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Hospital performance in England has got worse in the last year, according to the NHS watchdog's star-ratings system.

Problems with finances and targets caused a fall in the number of hospitals achieving the top grade for the first time in four years.

But the Healthcare Commission said primary care, mental health and ambulance trusts had improved.

However, the watchdog warned the whole health service had to get its finances in order or patient care would suffer.

One in four NHS trusts, and one in three hospital trusts had experienced financial difficulties.

A number of hospitals failed to meet a range of government targets.

62 out of 159 hospital trusts with A&E units failed to meet the 98% target for the number of people waiting for four hours, and one in 10 also failed to achieve the nine-month wait for an operation.

The star-ratings assess performance across a range of areas including waiting times, access to GPs, financial management, patient care and death rates, showed improvements had been made in reducing MRSA and the death rates for cancer, stroke and heart disease.

Three stars are awarded for high performance, two for good performance with some inconsistencies, one star where there are some concerns, and no stars indicate poor performance.

The number of hospital trusts achieving 2 or 3 stars dropped by 5% compared to the previous year.

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