One of the main problems with the current NHS “performance management regime” is that it doesn’t manage NHS performance.

One of the lessons you learn, quite early on, in any form of private or public service is that just because something is called something, it doesn’t mean that it actually does the thing that it is called.

And I think that’s the secret of what is called the NHSE ‘performance management system’. If you believed in the nominalism of things actually doing what they were called, then you would, in late 2023, worry a lot about how little the performance in the NHS appears to be managed. Numbers on waiting lists increase and it now looks as if the only way this year’s financial expenditure can be managed is by cutting the amount of elective work being carried out. Ensuring waiting lists go up rather than down.

While NHSE’s performance system may be doing all sort of things, one of them isn’t managing performance.

If you were responsible for managing it, you’d probably think that this system – which is meant to be doing something – isn’t. And if you wanted performance to be managed, if it was important, well you would start doing something else because the current system is not succeeding.

But if you are then let into the secret that ‘performance management’ is, in fact, only a set of administrative instructions that are performative rather than real, well then you would be less worried. Because if performance continues to decline, you can always point to the performance management system and say, “there it is – we are managing performance”. And that’s what’s important.

Just get a couple of Trust CEOs together and you will find they quickly swap stories about how they are being performance managed by NHSE, DHSC regions and ICBs.

After a few minutes you realise that they can (and often do) go on for hours about its regularity and absurdity, what they are asked for, and often the frantic speed required to get information together. So much so normal – of course local leaders complain about being managed.

But over the last few months what has surprised me has been hearing local CEOs complaining about the ineffectiveness of the system. Their refrain being, “…and there are never any consequences”.

This is different, because if no consequences flow from a performance management system, then all it is just an exercise in information gathering. Noticing how bad (or even good) things are is an exercise for researchers. If nothing ever really happens as a consequence of the performance information you provide then it really isn’t managing performance.

Having heard this for quite a few months now, I thought it was worth unpacking this lack of consequences a bit more.

Because it is rather odd to hear NHS CEOs complain that their national performance managers, when carrying out that role, don’t seem to have any real power to deliver consequences. The people who normally complain about not having any power are those same performance managers, but to hear those they manage complain about that lack of power, is, to say the least, different.

It does reflect where we are with the national system of the NHS.  I also think this offers some insight into at least two conundrums – why elective recovery isn’t really recovering and why overall NHSE performance management isn’t really managing performance.

Let’s start with extreme consequences. – Losing your job if you perform badly[1].

One of the issues lying behind this lack of consequences is the recognition that one of the most significant consequences, sacking the chair or the chief executive, can only really happen if there are others who want to do the job and are ready to replace the person being sacked.

If there isn’t a queue of people wanting the job, someone doing badly will not be replaced,

And there isn’t. The numbers of CEOs leaving voluntarily demonstrates, along with the very short shortlists to replace CEOs, that people don’t want to do these jobs.

If few people want to do their job, then there are real problems with persuading people that they could be sacked.

But why don’t people want this really important senior leadership job? (And this is where the performance management system has itself managed to create the conditions where it does not work).

I think the main reason for the reluctance is that although this is described as a senior leadership job, post holders are not treated as senior leaders.

Listening to the experience of current CEOs, they are not given the space to lead that senior leaders might expect.

Too much of the experience is hedged around by a complex series of different performance managers, all asking for information yesterday.

This is the circle of failure inherent in the current system. Senior leaders are not allowed to lead, so the next generation don t want the job and, because of that there are no consequences for inadequate performance by incumbents.

If you aren’t doing very well as a CEO you’ll probably feel pretty safe because you know there is not a queue of people waiting to do your job.

This is the crux of the medium-term problems. The way in which performance management of local leaders has been conducted, has resulted in people not wanting to do the job.

The current performance management system has undercut its own effectiveness by making the job of CEO so unattractive.

Probably time to change this.

[1] But note that even when as a CEO you lost your job for inadequate performance, you very often found yourself with another job – often working for the region that sacked you. And then you were often performance managing organisations whose performance was better than the one from which you were removed.