Hitting the target but missing the point
I will be writing a six-part series on the implications of the Mid Staffordshire Foundation Trust Public Inquiry, the most far-reaching investigation into the NHS since the Bristol Royal Infirmary Inquiry of 2001
In 2009, the Healthcare Commission pointed to three major failings at Mid Staffs: lack of transparency; tolerance of poor standards; and denial of problems, which resulted in an organisation failing to deliver what it is legally required to do. Some clinical areas were found to be grossly under-performing due to a lack of nursing leadership, lack of skilled staff, poor patient management, poor risk assessments and a general failure of governance at board level.
The public inquiry into events at Mid Staffs was launched in 2010 under the chairmanship of Robert Francis QC. What started as an attempt to learn lessons from the experiences of one hospital has expanded to include an analysis of the functioning of the NHS as a whole.
Some have commented that the Mid Staffs disaster was a product of continuous reorganisations, a target-driven culture, a preoccupation with efficiency savings and curbing the power of health professionals so that the quality of patient care became a secondary concern.
While there are advantages to target setting, it also has many shortcomings. Witnesses at the inquiry highlighted the following issues in their evidence:
- A focus on specifics rather than the whole;
- A focus only on that which can be quantitatively measured;
- Quantitative measurement may identify parts of a service that are good but other parts may be performing poorly;
- Creating the belief that achieving minimum standards is sufficient;
- Over-reliance on self-reporting;
- Temptation to “game” - that is making up the results or cheating.
“Hitting the target but missing the point” was a criticism frequently made during the inquiry mostly by nurses and doctors. Reducing the number of qualified staff, increasing the number of untrained personnel, and curtailing educational and training opportunities were targets that helped to cut costs, but these also were instrumental in eroding the culture in which high-quality care can flourish. Professor of safety at Imperial College Charles Vincent stated in his evidence that some healthcare organisations are now so complex that they require more resources to manage than to deliver the services they are supposed to provide. Perhaps we are finding the recent NHS reorganisations were not as well thought out as we imagined or that evidence base of modern management theory is not as robust as politicians believed it to be.
Much evidence to the inquiry by both clinical personnel and NHS civil servants, consisted of how target setting could be improved. Points made included:
- Creating organisations where a caring culture exists;
- Building clinical teams and environments where high-quality care is the main objective;
- Methods of organisational self-assessments need to be far more robust than they currently are;
- Target setting should be a combined effort involving, all professionals, patients and their relatives, commissioners, managers, royal colleges, universities and the local community;
- It should not be a box-ticking exercise carried out by non-clinical personnel;
- Improving services in the future will depend on having good data and using it wisely;
- While targets do have some part to play in improving healthcare in the future, it is quality that will drive lasting change.
Peter Nolan is professor of mental health nursing (emeritus)
Look out for the second article in this series, which will explore the issue of nursing under threat and nurses in turmoil.