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NHS performance management putting standards of care at risk

An obsession with targets in the NHS has encouraged behaviours that inflate achievements and mask problems, a report has warned.

Efforts to improve NHS care standards are being undermined by performance measures that encourage ‘gaming’ and that sap professional motivation, according to ‘Uses and Abuses of Performance Data in Healthcare’, a new report from Dr Foster

While increased access to healthcare data from English hospitals has increased transparency and helped identify serious failings in hospitals, such as the scandal of poor care at Mid Staffordshire NHS Trust, the report argues that an obsession with targets in the NHS is encouraging practices to mask problems.

Issues that the report identifies include ‘tunnel vision’ – excessive focus on only those aspects of clinical performance that are measured – through to ‘gaming’ – the willful manipulation of data to make performance appear better than the reality.

It highlights a number of examples of malpractice, such as two independent audits of NHS waiting lists, in 2003 and 2014, which show clear evidence of gaming of waiting time data, including deliberate misrecording in some trusts.

It also points out the “huge” variations between English NHS hospitals in the prevalence of patients coded as receiving palliative care and a continued drift upwards over time. Since palliative care patients are expected to die, this can make actual recorded deaths in hospital appear lower than expected.

Pressure to meet the four-hour waiting time target for A&E has also seen patients being held in ambulances outside hospitals to delay the ‘clock starting’; rooms and even corridors being designated as acute observation units so that patients can be categorised as having left A&E; and patients being admitted at the four-hour point to avoid breaches of the target.

Dr Foster’s Roger Taylor, the report’s co-author, said: “Good data can spotlight excellent practice and illuminate dark corners where things are going wrong.

“Conversely, measurement, target setting and publication of results can become oppressive, activity can be distorted to produce more acceptable numbers, and arguments about data validity can distract attention from real issues, diverting scarce resources from much-needed improvement.

“The challenge is to use performance data to provide accountability and stimulate improvement, without leading to adverse effects which swamp the intended gains.”

The report makes five key recommendations for tackling the problems it identified:

  • Make data quality as important as hitting targets – By initiating a long term audit programme to tackle misreporting and incomplete or inaccurate data recording.
  • Measure the context not just the indicator – Keeping performance measures under constant review, perhaps by multi-disciplinary specialist groups, including Royal Colleges and patient organisations.
  • Avoid thresholds and consider the potential to incentivise ‘gaming’ in design of metrics – Performance measures should be assessed according to the likelihood they will encourage abuse. Thresholds should be avoided wherever possible.
  • Be more open – Making data underlying performance management widely available and promoting ongoing assessment of the degree to which metrics are being gamed.
  • Apply measures fairly – In order to recognise legitimate mitigating factors such as resources and pressures outside the control of the organisation.

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