Government targets have led to real changes in the quality of NHS services, but national indicators are not sufficient to tell us whether performance against them actually affects the health of the local population.
We believe concentration on government targets alone tends to create a vertical or “north-south” (figure 1) accountability. This serves the interests of the regulatory authorities that deal with national averages but puts into question the relationship between government averages and NHS organisations’ responses to individual patients.
These questions are based on assumptions about the direction of travel service reform must take to meet changes in health problems.
Patient dissatisfaction and newly emerging issues, such as obesity, cardiovascular disease, diabetes, etc, will rightly provoke a response by government. But no matter how well intentioned national policy is, NHS trusts (as in commissioners and providers) can easily lose sight of the diversity and range of their own individual patients in a climate of strict regulation.
We argue that only a horizontal, or “east-west”, approach can adequately address the complexity and variability of the local community. It is necessary to work towards a balance between satisfying government needs for evaluation and assurance and keeping alive the focus on patients’ needs.
The NHS regulatory system exists to ensure that the risks of healthcare are minimised. However, when the consequence of not meeting national regulatory assessment is potentially a replacement of the management team, then it is inevitable that there will be a disproportionate preoccupation with “north-south” demand.
This presents a serious dilemma for managers and clinicians because they can only keep their jobs if they adhere to government demands but the sheer energy involved in doing so means they risk failing to meet their patients’ needs.
Nor is it simply targets and core standards that make up this vertically accountable system. There is also the framework underpinning all types of accountability, including templates, assurances, procedures, and instructions such as those for operating and business plans, world class commissioning assurance and the current registration process.
As healthcare has become more complex so too has the means of monitoring it.
Our experience is that performance monitoring in a standard NHS organisation is typified by:
- A focus on “traffic light” indicators of performance: these are the templates issued by the regulatory system, but they rarely make mention of actual patients (because they are concerned with averages). If trusts simply mirror this method locally they unwittingly omit this crucial ingredient.
- End of year reporting that highlights only performance against government composite scores: these are often all that NHS staff, the public and patients see in terms of how individual trusts have performed.
- A perpetual chasing of the “right” data or evidence within organisations by performance teams - i.e. that which fits the specific parameters set down by the regulating authority – this is often met with resistance, lethargy and sometimes even hostility from those responsible for providing data and evidence.
- A sense of helplessness among staff responsible for targets that are “red” because while they are responsible for turning the target “green”, they have, in fact, little if any authority to do anything practically about the actual service delivery involved. It is not always clear to them who is responsible for changing services to meet the target nor, indeed, that such a change would be in patients’ interests.
We suggest that the dilemma can be understood using the compass metaphor. National averages are important, but the resistance within organisations to reporting on them is grounded in a sense that they do not relate to local patients’ needs and circumstances.
Indeed, a paradox emerges in which, to reassure government that everything is done to minimise risks, the sheer energy that goes into responding to regulatory demands itself potentially creates the conditions where risks might be maximised.
For instance, the recent death of Baby P and subsequent inquiry could be seen as an extreme example of how managers could be misguided into believing that, as they were deemed to be meeting centrally determined targets and standards of quality by Osted, they must, by definition, be doing well.
A horizontal, east-west dominant system
An east-west dominant system (figure 2) would suggest collaborative support between managers and clinicians to develop a shared understanding of individual patient needs, and the flexibility to mobilise the resources available to meet them. If this can be achieved then performance indicators can be aligned accordingly and made more meaningful.
These indicators need to follow the patient’s condition in the context of their lives over time and must present a more meaningful and grounded picture to national indicators (although they might usefully complement the latter).
NHS organisations have, therefore, a double challenge: to meet government requests for reassurance (N-S) while also meeting specific patient needs in all their diversity and complexity that may not always be congruent with what government wants to do for the majority (E-W) (figure 3).
For instance, there has been for several years a national target to reduce infant mortality in deprived areas.
The indicators related to this target have included smoking during pregnancy and breastfeeding. Nonetheless, the national indicators can give only a partial view of progress towards actual reduction of infant mortality, and in themselves tell managers and clinicians nothing about the needs of individual mothers whose circumstance are variable and associated with a variety of interrelated socio-economic factors.
Local services must both meet the national markers and understand the profile of mothers who present to or are referred to maternity services, and how their particular characteristics and circumstances might help or hinder them in producing a healthy baby with good life chances.
This latter task requires gathering knowledge about the different profiles of patients entering the system, how they are referred (or present themselves), what happens to them in the system, and what their outcomes are on leaving the system. It requires a different set of questions about what is going on.
An east-west dominant system would be guided by the following set of principles:
- Everyone agrees on what is possible to do for patients.
- Everyone contributes to outcomes that are wanted.
- Managers can focus on creating the conditions in which the clinical work can be aligned to outcomes.
The challenge is to hold the tension between the task of satisfying government needs for evaluation and assurance while keeping alive the actual patients’ needs so that everyone can feel that they are collaborating to make a real difference.
Connecting north-south with east-west
The NHS needs to be regulated and national standards and targets are part of this regulation. The dilemma is how to balance meeting regulatory requirements with local patients’ needs in all their complexity.
In our work with PCTs and NHS trusts over the years, we have found no shortage of desire to plan and deliver services based on the east-west dominant system. Yet, at the same time we notice how easily performance reporting remains fixated on the specific blueprints and deadlines from the Care Quality Commission, the Audit Commission, the strategic health authority, etc, and the templates, guidelines, definitions and parameters set down for meeting them.
Perhaps this magnetic pull to the “north” is because traditionally the NHS has been driven by government directives. We don’t yet fully know what an east-west system would look like or how we might bring about the necessary tectonic shift in ways of thinking and working needed to address an east-west paradigm.
In other words, “feeding the beast” can feel the safer option because at least it is clear what is being asked and what to do.
Going East requires setting aside thinking and planning time that suspends north-south distractions temporarily and allows for a different conversation between different alliances.
Yvonne Webb is director of East West Performance www.eastwestperformance.co.uk