Under 16 Over 65 IMD Rank Index Rank alisation Bromley Hospitals 36 1 London 108.5 0.3169 20.15 15.77 16.58 NHS Trust The Newcastle Upon 12Tyne Hospitals NHS North East 106.4 0.1112 17.81 16.33 33.12 Foundation Trust Yorkshire and 14 3 Airedale NHS Trust 106.2 0.3271 21.55 14.68 28.31 the Humber Guy’s And St Thomas’ 43 4 London 106.0 0.7341 17.91 9.18 38.77 NHS Foundation Trust Hinchingbrooke East of 45 105.5 0.2099 18.99 14.15 13.58 Health Care NHS Trust England University Hospital 36of South Manchester North West 105.0 0.3203 18.33 14.40 28.12 NHS Foundation Trust Norfolk And Norwich East of 27University Hospital 105.0 0.0686 17.15 19.78 16.26 England NHS Trust King’s College 61 8 Hospital NHS London 104.9 0.6992 17.92 9.11 33.80 Foundation Trust Whipps Cross 119 9 University Hospital London 104.8 0.7534 22.03 10.15 33.48 NHS Trust Aintree University 810Hospitals NHS North West 104.6 0.1133 19.21 15.37 46.53 Foundation Trust Bolton Hospitals NHS 17 11 North West 104.5 0.1617 20.15 15.18 29.20 Trust Peterborough And East of 15 12 Stamford Hospitals 104.4 0.1356 19.78 16.25 16.30 England NHS Foundation Trust Basingstoke and 18 13 North Hampshire NHS South Central 104.2 0.1790 20.02 13.21 9.29 Foundation Trust Plymouth Hospitals 514 South West 104.0 0.0593 17.66 18.90 20.90 NHS Trust Sheffield Teaching Yorkshire and 10 15 Hospitals NHS 103.6 0.1900 18.43 15.94 29.56 the Humber Foundation Trust Royal Cornwall 616 South West 103.6 0.0617 17.55 19.30 25.02 Hospitals NHS Trust County Durham 25 17 And Darlington NHS North East 103.3 0.0761 19.54 16.17 27.76 Foundation Trust Wirral Hospital NHS 12 18 North West 103.2 0.1244 18.44 16.46 39.95 Trust University Hospital West 72 19 Birmingham NHS 103.2 0.6348 22.40 12.90 39.28 Midlands Foundation Trust Dartford And South East 48 20 103.1 0.1991 20.72 15.20 18.29 Gravesham NHS Trust Coast

Ipsos MORI: Frontiers of performance in the NHS II 83 Raw Ethnic PI Performance Score Trust Name Region Fraction- Under 16 Over 65 IMD Rank Index Rank alisation Mid Essex Hospital South East 31 21 103.1 0.1013 19.75 15.70 12.06 Services NHS Trust Coast Sandwell And West West 76 22 Birmingham Hospitals 103.0 0.6704 22.37 12.84 40.49 Midlands NHS Trust St Helens And 27 23 Knowsley Hospitals North West 103.0 0.0797 19.34 15.77 39.16 NHS Trust Heart Of England West 88 24 102.9 0.5839 23.09 13.48 39.64 NHS Foundation Trust Midlands The Royal West 46 25 Wolverhampton 102.9 0.3082 20.57 16.63 30.91 Midlands Hospitals NHS Trust Royal Devon 726And Exeter NHS South West 102.9 0.0635 16.86 21.29 18.45 Foundation Trust Taunton And Somerset 11 27 South West 102.9 0.0547 18.01 21.55 16.52 NHS Trust Cambridge University East of 21 28 Hospitals NHS 102.8 0.1751 18.77 14.53 9.81 England Foundation Trust Calderdale And Yorkshire and 53 29 Huddersfield NHS 102.8 0.2683 20.89 14.61 26.95 the Humber Foundation Trust South Tees Hospitals 34 30 North East 102.8 0.0747 19.82 16.10 31.52 NHS Trust Frimley Park Hospital South East 38 31 102.7 0.1808 20.05 13.74 7.15 NHS Foundation Trust Coast Royal West Sussex 932 South Central 102.6 0.0996 17.45 20.10 17.73 NHS Trust Ipswich Hospital NHS East of 19 33 102.5 0.1060 18.44 19.14 16.56 Trust England Milton Keynes General 62 34 South Central 102.5 0.2442 21.08 12.67 14.00 Hospital NHS Trust Barts And The London 113 35 London 102.4 0.7353 19.23 8.79 42.12 NHS Trust Epsom And St Helier 110 36 University Hospitals London 102.4 0.5339 19.12 12.59 16.10 NHS Trust Gloucestershire 24 37 Hospitals NHS South West 102.3 0.1010 18.62 18.29 13.08 Foundation Trust St George’s 94 38 London 102.3 0.6055 17.24 10.40 21.17 Healthcare NHS Trust United Bristol 16 39 South West 102.2 0.1693 17.78 14.73 20.83 Healthcare NHS Trust The Hillingdon 132 40 London 101.7 0.6360 20.68 12.54 20.35 Hospital NHS Trust Oxford Radcliffe 39 41 South Central 101.7 0.1969 19.08 14.30 10.55 Hospitals NHS Trust Pennine Acute 59 42 North West 101.7 0.3442 20.14 13.65 42.99 Hospitals NHS Trust Doncaster And Yorkshire and 51 43 Bassetlaw Hospitals 101.7 0.0651 19.73 16.54 31.22 the Humber NHS Foundation Trust

84 Ipsos MORI: Frontiers of performance in the NHS II Raw Ethnic PI Performance Score Trust Name Region Fraction- Under 16 Over 65 IMD Rank Index Rank alisation Southend University East of 54 44 Hospital NHS 101.6 0.0942 19.77 16.72 17.36 England Foundation Trust Homerton University 136 45 Hospital NHS London 101.6 0.7649 21.23 8.86 43.06 Foundation Trust East Sussex Hospitals 37 46 South Central 101.5 0.1009 18.82 20.96 16.60 NHS Trust York Hospitals NHS Yorkshire and 26 47 101.5 0.0810 17.81 16.98 15.47 Trust the Humber Queen Elizabeth 135 48 London 101.4 0.5671 20.94 11.22 29.90 Hospital NHS Trust Harrogate And District Yorkshire and 20 49 101.4 0.2109 17.43 15.70 21.72 NHS Foundation Trust the Humber South Warwickshire West 35 50 General Hospitals 101.4 0.2702 18.66 16.22 18.78 Midlands NHS Trust University Hospital Of West 32 51 North Staffordshire 101.3 0.0845 18.13 17.20 23.30 Midlands NHS Trust Royal Liverpool And 41 52 Broadgreen University North West 101.3 0.1309 18.80 15.27 47.07 Hospitals NHS Trust North Bristol NHS 29 53 South West 101.3 0.1687 17.91 14.46 20.68 Trust East Cheshire NHS 45 54 North West 101.2 0.1221 18.83 17.45 18.36 Trust Poole Hospital NHS 13 55 South West 101.2 0.0889 16.65 23.09 14.85 Trust Bedford Hospital NHS East of 73 56 101.1 0.2257 20.39 13.66 13.82 Trust England Central Manchester And Manchester 42 57 North West 101.1 0.3757 18.57 12.96 41.00 Children’s University Hospitals NHS Trust University Hospitals of 23 58 Morecambe Bay NHS North West 101.1 0.0562 17.31 20.01 18.88 Trust West Dorset General 33 59 South West 100.9 0.0700 17.77 21.29 14.81 Hospitals NHS Trust North Tees And 64 60 North East 100.9 0.0689 19.78 16.45 35.26 Hartlepool NHS Trust Brighton And Sussex 28 61 University Hospitals South Central 100.9 0.1540 17.45 18.40 18.12 NHS Trust Hammersmith 100 62 London 100.9 0.7333 16.31 10.47 28.95 Hospitals NHS Trust East Kent Hospitals South East 55 63 100.9 0.1036 19.17 18.27 19.20 NHS Trust Coast Wrightington, Wigan 66 64 North West 100.8 0.0968 19.81 15.31 28.07 And Leigh NHS Trust East Lancashire 95 65 North West 100.8 0.2257 21.24 14.77 25.20 Hospitals NHS Trust North Cheshire 65 66 North West 100.8 0.0578 19.77 15.14 27.73 Hospitals NHS Trust

Ipsos MORI: Frontiers of performance in the NHS II 85 Raw Ethnic PI Performance Score Trust Name Region Fraction- Under 16 Over 65 IMD Rank Index Rank alisation Barnet And Chase 131 67 Farm Hospitals NHS London 100.7 0.5993 19.55 14.34 16.09 Trust Burton Hospitals NHS West 70 68 100.7 0.1583 19.72 15.73 20.25 Trust Midlands Kettering General East 74 69 100.7 0.1533 19.97 14.91 15.68 Hospital NHS Trust Midlands Portsmouth Hospitals 40 70 South Central 100.7 0.0916 18.12 17.44 16.89 NHS Trust South Devon 22 71 Healthcare NHS South West 100.7 0.0641 16.86 20.56 18.02 Foundation Trust Salford Royal NHS 50 72 North West 100.6 0.3098 18.70 13.96 36.77 Foundation Trust Hull And East Yorkshire and 56 73 Yorkshire Hospitals 100.5 0.0652 18.85 16.49 27.94 the Humber NHS Trust Royal Berkshire NHS 77 74 South Central 100.4 0.2191 19.90 13.27 9.23 Foundation Trust Swindon And 84 75 Marlborough NHS South West 100.3 0.1086 20.25 15.42 11.01 Trust Chelsea And 79 76 Westminster Hospital London 100.2 0.6354 14.48 10.47 23.76 NHS Foundation Trust East And North East of 97 77 Hertfordshire NHS 100.2 0.2939 20.71 14.43 13.83 England Trust South Tyneside NHS 52 78 North East 100.1 0.0734 18.25 17.08 33.85 Foundation Trust West Suffolk Hospitals East of 69 79 100.0 0.1400 19.03 16.96 13.06 NHS Trust England Derby Hospitals NHS East 78 80 99.9 0.1600 19.51 15.81 21.34 Foundation Trust Midlands Nottingham University East 47 81 99.9 0.2213 17.67 14.81 27.87 Hospitals NHS Trust Midlands North Cumbria Acute 49 82 North West 99.9 0.0469 17.70 18.84 21.91 Hospitals NHS Trust Northern Lincolnshire Yorkshire and 68 83 And Goole Hospitals 99.8 0.0575 18.83 16.81 29.69 the Humber NHS Trust Royal Surrey County South East 82 84 99.8 0.1823 19.58 15.35 7.05 Hospital NHS Trust Coast Northern Devon 44 85 South West 99.7 0.0616 17.37 19.77 18.74 Healthcare NHS Trust Shrewsbury And West 71 86 Telford Hospital NHS 99.6 0.0990 18.73 17.86 16.36 Midlands Trust Royal Bournemouth And Christchurch 30 87 South West 99.6 0.0887 16.39 23.45 14.88 Hospitals NHS Foundation Trust University College 90 88 London Hospitals London 99.5 0.6891 14.41 10.20 33.73 NHS Foundation Trust

86 Ipsos MORI: Frontiers of performance in the NHS II Raw Ethnic PI Performance Score Trust Name Region Fraction- Under 16 Over 65 IMD Rank Index Rank alisation Leeds Teaching Yorkshire and 58 89 99.5 0.2206 17.98 14.36 29.93 Hospitals NHS Trust the Humber Blackpool, Fylde And 57 90 Wyre Hospitals NHS North West 99.4 0.1202 17.87 19.43 22.53 Trust The Rotherham NHS Yorkshire and 83 91 99.4 0.1636 19.25 15.71 32.80 Foundation Trust the Humber Good Hope Hospital West 116 92 99.4 0.4674 21.94 14.93 33.30 NHS Trust Midlands Barking, Havering And 144 93 Redbridge Hospitals London 99.3 0.4509 21.85 13.94 22.29 NHS Trust Basildon And Thurrock University East of 98 94 99.3 0.1241 19.87 16.31 16.02 Hospitals NHS England Foundation Trust The Whittington 127 95 London 99.3 0.6779 17.15 9.76 34.89 Hospital NHS Trust Mid Staffordshire West 80 96 General Hospitals 99.2 0.0889 18.94 16.59 20.31 Midlands NHS Trust Essex Rivers East of 75 97 99.2 0.1047 18.58 18.07 17.27 Healthcare NHS Trust England West Middlesex 137 98 University Hospital London 99.1 0.6408 18.97 11.51 19.42 NHS Trust Gateshead Health 67 99 North East 99.0 0.1057 18.07 15.75 34.39 NHS Foundation Trust Barnsley Hospital Yorkshire and 92 100 99.0 0.0630 19.38 15.98 29.98 NHS Foundation Trust the Humber Kingston Hospital 134 101 London 98.9 0.4104 18.47 12.79 11.33 NHS Trust 102 102 St Mary’s NHS Trust London 98.7 0.7103 14.51 10.65 29.88 Northumbria 63 103 Healthcare NHS North East 98.7 0.0851 17.60 16.88 29.53 Foundation Trust James Paget East of 60 104 University Hospitals 98.6 0.0689 17.30 19.80 19.30 England NHS Foundation Trust Bradford Teaching Yorkshire and 125 105 Hospitals NHS 98.6 0.3392 21.74 13.96 31.02 the Humber Foundation Trust Royal Free Hampstead 118 106 London 98.6 0.6999 15.80 10.14 33.10 NHS Trust Newham University 148 107 London 98.6 0.7625 22.37 8.96 37.22 Hospital NHS Trust West Hertfordshire East of 109 108 98.3 0.2928 20.57 15.02 11.73 Hospitals NHS Trust England Yeovil District Hospital 93 109 South West 98.3 0.0595 18.67 20.38 14.79 NHS Foundation Trust Winchester And 89 110 Eastleigh Healthcare South Central 98.0 0.1305 18.36 15.39 13.66 NHS Trust

Ipsos MORI: Frontiers of performance in the NHS II 87 Raw Ethnic PI Performance Score Trust Name Region Fraction- Under 16 Over 65 IMD Rank Index Rank alisation Southport And 96 111 Ormskirk Hospital North West 98.0 0.0627 18.48 18.72 25.42 NHS Trust Sherwood Forest East 101 112 Hospitals NHS 97.9 0.0668 18.90 16.42 28.72 Midlands Foundation Trust North West London 143 113 London 97.9 0.7468 19.95 13.06 19.21 Hospitals NHS Trust Scarborough And Yorkshire and 81 114 North East Yorkshire 97.9 0.0534 17.60 18.80 20.44 the Humber Health Care NHS Trust Chesterfield Royal East 91 115 Hospital NHS 97.8 0.0887 18.17 17.71 26.12 Midlands Foundation Trust The Queen Elizabeth East of 86 116 Hospital King’s Lynn 97.7 0.1014 17.93 20.44 17.65 England NHS Trust Salisbury NHS 87 117 South West 97.7 0.1171 17.92 17.73 12.97 Foundation Trust City Hospitals 99 118 Sunderland NHS North East 97.7 0.0562 18.39 17.26 34.86 Foundation Trust Worcestershire Acute West 103 119 97.5 0.0875 18.87 17.22 15.25 Hospitals NHS Trust Midlands Buckinghamshire 124 120 South Central 97.4 0.2936 20.39 15.75 10.39 Hospitals NHS Trust Lancashire Teaching 114 121 Hospitals NHS North West 97.4 0.1991 19.88 15.90 21.31 Foundation Trust Heatherwood And 120 122 Wexham Park South Central 97.4 0.4332 20.26 14.01 15.02 Hospitals NHS Trust Stockport NHS 104 123 North West 97.2 0.2319 18.74 15.03 27.80 Foundation Trust The Princess South East 122 124 Alexandra Hospital 97.2 0.2508 20.17 15.13 15.61 Coast NHS Trust Mid Yorkshire Yorkshire and 121 125 97.2 0.1649 20.12 14.78 30.76 Hospitals NHS Trust the Humber Northampton General East 123 126 97.1 0.1760 20.11 13.71 15.35 Hospital NHS Trust Midlands Dudley Group Of West 117 127 97.1 0.2650 19.73 17.29 27.91 Hospitals NHS Trust Midlands Worthing And South East 85 128 Southlands Hospitals 97.1 0.1479 17.22 19.11 18.92 Coast NHS Trust University Hospitals Coventry And West 108 129 97.0 0.2580 19.18 15.65 21.40 Warwickshire NHS Midlands Trust Queen Mary’s Sidcup 147 130 London 96.7 0.2884 20.09 15.90 17.77 NHS Trust

88 Ipsos MORI: Frontiers of performance in the NHS II Raw Ethnic PI Performance Score Trust Name Region Fraction- Under 16 Over 65 IMD Rank Index Rank alisation United Lincolnshire East 107 131 96.6 0.0596 18.45 18.18 18.97 Hospitals NHS Trust Midlands Hereford Hospitals West 112 132 96.5 0.0857 18.81 18.21 16.11 NHS Trust Midlands South East 129 133 Medway NHS Trust 96.5 0.1330 20.63 14.63 16.79 Coast Royal United Hospital 106 134 South West 96.4 0.1474 18.19 15.79 19.35 Bath NHS Trust Ashford And St Peter’s South East 128 135 96.3 0.2783 19.64 14.97 10.02 Hospitals NHS Trust Coast Weston Area Health 105 136 South West 96.1 0.1170 17.68 16.88 19.81 NHS Trust The Lewisham 146 137 London 96.0 0.5934 19.04 10.87 29.12 Hospital NHS Trust Countess Of Chester 111 138 Hospital NHS North West 96.0 0.1027 18.30 16.95 28.50 Foundation Trust Southampton 115 139 University Hospitals South Central 95.6 0.1288 18.20 15.86 13.78 NHS Trust Tameside And 139 140 Glossop Acute North West 95.5 0.2259 21.23 14.47 35.43 Services NHS Trust Maidstone And South East 133 141 Tunbridge Wells NHS 95.3 0.1177 20.30 15.04 13.79 Coast Trust The Mid Cheshire 126 142 North West 95.2 0.0807 18.64 16.96 19.80 Hospitals NHS Trust University Hospitals East 130 143 Of Leicester NHS 95.1 0.3766 19.42 14.54 19.83 Midlands Trust Luton And Dunstable East of 140 144 Hospital NHS 95.0 0.2921 20.85 14.29 13.30 England Foundation Trust Mayday Healthcare 149 145 London 94.8 0.5939 19.90 11.75 21.56 NHS Trust George Eliot Hospital West 138 146 94.0 0.2347 19.37 15.00 22.08 NHS Trust Midlands Walsall Hospitals NHS West 142 147 93.7 0.3440 20.94 16.31 32.39 Trust Midlands North Middlesex 150 148 University Hospital London 93.6 0.6849 20.90 11.03 30.95 NHS Trust Trafford Healthcare 141 149 North West 91.4 0.2556 18.38 14.40 31.97 NHS Trust Ealing Hospital NHS 151 150 London 91.3 0.7176 19.38 11.28 21.53 Trust Surrey And Sussex South East 145 151 91.2 0.2310 19.57 16.04 9.90 Healthcare NHS Trust Coast

Ipsos MORI: Frontiers of performance in the NHS II 89 Appendix B – Regression analysis

Regression analysis was carried out on the key dependent variables – patients’ ratings of the acute trust or PCT. Multiple regression techniques allow us to assess which of a selection of relevant independent variables are statistically related to a given dependent variable when all other significant variables under consideration have been taken into account. In this case, it allows us to analyse which factors listed below are significantly and independently associated with the ratings received by health bodies. Multiple regression allows us to explore the association between variables; however, evidence of an association does not necessarily imply a causal relationship. The results presented here therefore identify factors associated with high patient ratings.

The independent variables shown in the tables overleaf were considered as possible drivers, and entered into the model using a stepwise approach.

Key drivers of PCT patient ratings Independent variables used in regression analysis Reference Costs Standardised Mortality Ratio GPs per 100,000 population Percentage of population who are Under16 Percentage of population who are Over 65 Percentage of households that are owned outright by the occupier(s) Index of Multiple Deprivation Ethnic Fractionalisation East of England London North East Yorkshire and the Humber North West South Central South East Coast South West East Midlands West Midlands Dependent variable Patient rating derived from individual survey questions (see Appendix C)

Table 7: Key drivers of PCT patient ratings

90 Ipsos MORI: Frontiers of performance in the NHS II Key drivers of inpatient ratings (individual aspects of care) Independent variables used in regression analysis Q22. In your opinion, how clean was the hospital room or ward that you were in? (All) Q23. How clean were the toilets and bathrooms that you used in hospital? (All) Q26. When you had important questions to ask a doctor, did you get answers that you could understand? (All) Q36. Were you involved as much as you wanted to be in decisions about your care and treatment? (All) Q40. Were you given enough privacy when discussing your condition or treatment? (All) Q41. Were you given enough privacy when being examined or treated? (All) Q45. Do you think the hospital staff did everything they could to help control your pain? (Those who were ever in pain, i.e. Selected option 1 to Q44) Q64. Overall, did you feel you were treated with respect and dignity while you were in the hospital? (All) Dependent variable Q66. Overall, how would you rate the care you received? (All)

Table 8 Key drivers of inpatient ratings (individual aspects of care)

Key drivers of inpatient ratings Independent variables used in regression analysis Reference Costs Percentage of population who are Under 16 Percentage of population who are Over 65 Percentage of households that are owned outright by the occupier(s) Index of Multiple Deprivation Ethnic Fractionalisation East of England London North East Yorkshire and the Humber North West South Central South East Coast South West East Midlands West Midlands Dependent variable Q66. Overall, how would you rate the care you received? (All)

Table 9: Key drivers of inpatient ratings

Ipsos MORI: Frontiers of performance in the NHS II 91 Appendix C – Notes on the data

Limitations of the data

Both the PCT and the acute inpatient survey have been limited by the level and quality of information on patient satisfaction collected in the two surveys. The PCT patient surveys do not ask about overall satisfaction/ratings of care, hence the need to derive such a measure from individual questions (see below). And, whilst the 2006 acute inpatient survey did ask respondents to provide an overall assessment of the care they have received, this question has a biased scale, with three positive and only one wholly negative response possible, as follows:

Q. Overall, how would you rate the care you received? Excellent Very good Good Fair Poor

Moreover, the inpatient survey data that is in the public domain does not supply information on the percentage of patients responding according to this pre-coded list. Instead it uses a scoring system to arrive at a summary measure of overall ratings – where ‘excellent’ is allocated 100 points, ‘very good’ is allocated 75 points, ‘good’ is allocated 50 points, ‘fair’ 25 points and ‘poor’ zero points.

These measurement issues should be borne in mind when interpreting the findings presented in this report.

Deriving PCT overall patient scores

The overall patient rating for Primary Care Trusts was calculated from 28 questionnaire items from the 2005 PCT patient survey. The selection of the particular questions was based on individual survey questions used in the old star rating system to score patient experience in five ‘domains’:

• Access and waiting (5 questions)

• Safe, high quality co-ordinated care (5)

• Better information, more choice (10)

• Building relationships (3)

• Clean, comfortable, friendly place to be (5)

92 Ipsos MORI: Frontiers of performance in the NHS II While this system is no longer in use, the range of items and methodology used was considered the best overall measurement of the patient experience. It was also the closest approximation to previous analysis conducted.

In calculating the PCT overall patient rating, each question was recoded onto a scale of 0-100. The most desirable option within the question was assigned the value 100, and the least valuable assigned zero. Linear interpolation was used to calculate the intermediate values. Where there is no clear direction of desirability, the largest or most affirmative response was assigned the value of 100.

Each domain score was calculated by taking an unweighted average of each group of responses per domain. No information is available regarding the relative importance of each domain in contributing to positive patient experiences. Consequently, equal weight has been given to each of the five domains in calculating this overall measure.

Due to changes in the questions posed on the respective PCT patient surveys in 2003 and 2005, the lists of questions from which the overall rating is composed are not identical. The mean overall PCT score has increased from 0.770 for the 2003 survey to 0.801 for 2005 survey, though the extent to which this is attributable to the changes in constituent questions is unknown. Although the interpretative text contained in the body of the report examines differences between the two reports, it must be emphasised that caution is to be exercised when making direct comparisons between the reports.

Calculating Acute trust boundaries

Acute trusts do not operate within defined boundaries in the same way as PCTs but much of our own research has shown that patients tend to be referred to hospitals in their local area. Therefore, it was considered reasonable to explore the effect of local population factors for inpatient ratings of acute trusts. This required a method of calculating artificial trust boundaries, to estimate the likely population from which patients would be drawn. Several attempts were made to run different boundary schemes, assigning varying numbers of Output Areas (as defined by the Census) to each trust to obtain the optimum figure, so that every OA was allocated to a trust, while limiting any overlaps. It was found that a figure of 2100 resulted in the best overall scheme, so the nearest 2100 OAs were allocated to each trust to calculate the boundary to be used in the analysis of the effects of local population characteristics.

Ipsos MORI: Frontiers of performance in the NHS II 93 Notes

94 Ipsos MORI: Frontiers of performance in the NHS II Ipsos MORI: Frontiers of performance in the NHS II 95 96 Ipsos MORI: Frontiers of performance in the NHS II Ipsos MORI: Frontiers of performance in the NHS II 97 Further information

For more information on NHS research please contact:

Jonathan Nicholls [email protected]

Anna Quigley [email protected]

Caroline Webb [email protected]

Ben Page [email protected]

Alternatively you can call us on +44(0)20 7347 3000

Or visit our website at: http://www.ipsos-mori.com/nhs for information about our latest events, papers and thought leadership work.

98 Ipsos MORI: Frontiers of performance in the NHS II