The trouble with current NHSE performance management is that it doesn’t manage performance… especially in the last month of the year.

I should have known that as we approach the end of the financial year I would be bound to be write more posts about the continuing problems of NHSE performance management. The main problem being (altogether now) that it doesn’t manage performance.

So what are the key issues?

ISSUE 1. When does planning guidance not guide planning?

I write this on March 17. Those with an eye on the calendar will recognise that that is very close to the start of a new financial year. NHS CEOs will be regularly checking their inboxes for the arrival of the Planning Guidance for the year 2024/5 that begins in a few days’ time.

Just as “performance management” implies a particular kind of activity, ‘planning guidance’ is another interesting use of words.

From its title you would hope something called Planning Guidance 2024/5 might have the aim of offering guidance to the planning of NHS CEOs for the coming year 2024/5.

In this blog I often ask you to roleplay being an NHS trust CEO. (You may even be one?)  So here you are, March 17 2024, yet to receive the NHSE  planning guidance for the year that starts in under 3 weeks. Since you are roleplaying a ‘good’ CEO who is anxious that 2024/5 will be a better year than last, you will have been planning with your trust for the year starting in April since at least last December.

In fact, if you were unusual enough to have waited until the 17 March for the planning guidance to guide you (I may be wrong but that is what you might reasonably expect it to do) you would not really be planning for next year at all.

‘Good’ CEOs haven’t waited to be guided; they’ve already got on with the important work of planning for next year.  So at some stage in the next few days – when the planning guidance is published – they will have to retrofit the messages in the planning guidance to fit in with the planning that they have already done. There will be some pushing and tugging of words to make it fit but since you are a ‘good’ CEO you will have experience of having had to do this before and will know how to do it.

Apparently one of the reasons that the planning guidance is late this year is because the new Secretary of State thinks its goals lack ‘ambition’. But ambition is not really the problem. Ambition was not the problem last year when the Secretary of State’s boss the Prime Minister had the ambition to reduce numbers on waiting lists. That was a really good ambition. The problem was not with the ambition, the problem was with the delivery.  He could have had twice the ambition, and it would have made no difference.

Let’s be clear. If you issue guidance to CEOs with less than 3 weeks to go before implementation is meant to start you are encouraging them to ignore it because,

IT’S TOO LATE TO GUIDE PLANNING THAT HAS ALREADY HAD TO BE DONE!

(I’ll calm down now…)

ISSUE 2. Why does the NHSE phoning your senior staff to tell them off undermine CEOs ability to manage the performance of their trust?

(Returning now to our, now regular, task of exploring how performance management fails to manage performance.)

Hospital CEOs have been asked, in the second week of March, to confirm that their trust will hit an interim four-hour target (with 76% of emergency patients being seen in 4 hours or less). A target that has not been met in any month this year.

CEOs have been sent a form to sign committing them to deliver 76%. There is something touchingly naïve about believing that signing a piece of paper to say you will do something will be so much more motivating that believing it’s a good thing to do. When you don’t hit it, does someone ring you up and say, “But I have a paper signed by you saying that you will”.

What then happens to manage performance?

Time spent on such communication could alternatively been spent engaging with the CEO about the importance of the service for the patients in their location. But the assumption here is that fear will drive improvement more than actual improvement.

CEOs were also asked for the personal emails and phone numbers of their Senior Responsible Officers (SROs) overseeing Emergency Care.

Why ask for the SRO’s phone numbers and emails? Is it because someone at the centre wants to ring up them up and have a sharp word or two with them about the performance of their trust?

Why does this matter?

CEOS are appointed to run the trust. It is their responsibility to organises the trust to deliver its services. In this new arrangement someone at the centre is saying to the CEO you are not responsible for A & E, we are. And furthermore, we will ring up and performance manage the SRO on this issue. Undermining the position of the CEO.

What if, in discussion with the trust SRO, the national officer who has rung them up decides there needs to be more resource spent on A & E and less on say rehabilitation and recovery? Do the national officers start going to every acute trust board to ask for those resources? Do they just deploy them from the centre?

All of these scenarios undermine the position of the CEO to manage their trust. A key part of managing performance.

But of course, what many SROs are saying is that the centre is “asking for our emails so they know where to send the P45s.”

(National officers can’t sack trust SROs, but they can give the impression they can.)

Issue 3. Why does the offer to pay people extra money in the second week of March not incentivise better performance for the whole of the previous year?

NHS England confirmed in March that there would be new financial incentives for trusts to deliver better performance against A & E targets.

(Yes. I know. It is a bit late. But all of this is too late to actually incentivise. And here I want to make another point about failed incentives).

A part of these incentives is that the 10 trusts who deliver the greatest percentage improvement by the end of March 2024 (over January 2024), will each receive £2 million. The next 10 each receiving £1 million.

This is an unusual incentive. Again, roleplaying a ‘good’ CEO you are now planning for next year. Hopefully as a part of your planning you have a month-by-month improvement in A & E performance. This is not easy but you know – unlike all this last-minute panic from on high – that real improvement will need to grow month by month. Over the year, month by month, you can plan for x% improvement.

But then a member of your board points out the error of your ways. Last year’s financial incentive is just to improve from January to March. So, it’s daft to improve at all between April and January. In terms of NHSE financials it’s important to plan to make all your improvements between January and March. So, hold back improvement in the first 9 months and ram it all into the last 3.

Do that and you’ll get £2 million.

So, roleplaying again, how does this incentivise you to behave well?

Issue 4. Given there is some recognition that emergency care is systemic and not an acute trust issue, how does providing financial incentives only to a part incentivise the whole system?

We have all noticed that for much of the last year everyone – including NHSE – has been underlining the way in which most problems in the NHS are systemic and not just in a single trust. A considerable amount of time and effort has been invested in the important idea that problems for hospitals are caused by the flow of patients not just within the hospital, but also when entering and leaving the hospital.

Correctly the idea that 10-15% of beds are filled with patients who would be better off at home has been recognised as causing a problem at the front end of the hospital.

Much time has been spent on improving relationships with social care. NOT because acute trusts have become worried about social care per se – but because if that part of the system fails, so does the trust.

So, if you want to incentivise better A & E performance why not stick to the idea that this is a systemic and not an individual trust problem?

But I can understand NHSE’s problem of who, apart from trusts, is there to incentivise?   If only someone had created an organisational structure that they could incentivise at a system level, they would have been able to incentives those system leaders.

If only.

If only NHSE had persuaded the Government in 2022 to pass legislation creating organisations called Integrated Care Systems that had a responsibility to create better system relationships. If they had they could have incentivized the whole system rather than just a small part of it…

The trouble with current performance management is that it doesn’t manage performance.