Time for the NHS to change the way it manages performance?

Now, in March 2021, the high level of fatigue being experienced by health and social care staff is an established fact. Most NHS leaders now recognise the need for significant and prolonged management action in working with staff to help them through this difficult time.

Responses to Tuesday’s post included real-life examples of how exhausted staff were.

A huge number of patients have been waiting for treatment for a long period of time. The length of these waits increases the level of pain and distress in the country, and will also increase mortality. There is a growing recognition that post COVID-19 the NHS will need to increase levels of activity to provide the higher volumes of care that will be needed to reduce that pain and distress.

It is the link between these two truths that is the problem. There are no reserve teams of health and social care staff sitting out the pandemic somewhere that will now be free to boost NHS efforts by increasing workloads and so reduce the pain and stress of those waiting for treatment.

There is only one team  – and they are exhausted.

And to make an obvious point. Before COVID-19 the numbers of patients who were waiting for a long time was increasing. This increase had been partly caused by the fact that pre-pandemic the NHS was short of about 100,000 staff members. Even before COVID-19 staff were working hard to reduce long waits to make up for these staff shortages.

During COVID-19 staff have been working flat out to help the country get through a pandemic.

Now the danger is that the NHS are going to ask those same (too few and exhausted) staff to work even harder to cut down those long waiting lists.

That would be a recipe for disaster.

Before simply moving from the exhaustion of the pandemic to exhorting staff to work harder we need to stop and think for a moment.

This is especially the case because anyone who has worked in the NHS will recognise the particular, unpleasant style of performance management that runs through it.

It is a style of performance management that flows from one of the crucial themes of the NHS. The fact that it is not just a national organisation, but a nationalised organisation.

The public love the NHS because it is theirs. And it is felt to be ‘theirs’ because it is national and ‘nationalised’.

In this country nationalised means run from the ‘national centre’. When the UK had many more nationalised industries, it was normal for them all to be run from the centre.  Which meant national targets that were set and managed from that centre.

That ‘N’ part of the NHS sets the targets that the national public expect. These targets are then ‘cascaded’ from national to regional, regional to ICS and from ICS to each provider. The leadership of each provider then disseminates them through the organisation to the people who are delivering services.  What the NHS means by ‘performance management’ is the process of chasing performance down that line and getting each part of that – regional, ICS, provider, and provider unit to improve their performance.

So whilst the ‘providers of services’ for the NHS are all situated in different localities -and the whole organisation only ‘works’ if services are delivered in those quite different localities – NHS targets are set and run from a national centre.

As COVID-19 slowly recedes, national targets for waiting times are once more thrown into sharp focus and the performance management of those targets can be expected to come to the fore.

Many readers of these posts will have direct experience of NHS ‘performance management’ and will know it to be rather a shouty form of management, its main activity being to check on numbers chosen to represent performance and deliver a straightforward expectation that ‘you will do better’.

And when you do not, it’s ‘or else’.

And when you do not after that it becomes ‘or else’.

You can already hear the moral argument that will be deployed to back this up. It will juxtapose the needs of hundreds of thousands of patients who have been waiting for a long time against those of a struggling and understaffed workforce and say that the patients are more important. And it will tell its exhausted staff that they need to work much harder to meet their needs.

The main point of this post is to point out that if, in 2021, this form of performance management returns with its previous full force – staff will leave.

The twin realities of there being too many waiting patients and too many exhausted staff means we need now – not in a years’ time – a quite different style, tone, and content of performance management.

Let me be clear. I’m not saying that people on the waiting lists are not important, it’s just that this way of organising a service that is meant to help them will no longer work.

Rather than just shouting at providers to do more we need a much more nuanced approach to performance. One of the experiences that many commentators reported in the exceedingly early days of the pandemic was a continuous process of innovation where staff and service providers evolved new ways of delivering their services.

Staff were asked to think quickly about how this could be done. Agreement was often reached ‘in the time it took the kettle to boil’ – not 9 months to a year.

My next posts will explore how this approach might work to develop better service outputs after the pandemic, just as it did at its beginning.