A three-pronged attack

How will the new Government move away from top-down performance management in the NHS?

By Anna Dixon

Andrew Lansley is expected to set out his ambitions for the NHS in a White Paper to be published shortly. As the new Secretary of State for Health, he will outline the medium to long-term strategy for the health service as well as a series of structural changes that the Government wants to introduce by April 2012 - the earliest implementation date, given legislative requirements.

Earlier this month, the Department of Health published a revision to the NHS Operating Framework 2010/11, which sets out changes to key priorities for the year ahead. While limited in his ability to change what the NHS is expected to deliver in-year, it does put flesh on the bones of Mr Lansley’s earlier speeches, including the pre-election promise to scrap politically motivated targets that have no clinical justification. The framework tells us that the NHS should be “moving towards a health service that puts patients at the heart of decision-making, that focuses on quality and outcomes not processes and with more devolved responsibilities”.

Press reports heralded the abolition of waiting time targets of 18 weeks for A&E, access to GPs and referrals to treatment. But closer reading shows that targets for cancer and A&E patients have been retained, with only a small reduction of the four-hour A&E target threshold from 98 to 95 per cent. While the Department of Health will cease to centrally manage the 18-week “referral to treatment” target (the time it takes from a referral to treatment and a flagship Labour commitment), patients still have a legal right, established by the NHS Constitution, to be seen by a consultant within 18 weeks of referral. The onus is now on patients to enforce their rights.

The revisions mark the end of the “targets and terror” regime under which the Department of Health closely managed hospitals’ performance with serious consequences for chief executives. So what will drive health service providers to ensure patients get prompt access to care and maintain high standards of care?

In the absence of targets there appear to be three main mechanisms that the Government believes will ensure standards are maintained (ensuring waiting times do not rise) and other aspects of quality are improved: patient choice, more information, and greater power to GPs.

Will it work? Can informed patients, supported by GPs, drive quality improvements in the health service? Recently published research from the King’s Fund, Picker Institute, RAND Europe and Office of Health Economics on the implementation and impact of patient choice on providers provides some clues.

Patient choice

Patients are now legally entitled to a choice of provider when they are referred for elective treatment in hospital by their GP. About half (49 per cent) that we asked said that they were given a choice over where they were referred. Waiting time was ranked as the 7th most important factor, behind ones relating to quality of care, cleanliness and personal experience of the clinic. With the abolition of the centrally managed 18-week target, greater variation in waiting times may emerge and some hospitals may begin to compete to see patients sooner. This might result in waiting times becoming more important as a factor when choosing a hospital. However, in hypothetical choices, patients do not seem to value ever lower waiting times; beyond a certain time limit this no longer weighs heavily in their decision about where to go.

When offered a choice, many patients continue to attend their local hospital. However, we found that some were prepared to travel further, particularly those who had had a bad experience at their local hospital. This suggests providers will need to focus on experience of care, paying close attention to patients’ feedback and complaints, if they are to maintain the loyalty of local patients and the public.

Publishing information

Patients predominantly rely on their own personal experience, that of family or friends, or a recommendation from their GP. While information is important if patients are to make an informed choice, our research shows few use published performance information to help them to choose a hospital. In fact, only 4 per cent consulted the NHS Choices website and only 7 per cent had heard about the performance of local hospitals in published reports.

This is not grounds to delay publishing comparative performance information in a clear and accessible way. Other research shows that the publication of information itself has an impact on providers’ performance. By making information transparent it motivates “benchmark competition” with hospitals aiming to be top of the league table (or at least to avoid being bottom).

There is also more to do to make the information relevant and useful. Patients want information to be up-to-date and to know about the individual hospital, or consultant, where they will be treated, rather than only having access to information on “trusts” (which may include a number of hospital sites).

GPs

The Government is hoping to empower clinicians, in particular GPs, by devolving budgets and commissioning responsibilities. GPs will be expected to involve patients in decisions about their care and treatment as well as where they are referred.

We asked GPs about their experience of offering choice. They felt that consultations were too short to talk through the options in any detail and consequently offered choice tokenistically, generally assuming that most patients would want to attend their local hospital. Most admitted they would not offer choice if financial incentives were dropped. There is a real danger that GPs will not be active in supporting patient choice or helping patients make sense of the available information about the quality of providers.

The hospitals we spoke to recognised that GPs have a huge influence over where patients are referred; they saw GPs, not patients, as their main “customer”. Many monitored data on referral patterns and some had active “marketing” strategies aimed at GPs. In contrast, very few were directly marketing their services to patients.

The new coalition government has signalled its intention to move away from a top-down performance management to a system in which patients, information and GPs drive improvements. At the time of our research, staff running hospitals were focused on meeting the 18-week waiting time target, GPs were reluctantly offering choice and patients were making limited use of information. Consequently, patient choice was not having a significant direct impact on their services. Yet the fact that local patients had a choice to go to another hospital and that performance information was in the public domain were important to keep hospitals focused on their reputation, the need to improve and the experience of patients. While there is a danger that removing performance management will result in a rise in waiting times, it might also leave hospitals free to pay more attention to the other drivers of performance.

28 June 2010

Anna Dixon. Director of Policy, King's Fund