The performance monster

James Gubb, 12 June 2008

The press is littered today with references to a new report on system reform in the NHS produced jointly by the Audit Commission and the Healthcare Commission – two well respected watchdogs. It concludes ‘the [competitive] reforms [in the NHS] have not yet delivered the desired change’, adding that ‘there is no evidence from our fieldwork that choice policy has so far… led to an improvement in the quality of service offered’.

In fact, it adds ‘we have identified service improvement in some areas has been substantially delivered without using system reform’, pointing to the massive increase in funding and response to targets.
Yet is it really surprising that competitive reforms have largely failed to deliver?
The report speaks of several factors that have inhibited its uptake and success, primarily under-developed commissioning and weaknesses in the infrastructure available to support and monitor reforms. Fair enough.
As is the attention to the damaging effect of frequent structural organisation, particularly of Primary Care Trusts, the commissioners, and calls for a moratorium on ‘any further national top-down reorganisation of commissioners’.
But it seems inconceivable that the report speaks little if anything of the damaging effects of central direction and repeated micromanagement as a whole. Yes it mentions the fact ‘there has not been a clear vision that directs all policy initiatives to a well-understood objective’, but not enough is made of the consequences of this.
Change has been ad hoc, inconsistent, poorly though out, contradictory, demoralising and, with initiative after initiative pouring out from the centre has served to crush any competitive edge that was supposed to be garnered by the choice agenda and strong commissioning.
This is the analysis of Donald Light, an expert in comparative health care at Princeton, in a recent edition of the Journal of the Royal Society of Medicine:
“Most of the costly and extensive reforms of the NHS I have witnessed since 1990 have been half-baked and partially contrary to the previous ones so that an accretion of crosscutting changes has developed. Powerful, perverse and non-aligned incentives undermine the development of cost-effective, integrated services. Leaders keep changing, and each new one asserts his or her presence by correcting or reversing previous initiatives and instigating new ones.
“Current initiatives – such as ‘payment by results’, which has nothing to do with payment by results but rather payment by activity – build in perverse incentives that will distort services in new ways.
“Until the economics and organisation of services support cost-effective, integrated services of quality for patients, a culture of Confidence, Compassion, Connectedness and Curiosity will not happen.”
Significantly, the authors of a comprehensive new report on NHS quality for the Nuffield Trust agree. In analysing a bewildering array of ‘quality initiatives’, Leatherman and Sutherland identify “a predisposition to structural change and reconfiguration that undermines morale and produces widespread confusion”….citing a “‘flavour of the month’ tendency, where certain discrete instruments are infused with magical powers and implemented with haste as the sword that will slay the bad performance monster.”
But the true bad performance monster is the government and the DH. NHS organisations have remained subservient to their political masters, frantically struggling to meet, fix, or use whatever means possible to satisfy the latest target or priority – be it 18 weeks, deep-cleans of hospitals or building a Darzi centre. The customer is still the government, not the patient as the logic of genuine competition would entail.
In fact, many – including the former head of clinical governance at the NHS – would have it that such micromanagement has gone so far as to cause inhumanity to become a deep ‘system property’ of the NHS. And his is far from a lone voice.
Recently, the NHS Confederation published an insightful report complaining that compassion had gone out of health care. In another they estimated that 58 per cent of the bureaucracy (well over 600 a year) dumped on NHS organisations – often relating to targets etc. – served no meaningful internal purpose (read patient care).
In a recent survey by the Healthcare Commission, over half NHS staff thought patient care wasn’t the priority where they worked; an RCN poll of over 80 per cent of nursing staff revealed they left work with concerns that they hadn’t been able to treat patients with enough dignity or respect.
Hopefully the point has been made. The NHS is not in a pretty state.
Of course, many will argue that it’s precisely because of the attempts to smash the service with competitive reforms that this has been the case. But international evidence points to the benefits it can bring – as it has in most other walks of life. Doctors themselves readily admit that they are a competitive breed, wanting to better their colleagues in operative performance and the like.
As we have argued elsewhere, the real problem is that the government resolutely refuses to see any contradiction between introducing competitive-like frameworks and continually battering the NHS with targets. Contradictory reforms should be ironed out, but the government must, must, start to shift funding to the individual and stand back and permit a more organic way of working.