Developing NHS performance management to be less destructive: – adapting the process to manage hugely different provider achievements.

In my last few posts, I explored the problem likely to result from a potential clash between the potentially conflicting aims of NHS leadership. On the one hand is the challenge of carefully managing staff fatigue and occasional trauma caused by the long year of Covid, and on the other the absolute necessity to persuade those tired staff to turn their attention and hard work to the task of reducing the record backlog of patients waiting a long time for vital treatment.

The problem is exacerbated by the fact that the NHS’ traditional approach to performance management has been to chase numbers with added menace.  And that this methodology spares little thought to how the NHS can nurture fatigued staff in any way.

What I want to explore today is how NHS performance management could, in all its interactions with trusts that are being so managed recognise that, in terms of how likely they are to hit their targets, they are often operating in completely different conditions from each other.

(A coda to my main point here. If, as performance management is rolled out, very few of the trusts you are managing are reaching their targets, a large bell should be bonging away in the back of the head of the performance management systems mind saying “If only 5% of organisations are hitting the targets, then surely it is a mug’s game chasing the other 95% in the belief that they can reach them because it looks as if this problem is systemic rather than organisational.”

But why would trusts set themselves targets that they know they cannot achieve? Surely that would be setting themselves up to fail? Well the problem would have probably been caused by each trust being bullied into setting themselves targets that are completely impossible to achieve. (It would not surprise me if this were going on as I write this).

I imagine a conversation going something like,

NHSE/I Tell us when you think you can reduce your backlog to meet the constitutional standards”

TrustProbably June 2023”.


NHSE/I “That’s not good enough – how about June 2022?

TrustDon’t be daft How about February 2023

NHSE/I No, June 2022

TrustYou’ve got to be joking”

NHSE/I No, June 2022

Trust  “OK… and fingers are crossed”

NHSE/I Fine now send us your trajectory for hitting that target”.

to be followed rapidly in two months’ time,

NHSE/I Why are you missing your targets?”.

(…repeat ad nauseam)

We have all known for some time that this does not work. So, let’s hope it’s not being reproduced at the moment.

Any analysis of recent history, shows that when cutting into long waits, some trusts have been doing so much better than others. There is – as with any activity that has more than 30 examples – some form of distribution demonstrating how good trusts are at almost anything.

Given the amount of data that NHSE/I has about trusts’ achievements on maximum waiting times, it would be quite easy – the click of a button – to produce a distribution list  of how well different trusts have performed, say from 2017-2019, at reducing waiting lists. This would rank them in a distribution between good and bad.

All of this argument leads us to the conclusion that a wise system for managing trust performance in cutting into maximum waiting times will recognise that the performance to be managed is quite different in different trusts. That managing trusts that are doing well in the same way as trusts that are doing badly is, for want of a better phrase, ‘bad management’. Good management recognises that because, for any given task, different trusts will operate under hugely different conditions it’s necessary to manage them in quite different ways.

If a trust is doing very well in cutting waiting lists, then regularly chasing their numbers (with added menace) is probably a waste of everyone’s time. If one is floundering adding menace to performance management will have very little impact because – well, they are floundering, and the additional menace just washes off the anxiety of not achieving.

At the moment the trusts that were doing well before Covid are fearful that they will  be managed in the same way as everyone else.

So, my main point is to look at where trusts are and manage them very differently.

There is however a different point about performance that is not a point in time, but the reflection of a trajectory of performance.

Again, if you were to look at performance 2017-2019 the numbers will crucially, over that two-year period demonstrate that some have considerably improved, some have deteriorated and some have stayed about the same.

Trusts in the middle of the distribution could be there for at least three different reasons.

Trust A might – say at the end of 2016 – have been the worst in the country. And might, from 2017-2019, have clawed their way up an improvement road to halfway in the distribution. They are on the move. Given their hard work over the previous two years they have shown that they can improve and know how hard this is. Their view of their performance over the next two years is likely to be realistic.

Take another trust (let’s call it B) that at the end of 2016 was one of the best. However, the leadership of that trust had been persuaded by NHSE/I to go and run trust A. (NHS leaders will know this happens a lot!) It may be that for trust B this move has been disastrous and their performance is plummeting, and they are now moving sharply downwards and after 2 years are now in the middle of the distribution.

Now take a third trust (C). This is one that many people in the NHS will recognise. They have been in the middle for years. They keep their heads down – do not shout about how they are doing – and hope that nobody notices that they have been in the middle of the pack for years and years.

At this moment in time all three of these trusts have the same performance. They are not good, they are not bad – they are average. So, should their performance be managed in the same way?

Given their trajectories that would be daft. A needs encouragement. B needs a lot of help to replace the senior management that performance management sent to trust A, and C needs to be told that hiding in the pack does not work anymore – so what help do they all need to improve?

The point I am making here is not about kind or unkind performance management. I am talking about effectiveness. Treating all of three in the same way will not work. To improve these three very different trusts will need three different approaches.

In March 2021 waiting times are at a record high. Now is the time for differentiation in performance management.