Every few weeks it seems necessary to interrupt the flow of posts, on what the NHS needs to change and how to change it, to report on current experience of the performance management system operated by NHSE and the DHSC.
For the greater appreciation of these posts, it will help your understanding if you could put yourself in the role of a local NHS leader experiencing the current performance management process.
So, when reading this roleplay imagine you are a local leader. Say – for the purposes of this post – a director of an ICB. And because, dear reader, we can assume that you are decent sort, let’s assume you are really trying very hard to serve BOTH the interests of your local public by planning for their health care for the long-term, AND you trying to work within the performance management structure as laid down by the DHSC and NHSE. (After all the job is to deliver to your local people – that’s the ‘N’ of the NHS – so doing both is vital.)
Already in my posts this financial year we’ve learnt that the existing ‘payment by results’ system, intended to incentivise providers to do more work by paying them more money for doing it, was changed first in July and then again in November.
The point I made previously was that if you were a local leader who believed that your national leaders took performance management seriously, and believed it would impact your performance, you might look at the system – either when it was first introduced in April or later changed in July and think. “They have settled on a system to incentivise us to do more work, so I will work with the April system (or make that the July system) as if it is the system for the entire year. That will be my guide toy planning for the year.”
Or you may be a bit craftier than that. You might think that the people performance manging me will change their mind several times in the coming year. Even though they claim that this system will run for the whole year. you know that it will change. (Only a naïve person would think that because something is called an annual incentive scheme, that it would last a whole year.) You of course know better – being crafty you decide not to pay any attention to it.
When we returned to this annual scheme in November, NHSE was telling local leaders that they had to cut back on the growth of elective work by 2 % in order to balance the books. We noted then that a crafty local leader would not have listened to the annual performance management scheme in April or July because they would know it would be changed later in the year. Only an unwise local leader would have believed that when they were incentivising you to do more elective work, that they actually wanted you to do it.
After all, by November, the Prime Minister – who usually has a bit of say in all of this -was 11 months into his national pledge to increase elective work to reduce waiting list numbers during 2023, so surely they wouldn’t, in November, say do 2% less work because that would be hanging the PM out to dry?
But of course they did.
So, who was the cleverer local leader? The one who took the original incentive scheme seriously and did more work, or the one who waited, did nothing and then planned to use the money, which should have used for more work, to pay off deficits. AS they were eventually told to do.
Well, you wll be pleased to know that as of February of the current financial year, they are BOTH wrong.
Last week we learnt that the Government did not want you to move money from the dentistry budget, when it told you to do this in November. And to use that money to pay deficits – as they encouraged you to do in November – they now, in February, want you to spend the money (that you moved from the dentistry budget in November into deficits) on dentistry.
On 6 Feb the HSJ reported that,
The government is ordering the NHS to put a “firmer” ringfence around integrated care boards’ dental budgets.
(We will return to the really interesting notion of a ‘tighter ring fence’ in a minute).
All ICBs are now being told, in February, to produce monthly spending returns on the fact they are spending their dentistry budgets on dentistry,
This is a hallmark of the way in which Performance Management to doesn’t manage performance.
Being told to report on something much more frequently apparently gives performance managers the feeling that they are managing performance more successfully. But all it means is that there is more reporting.
It does not mean that the money you allocated to deficits (and are being performance managed on a monthly basis by someone focused on deficits) can be moved back into dentistry. But it does mean that two different people can now have a go at you (on a monthly basis) for not spending the same money in the two different ways – as you were instructed so to do.
If you followed November’s performance management and had moved your dentistry money into deficits, you will now be able to report, on a monthly basis, that there is no new money left for dentistry.
We now have a new category of ‘tighter ring fencing’. (Hence the monthly reporting). The analogy of a ring fence is something with a fence round it (the fence is in a ring) and all the things inside the fence have to be spent on one thing. And a tighter ring fence is one where the fence that is put around the money in a tighter way.
(Since the British Dental Association cruelly commented that the ring fence is ‘purely semantics’ perhaps it was a waste of time explaining what it meant).
So, a tighter ring fence is in some way scarier.
Now to be fair to everyone (Why do that? – ed) it was a previous Secretary of State who in November said the dentistry money could be spent on deficits. Now a new Secretary of State is saying several weeks later that he was wrong, and that the money needs to be spent on dentistry.
The point I am making here is that there are thousands of people whose job it is to receive reports, and thousands of others whose job it is to write them. Everyone involved in this process thinks that what they are doing is performance management. To help them in this belief it is called performance management.
But really, will any of this activity, in the in the last two months of this financial year, actually make any difference to the actual performance of the NHS?
Will this lead, between February and April, to there being more dentists?
Health care is a complex set of services. If you want to make a difference to how the NHS performs then you are going to have to understand and work with how local leaders actually make things happen. That takes time – for any serious change much more than a year. Which is why all the other posts about change I have written this year emphasise the need for a ten-year programme.
Over the last year a wise local leader would have got on with managing their own performance. But if they had been paying attention to those that are trying to manage their performance, they would have been changing what they are doing every few weeks.
This is not performance management. What it is I’ll let you decide.