Reversing performance in the UK National Health Service: from targets to teams

The UK’s 2010 and 2013 public inquiries into the Mid Staffordshire hospital scandal estimated that between 400 and 1,200 people died unnecessarily in just a four-year period. The inquiries, carried out by Robert Francis QC, identified a range of performance management problems within the National Health Service (NHS) stemming from a widespread preoccupation with nationally set targets, emphasizing an organizing principle of reducing costs rather than delivering quality patient care. The inquiries conclude that there had been a systemic failure at Mid Staffs; including a culture of bullying and secrecy regarding patient care, a focus on achieving externally set targets and budgeting, and low staff morale. This was explained, in part, by the performance culture in place where frontline staff worked within an “endemic culture of bullying” (Francis, 2010: Vol 1. B.38), forced to prioritize targets over patient welfare for fear of victimization and job loss which incentivized short cuts and “unacceptable standards of performance” (Francis, 2013: 111). Virtually no organization emerges from the inquiries with credit except the local campaign set up by the relatives of the victims. The reports provide few concrete recommendations to improve performance despite an emphasis within the Francis report on the urgent need for the NHS to reform its performance management. Although we offer no magic solutions to the structural problems across the organization, our proposal is that an important aspect of reform should be a reorientation away from targets and top-down management toward a model of inter-disciplinary and inter-organizational team working.