Research from the Nuffield Trust into how the healthcare hierarchy meddles in the management of emergencies has thrown up some worrying findings
In researching the recent problems in accident and emergency performance, I was struck by the way the NHS is managing the situation: there appears to be a large amount of activity across the system – conference calls, emails, phones calls – to check progress and request detailed information.
Is this adding value or causing problems? What were those involved hoping to achieve? And why is this type of activity thought to be an important part of the response?
To find out more, we spoke to a small sample of senior trust staff including chief executives, as well as commissioners, NHS England and the Trust Development Authority. We also had an informal conversation with Monitor.
I think our conclusions will not surprise many in the NHS but they ought to, because by any objective external view they speak of a significant organisational pathology.
‘The point at which things become most fraught is exactly when progress chasing becomes most intrusive’
It is possible that the sample was distorted and we may have overinterpreted the conclusions, so the following themes are presented tentatively.
Confusion from complexity
Unsurprisingly, the tripartite system of TDA, NHS England and Monitor makes for complexity, inefficiency and indecisiveness. There seems to be significant duplication of effort.
The three system management bodies are starting to recognise that they need to think about system solutions, but their remit is only for their own part of the system; it is hard for them to share risks.
A very significant amount of frontline management time is expended on collecting information, responding to requests, linking with other bodies, understanding multiple perspectives and coaxing collaboration between organisations.
‘Time that should be spent dealing with problems is diverted to reporting on actions’
We heard, for example, that site managers who should be spending their first hours at work checking on the hospital were frequently diverted by the need to gather information and to participate in conference calls.
Paradoxically, the point at which things become most fraught – for example, when a hospital runs out of beds – is exactly the point when the demand for information, actions and progress chasing becomes most intrusive.
Time that should be spent dealing with problems is diverted to reporting on the actions being taken and providing reassurance that previous action plans have been executed.
Information gathering, not action
A perplexing feature is that conference calls largely consist of collecting information and demanding action that would have been taken anyway.
We found those people conducting the calls – from commissioning support units or clinical commissioning groups, the TDA or NHS England – did not generally offer solutions to unblock other parts of the system.
‘Regulators did not have much confidence in the field’s capacity to sort out problems’
In most hierarchical systems it might be expected that those higher up might have more expertise or experience to offer or, at least, powers that could deal with issues beyond the reach of an individual hospital. This does not seem to be the case in the NHS; instead, those running these calls often had limited operational experience.
Do those responsible for this system believe that, without it, hospitals would relax and not respond to performance problems? Perhaps they think they are not sufficiently motivated.
‘Much of this ritual provides assurance and is sometimes called “blame engineering”’
It is not clear what the theory is that underpins this approach. But in our conversations there was a suggestion that the regulators did not have much confidence in the field’s capacity to sort out problems, though when pressed, they did recognise that they could not bring much practical help.
This low trust attitude had certainly communicated itself to the chief operating officer and chief executives we spoke to. This may not be new: strategic health authorities and regions before them have tended to take this view as well.
Ritual and false assurance
It seems that much of this is a ritual designed to provide assurance and to do what is sometimes called “blame engineering”.
The assurance may be false, but in obtaining, it the system manager receives a “get out of jail card” because they can point to the undertakings they have been given.
‘The hierarchy in the NHS seems to be too upward facing and creates a culture of fear’
The ritual gives comfort to people who are fielding demands for action and assurance from above but, in fact, have no real control over the situation and, even if they did, might not have the expertise to use it.
The people we spoke to were clear: they are providing assurance upwards and felt insecure if they could not show they knew what was happening and had been chasing progress.
Insufficient focus on improvement
The absence of a conversation about improvement and a shortage of some of the skills required to improve the system – particularly in the flow of patients between organisations – is a significant issue.
One is left with the feeling that a lot of effort is being wasted in ways that have very little to do with improving patient care, but are a lot about containing anxiety, providing the illusion of control and keeping the centre happy.
‘There is reason to be very concerned about the potential impact of this approach’
The hierarchy in the NHS seems to be too upward facing and the risk is that, in addition to wasting time and effort, it creates a culture of fear that, in spite of efforts to contain and neutralise it, is transmitted to frontline staff.
This could easily result in bullying, arbitrary interventions, frequent moves of patients (with risks in terms of increased morbidity and mortality), and other potentially very serious effects on patients and staff.
Pressurising people to improve when they do not have the time or skills – or where the problem is not under their control – creates huge frustration.
Good news and bad
If the reports we have been given are correct, there is reason to be very concerned about the potential impact of this approach. In a blog for the BMJ, David Oliver comments on how a culture of non-value adding, checking and progress chasing has infiltrated some hospitals as well.
‘Perhaps a trial of different approaches might be worth considering’
It is not all bad news. Monitor was seen by some foundation trusts as more sophisticated, more useful in their analyses, and more willing to allow space for the front line to sort things out. But the corollary is that if that’s not successful, it defaults – too quickly, some say – to failure management.
The TDA also has some expertise to provide advice on improvement, while some chief executives have managed to work with their CCGs to minimise this Brownian motion locally.
What is key is developing high quality relationships, having experienced local leaders used to working with each other, and recognising that the challenges are system-wide and need system solutions.
What’s the alternative?
The current approach does not seem to be fit for purpose. So the next question is: would removing it make things better or worse?
‘Perhaps a trial of different approaches might be worth considering’
The alternative is a richer set of indicators to measure system performance, with the onus put on local systems to sort out the problem, and an expectation that all calls from commissioners or regulators should be aimed at solving problems, not asking for updates.
Perhaps a trial of different approaches might be worth considering.
There are more fundamental questions raised here about the culture of management more generally, and we will be exploring the issues as part of our research programme this year.
Nigel Edwards is chief executive of the Nuffield Trust and former acting chief executive and director of policy at the NHS Confederation
- Read the Nuffield Trust report What’s behind the drop in A&E performance?