I was first appointed to an NHS board 25 years ago. I’ve seen pressures come and go and I’ve worked at times of real development and opportunity for patients. I can say objectively therefore that NHS performance pressures are at their greatest in my working life.
Despite hard work at the provider frontline which I see on my many visits, all four key secondary care targets covering emergency care, elective surgery, cancer and ambulance response times were missed last year, for the first time ever. This year, the elective surgery waiting list has grown to more than four million and, despite the priority given to emergency care, performance is stubbornly flat. Although there’s been good progress on reducing agency spend and stabilising provider finances, the sector will also record a financial deficit for the fifth year in a row.
The reasons for this are well known: rapidly rising demand, the longest and deepest financial squeeze in NHS history and a series of growing workforce problems. These sit alongside major challenges in primary and social care. The consistent failure, at both national and trust level, to meet NHS constitutional performance standards and balance the financial books, despite best efforts, brings a sharp focus to the question of how accountability works in this context.
The consistent failure, at both national and trust level, to meet NHS constitutional performance standards and balance the financial books, despite best efforts, brings a sharp focus to the question of how accountability works in this context.Chair
Seven years ago the assumption was that an average, well run, acute trust should be able to meet all its targets and generate a 5% financial surplus to reinvest in maintaining buildings, innovation, and developing new treatments and pathways. That was the test at the core of the initial foundation trust application process. The deteriorating strategic context means there is not a single acute trust in the country consistently meeting these criteria today. The same general position applies to mental health, community and ambulance trusts.
I strongly agree that NHS trust boards must be held to account for delivery, including an appropriate degree of performance stretch. But in the current environment, where the entire provider sector has been forced into deficit and is unable to meet its targets, the difference between 'reasonable stretch' and 'impossible to deliver' has become increasingly blurred.
The difference between “reasonable stretch” and “impossible to deliver” has become increasingly blurred.Chair
There is a simple but important truism: if a few trusts miss their targets when all others are meeting theirs, it’s likely to be a local trust or local system problem. Trusts can be held to account. But when every trust is consistently missing their targets, as is now the case, it’s clearly a national system level problem. How does accountability work then? Invent some new targets? Set an arbitrary new level below which performance should not fall? Shouldn’t national system leaders also have an accountability to design a system where trusts have a reasonable chance of success in delivering what is asked of them?
I see a harder edge to provider accountability, increasingly focused on individual provider leaders. The reality is that trust boards and leaders need to be fully supported to deliver in this increasingly challenging and difficult environment. Removal of senior leaders should always be the last resort.
A difficult job to do
Provider chief executive roles, in particular, are hard to do and difficult to fill. Despite the success of the aspiring chief executive programme NHS Providers has created with NHS Improvement and the NHS Leadership Academy, we shouldn’t kid ourselves that there is a long queue of willing and able replacements waiting to fill any provider chief executive gaps that emerge.
There is a particular issue around chief executives in the most challenged trusts – the places where a chief executive is most likely to be removed at the “request” of the centre. The NHS has a poor record of unreasonable impatience here. These trusts usually have long seated, intractable, problems – often of geography, workforce gaps and system weakness. For example, failure to meet the A&E target in these trusts can often be as much due to system level failure – in social care or general practice – as individual provider failure.
We shouldn’t kid ourselves that there is a long queue of willing and able replacements waiting to fill any provider CEO gaps that emerge.Chair
Chief executives in these trusts have been on a merry-go-round, with most lasting less than a year. It cannot make sense for trusts to have seven chief executives in six years or four chief executives in three years – two examples we have encountered at NHS Providers. That way lies continued failure.
Jim Mackey and Ed Smith at NHS Improvement helpfully slowed the merry-go-round. The success of Lesley Dwyer at Medway, Jackie Daniel at Morecambe Bay and Claire Panniker at Basildon showed that when we give the right chief executives time and air cover they will succeed. But there is a growing risk that, as NHS Improvement’s leadership changes, the merry-go-round speeds up once more.
Some will want to read this as the providers’ trade union arguing that poor performing chief executives should not be held to account. It isn’t. Normal distribution alone suggests that, in a class of 230, some will inevitably struggle, particularly as the chief executive role becomes more difficult. It is the task of local boards and system leaders to reach an evidence based, rounded, judgement on where a new chief executive is needed and to then effect the required change with respect and dignity.
That is very different from removing chief executives to encourage performance stretch in pursuit of an over ambitious goal in one performance area. We’ve been here before and it didn’t work then and it won’t work now. We gave up this approach last time precisely because it didn’t work.
So what’s the answer?
All roads lead to a mature, evidence based, two way, discussion between NHS system leaders and local leaders on what is genuinely deliverable in the current context, with performance expectations set accordingly. That should include a sensible performance stretch. This requires system leaders to accept the reality of the current context.
The forthcoming Budget provides an excellent opportunity to have this discussion. The government will determine how the extra NHS funds promised in the manifesto (and hopefully more) will be profiled over the parliament and what they expect in return. It is essential the NHS can deliver whatever is promised, and that we’re clear on what the priorities really are.
There is little point in setting trusts an impossible task and then removing their senior leaders when they inevitably fall short.Chair
Trust leaders will stretch every sinew to deliver NHS standards and balance their books – they always have and will continue to do so. But they’re not magicians – they can’t deliver the impossible. There is little point in setting trusts an impossible task and then removing their senior leaders when they inevitably fall short.
This article was first published by the HSJ on 26 September 2017