Recently
there is an increasing concern about mortality and morbidity in the
NHS. Let us for simplicity say that people are asking whether the
death rates and complication rates can be reduced. People are asking
if there are any avoidable components in relation to deaths and
complications and whether those avoidable problems can be eliminated
or at least reduced to minimum. People are also want to know who is
responsible or accountable for ensuring lower death and complication
rates.
NHS Directors
NHS
trusts are in the business of delivering healthcare to their
populations – that is the essential purpose of their existence. So
it may be reasonable to assume that the directors, who are the top
bosses of these trusts and their bosses (SHA equivalent, NHS England directors) will be assessed and rewarded against clinical
quality parameters of which deaths and complications are core.
Apparently
not. The contract for the managers especially when it comes to pay
uplifts and bonuses are very specific. I quote:
''It
is an essential criterion of the performance bonus scheme that the
organisation achieves its financial control target as agreed with its
grand parent organisation (see paragraphs 64 and 65 below).
Where
an organisation fails to do this, all its very senior managers will
be treated as Category D performers and so no awards (either annual
uplift or performance bonus payment) will be paid to them
The
annual uplift will be applied to the basic pay being paid to the post
holder (which would include any long-term RRP payment), provided
that:
the
organisation achieves its financial control target; and
the
individual concerned is judged as performing at Category A, B or C.
Those
in Categories A, B and C will receive this annual uplift to their
basic pay, which will be pensionable
Those
in Categories A and B will receive, in addition to the annual uplift,
a non-consolidated bonus payment, provided the essential criterion is
met –
i.e.
that the organisation achieves its financial control target. Bonus
payments will be non-pensionable, non-consolidated one-off payments
So it
is seems the only officially contracted criteria to be eligible for a
pay uplift and bonus is meeting the financial target (and something
woolly about being classed as A, B or C. In any case if you don't
meet the financial target it is an automatic D which means no pay
uplift or bonus irrespective of how much quality is improved and
mortality/morbidity is low
What
do you think might be happening in a manager's mind when priority
setting? Which director will be prepared to have a very low mortality
and morbidity and yet be classed as a failure and given a D. If ever
a CEO was prepared to do that what do you think that their
directors's mind would think given the fact that various director's
pay are set as a percentage of their CEO's pay. What does it tell Jo
public when the Finance Director's pay is linked to and set at 75% of the CEO pay
and all other directors get a lesser percentage? One lovely chain where there is clear financial incentive to reach financial targets and ensure the CEO gets a higher pay. I am sure my understanding is not perfect but it looks like a conflict of interest built into a contract - you could not make it up if you were writing fiction. Where do you think
the emphasis will lie? No guess work – it is explicit – financial
control target it is and nothing else.
Now do
I think for a minute that any CEO or director gets to work and says
'kill patients but save money', heck no. But we have all heard about
subliminals, motivation, contractual obligations playing a part in
how we perform. It does not sound sweet.
REGULATORS
We
then have regulators to oversee that trust bosses who are
contractually only obliged to serve the financial agenda are still
meeting some sort of standards that matter to a publicly funded
healthcare system – i.e. clinical quality with death and
complications at its core.
Lets
look at some of the regulators purposes:
Monitor:
Our main duty is to protect and promote the interests of patients. We
do this by promoting the provision of health care services which is
effective, efficient and economic, and maintains or improves the
quality of services.
CQC:
We
make sure hospitals, care homes, dental and GP surgeries, and all
other care services in England provide people with safe, effective,
compassionate and high-quality care, and we encourage them to make
improvements.
GMC:
Our purpose is to protect, promote and maintain the health and safety
of the public by ensuring proper standards in the practice of
medicine.
But
let us look at how it actually works out
CQC
The
CQC talks about safety and quality but when you look into what they
actually say there is no specific mention that organisations will be assessed
against their death and/or complication rates
For
God's sake how else do you assess care quality if you do not start
with death and complications.
MONITOR
It is
the government's aim to provide independence to NHS trusts by
allowing them foundation trust status. Clinical quality especially
reducing mortality and morbidity is not a criteria for affording
independence (though there is assessment on whether the trust is
governed properly)
With
10 out the 14 trusts under Keogh review being Foundation trusts, it
is reasonable to wonder what actually the question 'well governed'
means for Monitor.
BOSS'
BOSS – The Grandparent Organisation is DoH
It
looks like the department of health may have the overall
responsibility for mortality and morbidity reduction though those are
not explicitly spelt out in their website
It has
taken nearly a decade and half after HSMR was introduced that DoH is
making some moves to look into this. Perhaps better late than never.
But as the grandparent organisation DoH is responsible for setting
the contractual framework like it is in the first place.
What
about doctors and nurses?
Doctors
Doctors
bonuses in the form of CEAs are based on quality of service and
hopefully given to excellence. There is no requirement to demonstrate
reduction of mortality or morbidity but the hope is that those two
essential measures of quality will be considered explicitly when
these awards are made. That is sometimes the case, sometimes that is
not the case. In theory it is possible for even the highest award
holders to hold the awards without ever demonstrating a decrease in
mortality or morbidity.
Then
of course there is the GMC who will come down on doctors who are
caught out mainly due to significant single incidents which are reported. More recently the GMC due to its revalidation format
demands 'quality improvement' though does not explicitly demand
reduction of deaths and complications.
Nurses
Agenda
for change does not speak explicitly about improving clinical quality
or reducing mortality/morbidity.
So who is responsible for deaths and complications in the NHS?
It is
everyone's job but no one is required to do it and nobody is
responsible or accountable for it.
It
does not say in anyone's job description or contractual terms that
'it is your contractual duty to seek and achieve a reduction in
mortality and morbidity of your patients and when it is not achieved
to provide a reasonable explanation of why they have not been
achieved and what you will do to achieve them'. Nobody's pay scale is
linked to a reduction of mortality and morbidity. Therefore no one is
responsible or accountable for deaths and complications. People do it
as an optional extra, as a gesture of goodwill, from the goodness of
their hearts, as a side effect of their day jobs. There are so many organisations all claiming to be working for patients' protection, quality and so on but all they do is announce diktats on what others should do; they do not hold themselves accountable on behalf of or as representatives of their members by measured reductions in avoidable deaths or complications. It is always everybody's job, somebody else's job, each one of us wants to hold somebody else to account but never us.
That
is why it is so very impossible to deal with and so very difficult to
get meaningful sustainable improvements. The contractual
requirements, recognition and reward structures are all wrong in the
sense they are not geared to look for quality improvement. Looks like
this is a case where the structure and process results in just the
expected poor outcome.
There
are solutions – it is to use healthcare management methods to
manage healthcare and not to use as we do now - business, financial,
manufacturing, service industry or other management methods for
healthcare. Whether there is enough interest, knowledge or expertise
to do so is highly questionable.
Further Info: I am informed by an NHS FT Board Director that the NHS Board director's contract that is referred to in this blog does not apply to NHS FT Chief Exec or Board Directors.
It will be interesting to find out who it applies to.
Hemadri
15 August 2013
