The Healthcare Commission reports on NHS Trust failure

February 04, 2008 1:40 PM

The Healthcare Commission have today released a study (PDF) summarising some of the lessons they've learned from studying failing NHS Trusts.  There are three broad themes that should be of interest to anyone trying to learn policy lessons from the study:


1)  Management weaknesses

"We have found that the boards of NHS trusts we have investigated are particularly vulnerable to being consumed by the business of healthcare, in the form of mergers, reconfiguration of services, financial deficits, and targets.


[...]


Continuity of leadership is important, too. We have found recurring cases of poor leadership in the trusts we have investigated, with frequent changes in senior personnel and a lack of strategic direction, serious financial or capacity concerns and failure to deal with historical problems. In one case, there had been seven chief executives in 10 years, as well as four different trusts under three different health authorities – all creating a lack of continuity and follow-up of management action."

This lack of continuity isn't just a problem for NHS Trusts but also affects the very top of the NHS organisation.  Our report Wasting Lives: A statistical analysis of NHS performance since 1981 (PDF, pg. 31) revealed that there were twelve secretaries of state in the 23 years studied by the report.


Inexperienced and transient managers are distracted by procedural issues - such as mergers and financial deficits - and do not have the expertise and settled organisation that can ensure that these distractions do not harm standards of care.  If an organisation is unstable at the Chief Executive or Secretary of State level then the entire structure will suffer as more junior staff will have to work within the preoccupations of the higher-ups.


2)  How they understand the world


The Healthcare Commission sees the target culture and the poor use of outcome data as two separate problems.  They are actually two sides of the same issue.


NHS organisations are not controlled by the market, and the threat of creative destruction, as they operate as an effective monopoly with a unique access to taxpayer funding.  Instead, they are held to account by simplistic targets.  What that means is that data on performance isn't seen, by NHS Trusts, as a tool to aid decision making - in order to better serve patients - but as a resented source of embarassment, giving politicians and other authorities a stick with which to beat them.  This mindset is encouraged by the way the NHS is organised and makes effective decision making close to impossible.


3)  Poor standards in everyday non-critical care

"Poor care of patients on general wards – the relatively small number of our investigations of acute hospitals has revealed worryingly similar stories of poor care for patients on general wards. Patients who were older or otherwise vulnerable were most at risk, since they were most dependent on good nursing care and not always able to express their needs.


We found examples of patients not being helped with eating or cutting up their food, tablets not being given on time and medication missed, charts not completed properly, and patients being moved from one location to another because of the pressure on beds."

This is again the result of the NHS being monopolistic.  Without the threat of patients leaving and no longer providing their custom there is every incentive for NHS Trusts to cut corners on the little details that make hospital stays bearable but don't show up on the Government targets.  While most doctors, nurses and other hospital staff will still treat patients well out of common decency an incentive to cut corners will lead to substantial numbers of patients not getting the care they should be able to expect.

The Healthcare Commission have today released a study (PDF) summarising some of the lessons they've learned from studying failing NHS Trusts.  There are three broad themes that should be of interest to anyone trying to learn policy lessons from the study:


1)  Management weaknesses

"We have found that the boards of NHS trusts we have investigated are particularly vulnerable to being consumed by the business of healthcare, in the form of mergers, reconfiguration of services, financial deficits, and targets.


[...]


Continuity of leadership is important, too. We have found recurring cases of poor leadership in the trusts we have investigated, with frequent changes in senior personnel and a lack of strategic direction, serious financial or capacity concerns and failure to deal with historical problems. In one case, there had been seven chief executives in 10 years, as well as four different trusts under three different health authorities – all creating a lack of continuity and follow-up of management action."

This lack of continuity isn't just a problem for NHS Trusts but also affects the very top of the NHS organisation.  Our report Wasting Lives: A statistical analysis of NHS performance since 1981 (PDF, pg. 31) revealed that there were twelve secretaries of state in the 23 years studied by the report.


Inexperienced and transient managers are distracted by procedural issues - such as mergers and financial deficits - and do not have the expertise and settled organisation that can ensure that these distractions do not harm standards of care.  If an organisation is unstable at the Chief Executive or Secretary of State level then the entire structure will suffer as more junior staff will have to work within the preoccupations of the higher-ups.


2)  How they understand the world


The Healthcare Commission sees the target culture and the poor use of outcome data as two separate problems.  They are actually two sides of the same issue.


NHS organisations are not controlled by the market, and the threat of creative destruction, as they operate as an effective monopoly with a unique access to taxpayer funding.  Instead, they are held to account by simplistic targets.  What that means is that data on performance isn't seen, by NHS Trusts, as a tool to aid decision making - in order to better serve patients - but as a resented source of embarassment, giving politicians and other authorities a stick with which to beat them.  This mindset is encouraged by the way the NHS is organised and makes effective decision making close to impossible.


3)  Poor standards in everyday non-critical care

"Poor care of patients on general wards – the relatively small number of our investigations of acute hospitals has revealed worryingly similar stories of poor care for patients on general wards. Patients who were older or otherwise vulnerable were most at risk, since they were most dependent on good nursing care and not always able to express their needs.


We found examples of patients not being helped with eating or cutting up their food, tablets not being given on time and medication missed, charts not completed properly, and patients being moved from one location to another because of the pressure on beds."

This is again the result of the NHS being monopolistic.  Without the threat of patients leaving and no longer providing their custom there is every incentive for NHS Trusts to cut corners on the little details that make hospital stays bearable but don't show up on the Government targets.  While most doctors, nurses and other hospital staff will still treat patients well out of common decency an incentive to cut corners will lead to substantial numbers of patients not getting the care they should be able to expect.

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