We should not forget that currently one of the two main national organisations that manage the NHS is called NHS Improvement. This part of central NHS organisation has been involved since its creation – by combining the Trust Development Agency and Monitor – in the actual performance management of work carried out by NHS Trusts.
But whatever you call it, most trusts do not experience this performance management as one of ‘improvement’.
That is not to say that NHS Improvement does nothing about improvement. We will return to that later. But in the context of performance management, improvement seems to be the least part of it.
What we are exploring is the way in which the management of performance within the NHS is experienced – as chasing numbers with menace. And that this approach leaves little room for consideration of how the NHS can nurture its fatigued staff in any way.
What I want to explore today is how this performance management could contain, in all of its interactions with trusts that are being so managed, a direct offer of help with improvement.
The conversation needs to move from “How are your numbers and why aren’t you doing better?” To “How are your numbers? Have you thought about doing x or y or z?” and “If you decide to do x or y or z, then you could consider using green or white or red (at these email addresses) to help you”.
The next interaction – a few weeks later – could then be “How did it go with green or white or red? Do you need any help to use their suggestions?”
The tone of such a conversation is hugely different. By including offers of improvement, the person asking the questions has to be a lot less inquisitorial. The central issue is that they are in fact becoming complicit in helping improvement. After all they are coming up with suggestions for improvement and in playing that role, they are part of the help.
This is one of the reasons why performance management conversations do not involve suggestions of improvement. Wrongly, the process of performance management in the NHS raises the concern that by being complicit in conversations about improvement they will not be able to sufficiently separate themselves from the performance of trusts to be able to manage them correctly. Sympathetic involvement is seen as a problem.
This is the nub of the difficulty. In fact, as a matter of history and record, of course NHS performance managers are complicit with the performance of the trusts they are performance managing. As far as the public is concerned there is only one NHS here.
Let us be clear. From the public’s perspective, if an NHS trust fails, the NHS fails. There is no way that senior managers of NHSE/I ‘succeed’ if a trust fails. NHS elements are inextricably linked in the public mind and cannot be seen as separate. There are no ‘clean hands’.
Involvement in conversations about improvement take place in most other services. I know that changing from one cultural from of performance management conversation to another is not a simple shift but, if we do not want an exodus of fatigued staff, that is the today’s task.
BUT, and here I turn my gaze towards my colleagues in the improvement part of the NHS, the only way in which current performance managers can redirect conversations towards offers of improvement is if those of us involved in improving organisations can (as in my example above) come up with improvements x y and z and the email addresses of green, white, and red to help out.
In various guises, beginning with the Modernisation Agency in the early noughties, the improvement trade in the NHS has been going about its business for more than 20 years. Today there are thousands of people who are actively involved in working to improve a very wide range of health care and health activities.
In 2021 – given the breadth and depth of this experience – it should be possible to provide a very comprehensive list of tactics and strategies for improvement across all areas of work. It should also be possible (and this is crucial if you want learning to happen) to have at least three different examples of people and organisations that have succeeded in moving their aspect of improvement forward.
It is the job of the improvement business to come up with these examples now.
Of course, I understand that some might say it would be good to have another year to develop the detail. And of course, it would be good to have a three-year study of all the factors involved.
But we do not have the time.
(There were many scientists that would have liked another year to test vaccines to make sure they are effective over time – but that time was not available).
The great thing about the NHS is that someone, somewhere has usually succeeded in improving – in one way or another – almost everything. We need a comprehensive and dynamic directory of all of this work.
A real example from growing waiting lists. If NHS performance management of provider trusts is going to help improve the number of endoscopies they carry out it is the task of the improvement industry to come up with the best three examples of how that has been achieved.
Now is not the time to be precious. Now is the time to help.
We cannot expect performance managers to include examples of improvement in their conversations if the improvement industry does not provide them with those examples.
Improvement is the key task of NHSI. (There’s a clue in that last letter of its acronym).
Now, in its last year before abolition, it is time for it to live up to its name.