How fiddling the figures can lead to chaos

With a budget of £100bn, the NHS is one of the largest organisations in the world. It employs 1.3 million people in 59 specialties and makes contact with one million patients every 36 hours. An operation on such a scale is bound to make mistakes at least occasionally; the problem at Mid Staffordshire Hospital was that so many were made over such a long period of time without anyone apparently noticing. This is deeply concerning given the known fact that the medical profession has thrown up more serial killers than all other healthcare professions put together. Nursing comes a close second.

At the foundation of the NHS in 1948, it was understood that the needs of clinical staff would be met regardless of cost. Having countenanced what was effectively a blank cheque, it is not surprising the cost of running the service quickly exceeded original estimates. During the late 1960s and early 1970s, a series of public inquiries into learning disability, psychiatric and elderly care hospitals - frequently referred to as the “Cinderella services” - provided damning evidence that giving unlimited resources to staff and depending on their ability to self-regulate and oversee the provision of high-quality service were taking the NHS up a blind alley.

“A focus on targets rendered hospital managers more powerful than health professionals”

In the 1980s, before the Blair government introduced its target system in England at the start of the new century, incentives were brought in to try to improve performance. Governance by targets rests on the assumption that targets are effective in changing individuals’ and organisations’ behaviour in a positive direction. In the NHS, a focus on targets rendered hospital managers more powerful than health professionals and, although England was the first country in the world to define quality of care and to recognise the notion of “harm” with respect to care delivery, some staff were nonetheless encouraged to gather data merely to meet targets. It seems that “gaming” or “cheating” in order to meet targets and thus escape financial penalties became widespread.

Four types of gamers have been identified; the success of governance by targets rests on there being more service providers who fall into the first two groups than into the third and fourth. The first of these, the “saints” voluntarily disclose weaknesses in the system to central authorities; “honest triers” share the goals of central controllers and, although they do not draw attention to their failures, equally they do not attempt to fiddle data in order to meet targets. When we get to the “reactive gamers” who broadly share the goals of central controllers but cheat if given the opportunity to do so, a target-driven culture starts to fail. With the fourth category of “rational maniacs” who have the sole aim of manipulating data in order to conceal what is actually going on, the system falls into chaos and is perilously close to allowing an organisation to fall into disrepute.

Sir Liam Donaldson, former medical director at the Department of Health, told the Mid Staffordshire Foundation Trust Public Inquiry that nothing erodes the trust of healthcare staff as much as knowing that general managers are utilising data for ends other than the improvement of patient care. He asked that doctors and nurses be the guardians of good practice and constantly be intolerant of poor practice. So alarming have the consequences of gaming been that, in future, organisational self-assessment will provide only one stream of data for regulators. More weight will be given to data derived from direct observations and patient experiences.

Peter Nolan is professor of mental health nursing (emeritus)

Look out for part 4 on how nurse education has divided opinion

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