Managing performance is not about telling people when they do things wrong but engendering a desire in them to do things right, says Robert Creighton

Nigel Edwards’ comment piece illustrates not only that the NHS’s current structures for regulation and oversight are dysfunctional, but also that attitudes, expectations and behaviours play an important part in the effectiveness or otherwise of the system’s management of performance.

‘The manner in which people behave and the sophistication of their skills will always have a greater impact’

This argument is also advanced in the Nuffield Trust’s policy briefing What’s Behind the A&E “Crisis”?, in which the complexity of the issues is described and the NHS’s current, crude approaches to managing accident and emergency performance are challenged. 

The NHS needs to find more sophisticated and skillful approaches by which regulators and system managers (NHS England, Monitor, the NHS Trust Development Authority and the Care Quality Commission) can apply their performance management functions to stimulate real improvements in services.

It is important to be clear right away about the core point in this.

Robert Creighton

It doesn’t mean regulators and system managers simply getting better at measuring, monitoring and commenting on performance – which they do in abundance.

It means prompting and sustaining widespread and rapid performance improvement, and creating conditions in which performance failure can be more readily avoided.

It is my experience that this is what all thoughtful people working at the level of regulation and system management espouse and aspire to, although it may not always appear so.

Nobody wants structural change for the sake of it, and it would be churlish and inappropriate to rely on a re-organisation of the intermediate tiers to bring about the necessary changes.

That may be necessary, but is certainly not sufficient. Whatever the organisational arrangements, the manner in which people behave and the sophistication of their skills will always have the greater impact.

Driving improvements

The starting point for a more skillful approach to performance management must be an understanding of what drives improvement.

People who work in the NHS are not driven by being told to improve by someone else, but by personal commitment, responsibility and pride in the quality of their work and service.

An intelligent form of performance management would seek to create conditions to maximise the scope for this inherent motivation to flourish.

‘People aren’t driven by being told to improve by someone else, but by personal commitment and pride in the quality of their work’

The basis for this would be the recognition of, and respect for, expertise at, or very close to, the point of delivery, along with a commitment to generating and enhancing that expertise where it is needed.

This would be in contrast to a model in which frontline staff are considered unwilling and unable to embrace improvement, and are undeserving of the skills to do so effectively – a model in which people distant from the front line think they know better and need to both berate and instruct colleagues in the field.

As things stand, it is too often the case that regulatory body’s staff and system managers (the intermediate tiers of the NHS) do, in one sense, know more than staff in the field.

They have often been the beneficiaries of training and development that have enhanced their theoretical knowledge of improvement techniques; they have undoubtedly successfully used these techniques earlier in their careers but are no longer in a position to apply them directly.

Knowledge and skills in this area are currently scarce and confer authority, and it is bound to be tempting for them to be retained among the cognoscenti. This is counterproductive.

Relevant skills are needed more in the field; knowledge, rather than being scarce and esoteric, needs to be accessible and disseminated.

This doesn’t mean, of course, that intermediate tiers have no practical role in performance improvement.

They can and should make four valuable – indeed, critical – contributions, all of which are derived from, and legitimate to, their position in the system. They should:

  • promote a more subtle understanding of the complex issues involved and develop more sophisticated indicators of performance to ensure attention is paid to the most important drivers of improvement;
  • act as critical friends and use their broad overview to challenge complacency and inspire continuous improvement through intelligent comparison to reduce risks of performance failure;
  • encourage the sharing of good practice and mutual learning by supporting frontline performance improvement; and
  • model collaboration and mutual consistency to remove blockages between different regimes, policies and priorities and promote system-wide (rather than institution-specific) improvement.

The ‘inbetweeners’

Intermediate tiers also have a crucially valuable political role: to act as buffers between central government and the main body of the NHS.

In spite of the wilder aspirations for the current system – for the NHS to be distanced from national politics – it is inconceivable that ministers will restrain themselves from exerting all the pressure they can to drive up NHS performance, and it is legitimate for them to do so.

Too often this manifests negatively, in blame and demands for impossible transformations.

‘It’s inconceivable that MPs will restrain themselves from exerting all the pressure they can to drive up NHS performance’

To give the NHS the space it needs, this negative energy needs to be absorbed or dissipated, rather than being amplified.

That is the hardest part of the role of system managers and regulators; it takes not only a lot of skill but also a lot of resilience to provide this sort of cover to the front line.

It also requires confidence that the front line is seriously committed to, and capable of, self-improvement, and doesn’t need to be hounded and harried.

So we come full circle, back to the absolute necessity to invest appropriately in the attitudes and skills of staff who can make a real difference on the ground.

Robert Creighton is a former NHS chief executive, now an independent consultant and a visiting fellow of the Nuffield Trust