What Poses More Danger To The NHS; Dirty Data Or Dumb Leadership? goo.gl/0ze7q
Writing blogs on poor management of the NHS is like shooting the proverbial fish in the barrel, but two articles in the papers this weekend have raised the insanity levels higher than ever. The first piece brought forth the startling revelation that Jeremy Hunt wants to criminalise the gaming of targets
The Government is going to solve the problems in the NHS by prosecuting anyone deemed to have fiddled figures to meet their targets. This angers me on many levels, so let me try to summarise the situation that Hunt is attempting to solve;
- Government sets arbitrary targets, which trigger punishments if not met.
- Targets become the important focus of attention for management, who push targets down the hierarchy, imposing them on the workers in the system.
- Government sets the policies and thinking, which dictates how managers create systems and budgets, by which people must work to meet the targets.
- Inadequate systems created by wayward thinking, cause targets to be missed.
- Fearful of the punishments that will arise, people do the only thing available to them to meet the arbitrary targets: they “game” the system.
- Patients die as a result of the poor systems, whilst management. focus on the targets and the workers.
- Government is provided with copious evidence that the focus on targets has caused the system to fail patients.
Targets do not work. There is a tidal wave of evidence that tells us this, from bankers to schools, via policing and the NHS, but consecutive Governments have clung to them like a comfort blanket. Targets give the illusion of control, but the truth is the complete opposite. I do not intend to go into detail on why targets are such a bad thing, as I have done just that in previous blogs. If you want to find out more, please follow the links I have provided at the end of this blog. @AndyTBrogan nicely summed up the effect of targets when he said that “in the short term, they may get people to do stuff, but they suck the heart and soul out of what they are doing”.
So, what are our Government proposing to do to improve things? Is it;
- Abolish targets and refocus attention on the needs of patients;
- Remove some of the worst targets, most prone to gaming;
- Enforce the targets more rigorously and make it a criminal office to record inaccurate data
Only option 1 will work. Words fail me that any sane person could choose option 3. However, this is Jeremy Hunt we are talking about. To quote Deming; “wherever there is fear, there will be wrong figures”. This policy takes the culture of fear and ratchets it up to 11. More fear will lead to more wrong data, but it will just be more cunningly concealed.
Let’s think about Hunt’s proposal logically for a moment…
- How will prosecutors distinguish between an honest mistake and a deliberate fiddle? If I transpose a figure, did I do it deliberately or accidentally?
- Who will define exactly how the figures need to be prepared? Think of tax laws; is it avoidance of the target, or evasion?
- If figures were found to be falsified, were they caused by a “rogue” worker, or systemic fraud? How will we truly know?
To answer those questions will require policing. The logical conclusion is that figures will have to be more rigorously audited. Will we have a specific accounting body that verifies hospital data? How much would that cost exactly? Cost that is, in terms of the auditors themselves and the time and effort incurred by the NHS in preparing and checking the figures.
Criminalising data falsification will focus management attention even further away from the patient and further into accountancy and accountability. It is the wrong thing spectacularly wronger. This policy is like recognising that corporal punishment isn’t working and then proposing that we make it more brutal.
The problem is that the system is the main factor affecting performance. In turn, the system is affected by the thinking of those at the top. We currently pass responsibility for performance down the hierarchy, but do nurses actually have the power and authority to change the system? If they can’t change the system, the only way to hit the targets is to cheat the system, or cheat the figures.
So what to do instead?
The unavoidable truth is that sustainable improvement will not happen until the thinking changes at the top. If the thinking changes, it will allow us to replace arbitrary targets with measures of performance that are linked directly to purpose. The crucial part is that measures must be used to learn about current performance, but not to make people accountable. Instead they must be used by the people who actually do the work to help them improve the system.
There are 5 tests of a good performance measure. To be truly useful they must;
- Helps us understand and improve performance
- Be derived from the work
- Demonstrate capability and variation
- Be in the hands of the people who do the work to control and improve the work
- Be used by managers to actively, act on the system
Which brings me to the second article, which alleges that the Government was guilty of ignoring data on hospital death rates Professor Sir Brian Jarman, who co-founded the health statistics and research service Doctor Foster, claims that in 2010 he sent the then health secretary Andy Burnham a list of hospitals with higher-than-average death rates, but no action was taken.
The fundamental fact that most people fail to understand is that producing any sort of performance data does not in itself change anything. Measures can never provide us with any answers, but good ones will prompt us to go away and ask the right questions. Used correctly, managers can identify where they need to go and look, to see what actual performance looks like and why it is delivering the data seen in the measures. This is absolutely not achieved by sending others to carry out audit and inspection. This is managers using data intelligently to go and see the work themselves, which is the only way to understand and improve the systems they ask people to work in.
None of these changes are possible until the thinking changes at the very top of the NHS. If Government continues to believe that fear improves performance and enforces it with inspection and prosecutions, then the future looks very bleak indeed.
Here are some fantastic links that explain why targets do not work;
Try almost any of Inspector Guilfoyle’s blog entries here;
Type targets into the search box here;
This is a great summary piece, which provides further links to plenty of evidence;
You can also read my previous blogs to see the effect that targets had on me. For example;