Don’t shoot the messenger
The Sunday Times has recently run a series on the current
state of the Health Service and the growth in bureaucracy. “Ministers
insist that the NHS is improving, but their focus on targets has led to
a boom in the recruitment of managers and number-crunchers while patient
services suffer.”1
Health Service managers, of course, have always been the butt of
cheap jibes, good for a laugh amongst the groundlings, and an easy
target for politicians concerned only with the next sound bite, and
almost entirely unconcerned with reality. But for all that, the Times
articles reveal some very uncomfortable facts. The NHS Confederation is
about to embark on an analysis of the more than 600 pieces of data that
hospital trusts are required to produce each month: it is said that,
collected together in large boxes, they form a tower over six feet high.
And the Cabinet Office — which presumably was not uninvolved in the
process that these figures describe — is shortly to publish a report on
the value of all this endeavour.
How did all this come about? What happened to Edith Körner’s concept
that the only information to flow to the centre should be that derived
from operational data needed to run the healthcare organisation
concerned? What has prompted this burgeoning of central returns, at a
time when the flavour of the month is to offer greater freedoms to
workers in the field?
The short answer is that this is the inevitable concomitant of
centralisation. This is not the place to argue the merits of
centralisation or decentralisation in the NHS: that discussion has been
going on since 1948, and mirrors the organisational and structural
tension that cannot be avoided in an organisation as large as the NHS.
It is, however, the place to observe that centralisation should have a
purpose, the most obvious being to exercise greater direction and
control, hopefully in pursuit of an established plan. This
administration does indeed have The NHS Plan, and some of the
targets currently imposed on the Service might, directly or indirectly,
be implied from it. The problem about targets, however, is that,
inconveniently, people may ask whether they are being met. At that
point, a decentralising administration will refer questions to
authorities on the ground: a centralising administration will wish to
answer and will therefore need to find out, and — hey presto — another
central return is born. It was the overall effect of this random
approach over the years that informed Edith Körner’s determination to
restrict central requirements to abstractions from live operational data
— and that was at a time when targets (in today’s sense) were few. In
today’s climate, when specific targets are substantially greater in
number, it is not of itself ‘wrong’ to collect data about them: it is,
however, not unreasonable to hope that the results should be accurate
and coherent, and that the effort involved in their collection should
not outweigh their practical value.
Sadly, that cannot be said of the present situation. The existence of
so many targets demonstrates a lack of clarity at the centre about what
really matters, and an absence of management maturity. Whilst those
circumstances persist, demands for data will continue to burgeon, as
will the number of man-hours needed to meet them. The answer lies
entirely in the hands of ministers — it is to them that the complaints
of The Sunday Times, and its stablemate, The Sun, should
be directed.
In this issue, our wide range of topics shows some of the diversity
that is the NHS, and in so doing shows just how necessary is clarity of
purpose for so large an organisation. In his article, Roger Staton, Head
of Social Care Information Policy, Department of Health, describes the
work in progress to foster the integration of healthcare and socialcare,
and the associated integration of service-users’ records. Paul Jenkins,
National Project Manager for NHS Direct, reports on the work of NHS
Direct Online in 2003. Keith Clough and his colleague Ian Jardine
from the Modernising Healthcare Partnership look at the current state
of telemedicine, and in particular what developments have taken place in
the last five years. Finally, and very much in line with the problems of
data collection and analysis upon which this editorial has already
touched, David Tucker, Data Quality Services Manager for the NHSIA Data
and Information Standards Programme, looks at the turning point for data
accreditation.
An issue of the Journal covering a range of topics emphasises
just how complex and varied the delivery of healthcare can be, while
offering an opportunity to look at wider perspectives. Complexity,
however, is no excuse for muddled thinking at the centre: rather, it
demands far greater clarity of purpose. Looking at the large and
unco-ordinated demands for data might be a good place to start.
Michael Fairey
Reference
1. A funny way to run a hospital. The Sunday
Times 2003; 1 June: 12–13. |
