Narinder Singh is a Senior Parliamentary Researcher in the House of Commons.
I know Tony Blair was known for his ‘education, education, educatio’n mantra – but it could’ve just as easily been KPIs, KPIs, KPIs if it was slightly more catchy.
KPIs (Key Performance Indicators for normal people) are something I spent the early part of my working life chasing, during my time at the NHS as a Performance Analyst (fancy way of saying I used to look at a lot of spreadsheets).
During this job, under both a Labour and Coalition Government, I saw first-hand how the various KPIs, targets and data could be used for good to help drive improvements and efficiency. But I also saw the bad and unintended consequences they could have, something Sajid Javid is rightly mindful of in his worthwhile quest to add more transparency to the data.
Starting with bad, many will remember the popular Labour pledge for anyone to be able to see their GP within 48 hours. Sounds good, right? Who could argue with that – yes please put that target in place! Except, it was largely smoke and mirrors. The way this target was monitored was that someone from what was then known as a ‘Primary Care Trust’ would phone the surgeries to ascertain their next appointment (not as a mystery shopper) to ask the question.
If the response was that they didn’t have anything within 48 hours, they were gently ‘nudged’ towards indicating that they would see someone. They knew the game; we knew the game. I don’t know at what level the decision was taken to play it, whether it came from the top or was an innovation from one of the many mid-tiers. Either way it was a fabricated exercise to be able to say all practices were offering appointments within 48 hours, Minister – without addressing the underlying issues around access. Fairly certain my old Trust was not alone in fudging this exercise.
Targets often start from a good intention – for example, patients presenting at A&E to be seen within 48 hours. But with the target often comes an unintended consequence, such as hospitals unnecessarily admitting patients instead. This was quite clearly visible in the admissions data before and after that target was introduced in 2004.
Moving on to the current day, GP surgeries have performed heroics to carry out the vaccine rollout and deserve our praise and thanks for this, but sadly it has come at a cost in terms of routine appointments, somewhat inevitably as staff/resource were diverted towards the rollout. Pre-rollout, appointments were rightly restricted and largely virtual, as ill people gathering in a surgery would’ve been a recipe for disaster.
To try and inject more capacity, the Health Secretary announced a £250m funding package – presumably good news to be welcomed by all surgeries? Not quite. Because with this, he’s trying to add some transparency to the data so that patients can see how their practice is performing on this.
Many people are under the illusion that GP surgeries are part of some big-government NHS bloc, they aren’t. They are largely private businesses made up of partners, who are commissioned by the NHS to provide certain services, some of which are part of their ‘core’ contract and others being ‘enhanced services’.
As with any industry or sector, there are some good and some not so good operators. In my Performance Analyst role, I had ‘league tables’ of every surgery in my patch across a measure of indicators, and you could quite easily see which were at the top of most and the common names appearing at the bottom on virtually every measure. If we hide away from the data, we miss the opportunity to analyse, compare and contrast to see where the examples of good practice are and where the bad ones are, that fundamentally aren’t delivering for their patients.
Predictably, GP representative bodies have responded negatively to this proposal – their job is to look out for and represent their members (surgeries).
But the Health Secretary is right to press on. It isn’t a case of naming and shaming, but these comparison tables provide a chance to analysts and commissioners to look at where the issues are, and for patients to vote with their feet if they aren’t happy. Funding follows the patient on a per head basis, so any practice needs to maintain their list if they want to survive.
I started off by highlighting a couple of bad examples of target driven exercises because it’s something we always need to be mindful of. Targets aren’t always good but if the data is used correctly, it can help to drive improvement for patients. This is something we saw at my old Trust where we often ‘buddied’, so a bad practice could learn from a good one.
Only by having the data and league tables in the first place, were we able to do this. We saw improvements in a number of areas, which ultimately benefited the patients. Javid is correct to be injecting £250m into primary care, but doing so with monitoring attached so he and the patients can see how the money is being used to improve access.
While I no longer work for the NHS, my experience was overwhelmingly positive and I worked with some incredible people, both clinical and non-clinical colleagues. Decisions such as the recent one taken by the Health Secretary aren’t going to be popular or win him many friends amongst GPs, but they are necessary if we want to drive improvements that patients deserve.