There was much to admire in Wes Streeting’s speech to the NHS Providers conference writes Steve Black
Wes Streeting’s speech to the NHS Providers conference (full text here) attracted a lot of ire. What seemed to upset most was a promise to establish performance league tables for NHS trusts and his proposal to cut the pay of, and possibly dismiss, bad managers.
The Guardian headline read Streeting’s hospital league table plan riles NHS medics and bosses. It also published an opinion piece by Rachel Clarke arguing the health and social care secretary should not blame senior NHS staff for the service’s bad performance.
Two things annoyed me about the reaction to the speech. The first was that it did not better reflect the more noteworthy and nuanced ideas included in Mr Streeting’s speech. The second was that the arguments against league tables and performance transparency were bad ones.
What did Streeting say?
The press releases issued on Monday and Tuesday in advance of the speech on Wednesday were deliberately aimed at generating press coverage before anyone had seen the detail of what Mr Streeting would say. Both made much play of the government’s determination to ensure there were “no more rewards for failure” for those in the service’s top ranks.
Mr Steeting’s speech — made of course after the press had turned its attention elsewhere — was more conciliatory.
For example, here is a longer quote about management from the speech:
“No more manager bashing for manager bashing’s sake.
Lord Darzi’s investigation into the NHS concluded that the problem is not too many managers but too few with the right skills and capabilities.
…I could be no more popular than announce [sic] the sacking of lots of managers, but that would not be the right thing to do.
…I am prepared to make an unpopular argument with the public about the value of good leaders. The NHS is one of the biggest organisations in the world. We should be competing with global businesses to attract top talent, and for that, we need to attract and retain the best.”
That suggests a radical shift from previous NHS attitudes about management that is extremely welcome.
There are similar paragraphs on hospital performance that also contrast greatly with the headlines created by the government press releases. The details imply a far more nuanced philosophy about performance management than “targets and terror” or league tables.
For example, Mr Streeting’s positive approach to earned autonomy is a welcome and radical shift from the recent direction of travel.
He said: “Starting with the best-performing trusts, providers should be given greater freedom and flexibility to innovate, run community services and manage their own house to meet the needs of their patients.
“This is planned to work alongside another radical shift I’ve long recommended: vastly simplifying the targets and goals.
“Clear priorities mean a few, not 50 different targets. So the instructions coming out in the forthcoming NHS mandate and following planning guidance will be short.”
Part of the reason hospitals find it hard to improve is the proliferation of so many targets, making it impossible to prioritise which ones matter most, thereby diluting their improvement efforts to a homeopathic level on each. Clarity about the small number of key goals is far more useful.
Mr Streeting also, refreshingly, claimed that his goal was not to advocate for the NHS, doctors or hospitals, but for patients. This contrasts sharply with much of the reaction to his speech, which, to me, felt like lobbying for specific NHS interests.
Not good arguments
Dr Clarke’s argument was that performance metrics and league tables cannot measure the soft factors that matter most. Some leaders complained that simplistic league tables might encourage patients to “shun their local hospitals”.
These are not good arguments. If performance is poor (say many patients wait 12 hours in accident and emergency) then no amount of compassionate care will compensate. If hospitals are poor performers, then why would the NHS defend the hospital against patients choosing better care elsewhere?
Many of the arguments are suffused with the zombie idea that performance is not the fault of the hospital. This is nonsense. Many major aspects of poor patient care are the result of bad decisions made inside the hospitals. And the public deserves transparency about that performance. Honesty about performance is also critical for improvement. Hiding the performance to protect hospitals is the opposite of what is needed to improve the NHS.
The best criticism of league tables is that they are a poor way to communicate performance information because they highlight trivial differences rather than important ones. For example, mortality metrics like HSMR and SHMI can divide hospitals into three groups — good, average and bad — but not produce meaningful rankings.
However, many metrics deserve to be more transparent so managers can focus on where they need to improve and the public can see which hospitals are better so they can push for improvement or choose a different one.
Mr Streeting seems committed to transparency, which is a good thing.
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