Worst 10 Trusts for Management of Access Targets - Disproportionately FTs

It is a well-known secret that targets based on clock-stops promotes inappropriate behaviour.  They motivate Trusts to focus on ensuring that most of the people starting definitive treatment are within 18 weeks, rather than treating patients in referral order (after allowing for clinical urgency).  It is a subtle, but important distinction; and Trusts can get stuck in the trap of managing clock-stops - not their total patient base.

This post names and shames the worst of these Trusts.  And it finds that Foundation Trusts are actually poorer at governing access targets.  So much for the ability of FTs to improve performance and governance.

This inappropriate management does not necessarily happen by strategy.  It can happen by by the natural dynamics of actions in a Trust, without active thought to it.  For example, how many Trusts have breach lists - patients who will breach if not treated imminently?  And how many service managers run around trying to get these patients on a proximate operating list?  The effect of this is not to treat patients in order of referral; but to focus on those patients who are about to breach 18 weeks.  The effect of this is to treat people within 18 weeks disproportionately.

It also happens because of the culture within the system to achieve 18 weeks.  To take this out of context, it is a bit like the treatment of Iraqi prisoners.  The Western Forces had no active strategy to degrade prisoners at Abu Ghraib; but the overall culture and philosophy of the western forces was to demonise and dehumanise the opposition.  In addition, there were subliminal signals from leaders that international humanitarian law was over-zealous.  That slowly results in (to coin a phrase) "institutional torture".  Similary, the culture, targets and performance management within Trusts is on 18 weeks.  Senior management do not focus on the length of the longest waiters (and still waiting), but on the 18 week target - which focuses on those being treated in the month.  The result is "institutional neglect" of long-waiters.

This culture also results in many concrete actions to intensify the problem.  In any management meeting, more time is spent on those specialities and services whose performance is at the threshold - who have marginally breached or a marginal change will lead them to breach.  Central resources, such as analytics, IT, transformation (what is that, by the way?), strategy and - critically - investment, get disproportionately devoted to these areas.  The end result is that those areas with much greater difficulties (e.g., orthopaedics) get ghettoed into the "too difficult" box, and resources are spent negotiating different profiles with commissioners for those.  The overall result is that patients get treated out of referral order (without clinical justification).

So if that is the problem, how do you identify the worst offenders.  This can be done by looking at the discrepancy between the time people being treated have waited, versus the length of time waited by those not being treated.  In general, if you are managing by referral order (disregarding clinical urgency), people being treated should have waited longer than those waiting for treatment.  So if we look at the statistics on referral published by DoH, the percentage of patients treated within 18 weeks should be far lower than the percentage of untreated people within 18 weeks.  So if we are exactly meeting the existing "clock-stop" targets, on average at least 92.5% of all patients (admitted and non-admitted) would have waited less than 18 weeks (this assumes that there are equal admitted and non-admitted pathways - a simplifying assumption).  Therefore, much more than 92.5% of patients waiting for treatment should have waited less than 18 weeks.  But if we find that only 87.5% of patients not yet treated have waited less than 18 weeks, then I conclude that there has been inappropriate management going on.  And I define a new score - which I have called the MM Obstacle Score of -5% (which is 92.5%-87.5%).  In fact, any negative score, and slightly positive scores probably indicates that Trusts are mismanaging access targets.

[I realise that urgency does change this significantly.  I will return to incorporating this factor on a future date. For now, I realise that this is a simplified picture.]

And now to the list of the worst 10 performers.  This is presented at the top of the blog, with their MM Obstacle Scores based on November 2011 statistics.

8 of the worst 10 are actually FTs.  And they are meant to be the ones with a proven ability to govern themselves better.  In fact, if one considers the 180 Trusts who had admissions of more than 5 patients in November 2011, 60% of the worst performers were FTs, whereas only 51% of the best performers were FTs.  FTs are systematically poorer performers than other Trusts in this measure.  And they are meant to be better at self- governance!

Blog Post Updated on Monday 23rd January 2012, 16:00, to include bring out the fact that Foundation Trusts were disproportionately poorer performers.

Full Text of Clare Gerada's letter to Members

You may have read about the letter that Royal College of GPs Chair - Clare Gerada - sent to her membership.  For example, the Guardian titled their piece: NHS reform bill 'threatens its long term survival.'  The Telegraph titles their piece on the letter NHS reforms must be stopped for 'patient safety'.

From this coverage, you may think that this was a rabble rousing letter.  In fact, it is much more "on the fence" affair seeking membership views.  In effect it is a cover letter for a survey.  The full text of the letter is produced below.

Of course, there are ifs and buts.  For example, the wording of the letter is very leading.  And the full results of the survey will not be published; and Clare can mine the data for her agenda.

However, the coverage is excessive, and may further induce strident views from GPs in their response.  All self-fulfilling . . .

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Here is the full text of the letter

Survey on the Health & Social Care Bill

Message from Dr Clare Gerada, RCGP Chair 21 December 2011

Dear RCGP Member,

As you know, the Health and Social Care Bill is in the final stages of its passage through Parliament and this will be the last opportunity for the College to seek your views. This short survey is designed to test out member opinion on recent developments in relation to the Bill and how the College should respond. I feel it is important to share this with all our members in the UK, not only to keep you up to date with the issues, but to gather as many of your views as possible as we prepare to take important decisions for both the College and the future of the NHS.

We have reached a critical moment in the College’s work to take forward our profession’s concerns about the Heath and Social Care Bill. When we look back in years to come, I want there to be no misunderstanding of the position the College has taken or criticism that we did not do enough to inform and engage members or to protect patients and the NHS.

Since September 2010, the College has articulated a consistent position in relation to the Health and Social Care Bill. Although the College has been active in raising GPs’ concerns - submitting a full response to the White Paper consultation last year, engaging with the Future Forum listening exercise over the summer and proposing amendments to the Bill to try and improve it – fundamental concerns remain and the NHS faces an uncertain, potentially very unstable future. We have not to date opposed the Bill outright but have made it very clear (pdf document) that it removes the systems and structures that underpin the NHS in England through:

The removal of the Secretary of State’s legal responsibility for providing a comprehensive health service. Dismantling the system of commissioning responsibility for area based geographically defined populations, replacing it with commissioning based on populations registered with general practices.

The overriding emphasis on competition and any qualified provider, rather than integration and shared working. Introducing new arrangements for postgraduate medical education and training, moving to a system of ‘Local Education and Training Boards’, funded by a levy. This will not be as fair, efficient or effective as the current system and may not safeguard the important role played by deaneries.

As the Bill has progressed through Parliament, further evidence has emerged which has deepened our concerns. The NHS Operating Framework for 2012/13 (pdf document) confirmed that Clinical Commissioning Groups (CCGs) will be asked to function on operating costs of just £25 per head of the population, a substantial reduction on current levels. In the meantime, draft guidance published by the Department of Health (pdf document) has raised concerns that the market for providing ‘commissioning support’ to CCGs will be dominated by a small number of large commercial providers offering end-to-end packages of support, undermining the principle that commissioning should be clinician-led. These developments – combined with the challenge across the NHS in England of finding £20 billion of efficiency savings – are resulting in a greatly altered landscape. If CCGs are given responsibility without power, there is also a risk that public frustration about the need to ‘ration’ health services could unfairly be targeted at GPs.

Repeatedly our surveys and communications with members have revealed that GPs are concerned that the reforms will weaken the effectiveness of the NHS and its long-term survival as a public service covering the whole population. For example, in our most recent snapshot survey of RCGP members in October 2011, 65.3 per cent of respondents expressed disagreement that theGovernment’s reforms would lead to more cost effective delivery of care, and 66.3 per cent disagreed that they would result in better patient care.

From the outset of the Government’s proposed healthcare reforms, we have been clear that:

• We fully support greater clinician involvement in commissioning and planning services for geographically defined area based populations.
• We believe that provider side reforms could deal with many of the issues without the need for repeated organisational change or many of the proposed reforms.
• In particular, we believe improvements could be brought about by models of care such as GP Federations, where practices can pool expertise and resources to deliver broader services to patients close to their homes, working as appropriate with other NHS, third sector and private providers.

Over the longer term, it is also important that we work with politicians and the public to determine what the NHS should be providing, how it should be funded and how, over the next decade we address the big health issues facing our population. It is our view of course that in order to create an NHS that is fit for the future, this must include more GPs spending more time with their patients.

As a profession we must now decide on a way forward which reflects our unique understanding of how these changes will impact on the health system we work in and the patients in our care. Should the College decide to call for the Bill to be withdrawn, there is no guarantee that this will be successful. Nonetheless, it is my view, and that of many others, that stopping the Bill now, placing GPs in the majority on the boards of the PCT Clusters/NCB outposts and focusing on addressing the serious financial crises facing the NHS, is the safest way forward for patients and communities.

It is important to note that as a registered charity the College is, and will always remain, party politically neutral in its stance on the reforms. We have been working with Government Ministers and the Department of Health team to ensure that the voices of GPs and their patients are heard as the implementation of the reforms progresses, and this is something we will continue to do. However, this does not prevent the College taking a professional stance on whether to support or oppose changes that affect us, patients and the NHS so directly.

As doctors, we need to justify our practice by reference to the best available evidence, and the evidence, little that there is, suggests that the changes being introduced through the Bill are not going to bring about the improvements in efficiency, quality or equity the NHS desperately needs.

Your views matter and will help shape this crucial debate. Please take a moment to to complete a short survey on this issue .

Yours sincerely,

Dr Clare Gerada Chair of Council

Why NHS Direct is sitting on one nail

Militant Manager is always puzzled by some things in the National Health Service.  Why do GPs vote for less private sector involvement when they are private contractors themselves?  Why do NHS Trusts work so hard to abide by the EU Working Time Directive, yet allow their consultants to moonlight in the private sector without any restriction on working hours?  Why are there so many bodies who bring out (at times conflicting, and contradictory) guidelines, and rules?  Why would a Secretary of State believe that the optimal method of arriving at the best size of commissioning bodies is by imposing arbitrary management cost allowances?  How can those organisations that rely on concentrated, block contracts ever be judged suitably independent to satisfy the requirements of Foundation Trust status?

It is this last question that I wish to address today.  And it brought into stark relief by NHS Direct which has announced its intention to seek FT status.

Militant Manager knows buy-out and venture capital types (some of them have washed up in Monitor).  Buy-out and venture capital types are good for three things: one is running a good LBO model on Excel (which is not very useful in any other walk of life); two is sitting on boards looking empathetic, but continuously wondering how they are going to explain this to their limited partners and colleagues; and the third is to glean a vague sense of what factors could bring a company down suddenly.

And it is this last thing that is useful in this instance.  One of the things that gets them more excited than a good LBO model, and a board meeting going off plan, is a business with a concentrated customer base.  They know that this will make independence and sustainability difficult.  And given these private equity types have only three useful things to say to the world, we should pay attention to at least one of them.

A business that depends on a very concentrated customer base - and in NHS Direct's case, almost entirely on one customer - is not a business (let alone a self-sustaining one).  It is a hobby like a vintage motorbicycle - entertaining for the owner/ client, but first to be jettisoned in harder times.  Or it is a project - like measuring lichen on Derbyshire hills to understand whether they grow in the sun or shade; whether they grow near roads or near forests.  At the very best, it is an outsourced contract from that key client.  It is most certainly not a client.

The sharper amongst you will be wondering why this does not apply to other project companies like Serco or Capita.  But there is a difference.  Serco and Capita have a large number of contracts; which are not co-terminous and are spread across sectors, clients and geographies.  It is a bit like nails.  If you sit on one nail, it is quite painful and lethal.  But if you sit on a thousand nails, then it is uncomfortable, but not lethal.  Nick Chapman is sitting on one nail.  Tom Riall is sitting on a 1,000.  Whose arse would you rather be?

The even more sharper amongst you will now be wondering why this argument does not apply to Mental Health Trusts, and/ or Community Trusts.  And MM would argue that it does.  But it is a question of degree and judgement.  The four axes to judge on are:

1. The concentration of payors, and their correlation with each other.  NHS Direct has one customer now, but even when 111 is implemented and it gets 10 customers, the customers will be looking to it for the same niche. A niche borne of national initiative.  So if one cancels a contract, it is likely to be because of a change in policy which is replicated elsewhere - so the customers decisions in this regard are very correlated.
2. The avoidability of the fundamental need.  Schizophrenia is not going to go away.  But the need for 111 may well do so.  So Mental Health Trusts are more sustainable than NHS Direct.
3. The distribution of decision making.  Mental Health Trusts get referrals from 100-200 GPs from each PCT - which evidences distributed decision making.  And the PCT commissioning decision is borne of a long history with a number of related parties involved, including social services, police and PCTs.  NHS Direct gets commissioned by some pointy-headed person in the East of England.
4. The independence of price.  In acute care, PbR and tariff are not set by customer and provider.  They are set independently of both, and are a "datum".  This enhances independence.

So when judging the sustainability of organisations, one has to look at these four axes.  So what do I conclude from this:

• NHS Direct is at the extreme of suitability for FT status, and is basically not suitable. Hopefully somebody will listen to me this time.  Not like last time, when nobody listened to me when I said that Europe was not a sustainable single currency area.
• Many Mental Health Trusts and Community Trusts also fail this fundamental test.   Forget about Ambulance Trusts.
• Monitor should start to realise this.  At the moment, Monitor just judges whether the organisation is well controlled and managed at the time of authorisation - but it is possible to manage a hobby or a project well.  The question is whether it is sustainable, and Monitor's assessment (like investment bank risk models in 2007) does not really take into account the full range of eventualities.
• With the concentration of commissioning, acute Trusts are also becoming less sustainable.

The truth, however, is that it is hard for all parties to consider this reality.  They would rather whistle while they sit on a nail.

The similarities between car design and NHS structures

Car companies have a sophisticated strategy for their cars over time.  Their initial authority is over a particular segment.  But over time, they want to play in different segments.  And they do this by slowly invading that space with a model that consumers are familiar with, and taking their authority and consumers with them.  At the same time, they introduce a different model to fill a space customers already trust the marque with.

This can be seen clearly with Volkswagen's hatchback strategy.  So today's Volkswagen Golf (which is in its 6th iteration, i.e. Mk6) is 50% larger than the original Golf Mk1 introduced in 1975.  It is in effect an offering for an entirely different customer segment.

But on average cars do not get bigger.  And that is because as one model migrates away from its entry configuration, the marque introduces a new model to fill the space it leaves behind.  In Volkswagen's case, as its first family hatchback (the Golf) grew in size, it first introduced the Polo and, as that also grew in parallel with the Golf, it introduced the Lupo/ Fox.

The size changes of Volkswagen's hatchbacks since 1975 can be seen in the chart below.  Size in this instance is calculated as the floor area of the car (length x width) in square metres.

Plus ca change, plus c'est la meme chose.  Even though each model gets bigger, the overall market still looks similar.  So you can see that Volkswagen had an offering in the size range of 5.5 to 6.0 sqm from 1975 to today.  And ever since the early 1980s, it has had a model in the size range of 6.0 to 7.0 sqm.  So though things look like they are changing, they are not.  My child has illustrated this paradox with a drawing of her own.  It is meant to show that each column and each row has a car of each size (small, medium and large) even though it all looks different (at least that is what it is meant to show; please cut her some slack, she is only in the 4-6 bracket).

What does this have to do with the NHS.  The similarities are uncanny.  The thing that changes here are the commissioning bodies.  As a proxy for size, Militant Manager has used the number of bodies that cover England.  So if 5 bodies of a certain level cover England, they would cover a much larger population each than if 50 bodies did the same job.

The similarities between the NHS and car design can be shown by the size changes of NHS commissioning bodies since 1990 - as illustrated in the chart below.

This shows that new bodies are introduced at a small size; and over time they grow in size with each restructure.  Over time bodies grow and die; but new ones are introduced.  So 500 PCGs have now made way for 50 PCT Clusters; 100+ Health Authorities will make way for 4 SHA Clusters by 2012.

It's deja vu all over again.  Despite these changes, nothing really changes.  So as you can see there has always been a body at the 300-500 size level since 1997.  And there has also been a regional structure between the Department of Health and this 300-500 level. 

These are incontrovertible facts; but each generation of politicians and officials think they can do something new.  And like those amongst our organisations who feel there is a technical fix to everything; there are those that think there are structural fixes to everything.

I fear that this may all be caused by the management consultants.  Who has not heard of the consultancy who gets called into a decentralised firm, and insists it should be centralised; and goes into a centralised firm, and calls for decentralisation?  This also sounds like the product of a series of structural reviews by consultants - who understand the problems with current situations; but cannot optimise overall; and cannot place their solutions in greater historic context.

But there isn't a structural fix for everything.  Somebody has already thought of it 20 years ago; and we are all tired of structural fixes.  After a series of these changes, we are exactly where we started.  And a lot of effort, time and money has gone into navel gazing.  The NHS structure is not a consumer problem like car design.

So what are the other lessons for the NHS:

1.  NHS structures change too quickly.  If car companies take 6-7 years to introduce a new model because it takes that long for consumers to adapt and factories to settle down and then be retooled; why would you think that organisational structures (which require much greater familiarity and comfort) can be turned on its head every 3-5 years (as seems to be the current average in the NHS).

2.  The NHS introduces too many names.  After any restructure, there is no need to call it different.  So District Health Authorities need not have been called Health Authorities and then Strategic Health Authorities.  The NHS could have built 20 years of brand equity in the simple, all-season name of "Health Authority."  In fact, while we are on the topic of ridiculous arguments, the NHS' names are too boring.  Why cannot SHAs be called the "Kalahari" or "Focus."  We should be more imaginative.

3.  There is no beauty in symmetry.  So though Volkswagen cover the small family segment via three equally spaced hatchbacks, other marques do it differently.  And there is no "Department for Cars" that mandates a symmetrical approach in every company.  Similarly, the NHS should be able to develop its structures differently in different areas.