England's top hospital inspector has warned that safety remains a "real concern" in the NHS after it emerged four out of five NHS trusts need to improve on patient safety.
Professor Sir Mike Richards said the NHS "stands on a burning platform" following the first round of new inspections of the nation's hospitals.
The Care Quality Commission's (CQC) chief inspector of hospitals said it has become clear the model of acute hospital care which once worked well for the NHS "cannot continue to meet the needs of today's population".
He said there is a "wide variation in quality" between hospitals and between services within the same hospital, following the first round of comprehensive inspections of England's 136 acute non-specialist trusts and all 18 specialist trusts.
Inspectors uncovered pockets of "very poor quality care" in good hospitals, he added.
He said the scale of the challenge is "unprecedented".
Sir Mike said rising demand for care and economic pressures are creating "difficult-to-manage situations that are putting patient care at risk".
The CQC's State of Hospitals report says: "The safety of hospitals remains our biggest concern, with four out of five trusts needing to improve."
Sir Mike criticised a "failure to learn" when things go wrong.
Overall 81% of the 136 non-specialist trusts were deemed to be inadequate or to require improvement for safety.
Some 11% of hospital trusts were given the lowest rating for safety.
None received a rating of outstanding in this area.
The authors of the report said some trusts have "blind spots" about the quality of care they are delivering.
More than half of specialist trusts (53%) were rated as requiring improvement in terms of safety.
The authors of the report wrote: "We are also concerned that some may be over-reliant on their reputation and not assuring themselves of the quality of care they are delivering."
Across 199 urgent and emergency services inspected, 7% were deemed to be inadequate.
Urgent and emergency services and medical care had more ratings of inadequate and requires improvement than good or outstanding, the report said.
The CQC said the proportion of urgent and emergency services rated inadequate reflects that many A&E services are struggling to cope with increasing numbers of patients.
The regulator introduced a new inspection programme in 2013 following the publication of the public inquiry report into the care scandal at Mid Staffordshire NHS Foundation Trust.
It has inspected all NHS acute and specialist hospital trusts under the new regime.
The latest report, which brings together all the inspections, highlights areas for concern but also praises improvements and celebrates outstanding care.
NHS staff have been applauded for their caring attitudes to patients, and the report shows no hospital trust has been given the lowest rating for providing a caring atmosphere for patients.
"Frontline staff are the heroes of our reports," the authors wrote. "We have found high levels of compassionate care in virtually every hospital."
Sir Mike said: "We have witnessed some fantastic care and examples of innovative practice, but we have also found a wide variation in quality both between hospitals and between services within the same hospital.
"Safety remains a real concern, often due to a failure to learn when things go wrong.
"Strong leadership that instils a culture of learning and an environment where staff are listened to can play a vital part in bringing about improvements.
"Overwhelmingly, we see staff behaving in a caring way, which is supported by what we hear from patients. The unwavering dedication and commitment of staff shines out from our inspection reports.
"What is clear is that while staff continue to work hard to deliver good care, the model of acute care that once worked well cannot continue to meet the needs of today's population.
"The NHS now stands on a burning platform - the need for change is clear, but finding the resources and energy to deliver that change while simultaneously providing safe patient care can seem almost impossible.
"What this report demonstrates, however, is that transformational change is possible, even in the most challenging of circumstances - we have witnessed it, and seen the evidence that making practical changes to the way that care is delivered can benefit patients."
His foreword to the report adds: "The scale of the challenge that hospitals are now facing is unprecedented - rising demand coupled with economic pressures are creating difficult-to-manage situations that are putting patient care at risk."
An NHS England spokesman said: "CQC are right to praise dedicated NHS staff for delivering great care under pressure, and they are also right to argue for the more profound changes now being planned in how acute hospital care is delivered across England."
Key findings of watchdog's State of Care report
Here are some of the findings of the CQC's The State of Care in NHS Acute Hospitals report.
- Inspectors raised concerns over the physical environment of A&Es which were built when demand was much lower
- Ambulances queuing outside A&E "has been normalised and is routine"
- When examining the four-hour A&E target they found that trusts rated inadequate or requiring improvement experienced the largest decreases in performance
- Inspectors raised concerns about nurses being overstretched on medical wards and a "growing pressure" on junior doctors covering large numbers of acutely ill patients, particularly out of hours
- "Too many" last-minute surgeries were called off because of a lack of beds
- Maternity services are under growing pressure because of higher numbers of women giving birth and more complex cases. In some cases "one-to-one" labour is not achieved because of staffing issues
- With end of life care, which spans whole hospital sites, some organisations view caring for the dying as a "peripheral activity managed solely by a specialist palliative care team, rather than a core activity of the hospital"
- There were problems with decisions not to attempt cardiopulmonary resuscitation - also known as DNRs (do not resuscitate) - where often forms were not filled in properly so a decision was "ambiguous"
- Trusts struggling to balance the books are also likely to be given poorer ratings. The authors wrote: "Our ratings for acute non-specialist trusts against their financial performance shows a correlation between our ratings and the trusts' deficits"
- Variation in care is linked to the quality of leadership, at ward, hospital or trust level
- Ensuring there are enough staff with the appropriate skills mix "remains a challenge for acute trusts"
- Staffing concerns arose across different services, but nurse staffing in medical and elderly care wards is a common concern. Inspectors also found frequent concerns with the numbers of midwives on maternity units and medical staffing shortages in many emergency departments
- Organisations were praised for the care they showed patients, but where issues were identified, these mainly resulted from poor staffing levels
- When staff are stretched too thinly, "compassion can be lost as staff become focused on the immediate task in hand and not on the person in front of them who they are caring for"
- Hospitals are facing "unprecedented" demand for urgent and emergency care. In December a third of trusts issued alerts warning they needed urgent action to cope with the pressure of patient numbers
- Many hospitals face a daily struggle throughout the year to find suitable beds for emergency and planned admissions
- Inspectors said some improvements can be made relatively cheaply. They wrote: "Protecting patients from infection with good hand hygiene and minimising the risks of 'never events' through full use of the World Health Organisation's Surgical Safety Checklist cost very little, and yet we have seen much poor practice"
- An important tool in patient safety is an early warning score system, but: "In many hospitals this is not used proactively or effectively, with staff falling back on their own clinical judgment and not recognising or recording change, or not acting appropriately on the early warning scores. Staff in these cases appear to view the early warning score as a burdensome paper exercise, rather than an essential tool to protect patients"
- Poor multidisciplinary team working has a major impact on the quality of care. "In a minority of services staff were working in professional silos. Generally, this resulted in a rating of requires improvement. In a few services, we found unacceptably poor relations between different staff groups - these services were rated inadequate"
- There were too many examples of trust boards being "too concerned" about their organisation's reputation and this led to a lack of openness about quality issues
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