In one of two voluminous reports on the disaster of the Mid-Staffs Hospital Trust, where between 400 and 1,200 people may have died unnecessarily, Robert Francis QC noted that those giving evidence used the phrase ‘in hindsight’ 378 times.
In hindsight, his reports write the damning epitaph not just of a dysfunctional hospital organisation (Mid-Staffs was ‘the most shocking failure in the history of the NHS’, according to Health Secretary Jeremy Hunt), not just of the national healthcare system , but of the entire public-sector management paradigm.
The first Francis report graphically described the appalling suffering caused by and to individuals under the regime of ‘targets and terror’ in a single organisation.
The second equally mercilessly documents the failure of every one of the plethora of watchdogs, regulators, inspectors and superior management tiers, up to and including the central NHS cadres in Whitehall, to notice what was happening, let alone raise the alarm or do anything to stop it.
The failure was complete, embracing every actor in the drama, from lowliest auxiliary to the minister and top civil servant in charge. To provide the finishing touch to this masterpiece of failure, it is Teflon-plated, not a shred of accountability or responsibility attaching to any of the parties involved.
Unlike politicians and the press, which assume that every management debacle has special causes, mostly in the shape of flawed individuals, no one who has thought even for a minute about the organisation as a system will be surprised by this cascade of failure.
It is built into a system that might have been designed to fail every practical and human test.
As to why, a Scottish TUC research report published last week under the self-explanatory title ‘Performance Management and the New Workplace Tyranny’ handily describes just the cycle of work intensification, cost cutting, task-standardisation and IT-monitoring that (often coupled with outsourcing) decisively broke the link with compassion and care.
This is the morally and economically bankrupt ‘deliverology’ that New Labour built, the public-sector variant of the ideological shareholder-first, externalising travesty that in the private sector presented us with sub-prime, Lehman, and the financial meltdown. Unwittingly emphasizing how closely they are related, David Cameron’s dismal addition to Francis’ 290 recommendations is to propose performance-related pay for clinical staff – the very thing that in the finance sector almost brought the walls of capitalism tumbling down.
Performance management, with its relentless focus on individual targets, is the link between the two. Targets simplify, fragment and pull teams apart, focusing workers (whether clinical or professional, public sector or private) on themselves, bosses and regulators rather than customers or patients. Targets being invariably arbitrary, bearing no relation to the capacity of the system to make them, the only way workers can reliably meet them is by working on the one thing they can control: the numbers. They cheat. As a recent Guardian article noted, ‘"target-based performance management always creates 'gaming' ". Not sometimes. Not frequently. Always’.
This means that the numbers managers receive are wrong. This matters, since as Francis observed, Mid-Staffs managers managed by numbers and abstractions rather than interaction with the front line. Here is one reason why they were blind to what was going on under their noses.
But they are usually the wrong numbers anyway. To serve as a guide to improvement, a measure must be related to purpose from the customer’s point of view – the end-to-end time to let a property, do a repair, diagnose and treat a patient. Most of the measures managers are obsessed with (standard response times, call-handling times, agreed service levels) measure activity, not purpose. So even if the numbers had been correct managers would have still been in the dark: in the blackest of satire, patients died while managers fretted about people meeting irrelevant targets.
Let’s sum up. The NHS is an organisation where staff face in the wrong direction, the numbers are fiddled and the measures irrelevant, and managers spend the vast majority of their time beating up on individuals instead of attending to their real job, seeing to the system.
In this light the only surprise is that there aren't more mistakes; brutally, if lives are saved it is despite, not because of, a system that mass-produces care packages to meet abstract meta-targets – cutting MRSA by half, a four-hour wait in A&E – rather than to respond to individual need. The system simply isn't set up to do care and compassion. But since people experience care as individuals, even when targets are hit patients feel no improvement. Try boasting about success in cutting MRSA to those still infected, for example.
The management of the NHS has itself become a disease. Responding to the Mid-Staffs disaster by piling on more regulation and inspection, setting service standards for compassion, intensifying the performance management regime and threatening criminal charges is like trying to bludgeon a patient back to life. Instead, we need to start at the other end, with the patient, and design an organisation that can respond to patients,' not ministers' or commissioners', needs. Unless and until the NHS sickness is wiped out, there will be more Mid-Staffs (five more hospitals are being investigated) not fewer.