Writing in HSJ, Trust Chair and HCSA President Matthew Swindells argues NHS managers must be held accountable for efficiency and quality, but transparency, fair funding allocations, and a balanced performance regime are also key to driving improvement
Wes Streeting has said “senior NHS leaders will be denied pay rises if key improvements are not made” and “persistently failing managers [will] be sacked”.
I agree NHS leaders need to own the reality that some systems and providers are doing a better job for patients with the same or fewer resources per head than others. A reduction in unwarranted variation is an important step on the path to an affordable NHS.
But, if managers are to be held accountable, then we need to return to the transparency of financial and clinical performance that was lost during covid. We also need to move away from the simplicity of punishment beatings for missing targets and budgets.
Managers aren’t accountable for the NHS’s budget. The sum is decided by Number 10 and the Treasury, and the allocation by NHS England in conjunction with the Department of Health and Social Care. But, they are accountable for living within it.
The nature and effectiveness of care is decided by integrated care boards and providers - by the former’s pathways and systems management, and by the latter’s productivity.
The quality of care is (overwhelmingly) determined by the processes and practices put in place by managers and clinicians.
Financial allocations to systems It is understandable that ICB financial allocations were thrown out of alignment during covid. However, one of the guiding principles of the NHS funding model is that populations will be allocated their fair share of the pot. If that is not the case, it is hard to argue that a like-for-like assessment can be made of systems’, organisations’ or managers’ performance.
In 2023-24, the most “over-funded” ICB was Surrey, which received 8.1 per cent more than the funding formula would normally have allocated. The furthest below was Birmingham at -3.2 per cent.
An understanding of the relative funding levels of systems seems important when holding managers to account and deciding where to intervene.
Efficiency and effectiveness of providers The provider efficiency calculation for acute, community, and mental health services, now known as the National Cost Collection Index, has just been published for 2023-24.
There is lots of debate about the robustness of the calculation, but it’s the only one we have. If the formula needs to be improved, that’s on NHSE, and if the data doesn’t show a provider in as good a light as they’d like, then they need to sort their submission out.
Across the acute sector, the NCCI index ranges from 131 to 72. If you look at ICB level, including community and mental health services, the range is 113 to 83. So some systems are spending almost a third more per intervention than other systems. Managers should be held to account for that.
We also have summary hospital mortality indicator rates - whilst hospital mortality is not a perfect measure of care quality, as Nigel Hawkes said in his 2013 review, HSMR consistently provide “a signal” that something is “seriously wrong”.
NHSE publishes SHMI data for every acute trust each month. While the majority of hospitals are within the expected range, 11 hospitals are significantly worse than expected (up to 30 per cent more deaths than expected) and 11 are significantly better (up to 30 per cent fewer deaths than expected). This seems like something the Care Quality Commission ought to care about.
Date: 20 January