Caroline Oliver

 March 2009


As the hand wringing continues following the Healthcare Commission’s report on its investigation into mortality rates at Mid-Staffordshire NHS Foundation Trust, I want you to remember two things.  First, in healthcare, means targets can kill.  Second, in healthcare, the work of boards really matters.


Dr. John Carver, the theorist behind the Policy Governance approach to board leadership, has distinguished organisational "ends" - the reasons for an organisation’s existence - as the answers to three questions “what benefit, for which people, at what level of cost-efficiency” and "means" as everything else.  In other words, he has distinguished matters of organisational purpose from matters pertaining to the fulfillment of that purpose. 


Seen through this lens, it is clear that many of the NHS national targets are means targets rather than ends targets.  The NHS does not exist for waiting times to be x or y weeks.  The NHS does not exist for patients to be free from hospital acquired infections.  The NHS does not exist in order to be financially sound.  Vital as all these things are, they are not what the NHS is for. 


Contemplating Mid-Staffordshire’s mortality rates, NHS Confederation policy director Nigel Edwards is reported (HSJ 18 March 2009) as noting that the trust scored ''double good'' in the most recent annual health check and commenting ''There may be some interesting questions to be raised about the overall regulatory systems we have''.  I would propose that there is no “may” about it - we need to start raising those questions right now.


Clearly, the problem is not that the NHS lacks external and internal assurance systems – indeed the concern of frontline workers and managers with the burden of managing such systems is well-known.  The main problem I would suggest is rather that current assurance systems are often assuring the wrong things, by which I mean that they are assuring compliance with matters of means rather than ends. 


The results can sometimes be tragic as in the case of Mid-Staffordshire where, according to the Times (18 March 2009), managers were asking doctors to leave seriously ill patients to treat minor ailments instead, and patients were being dumped into wards near A&E, all so that the waiting time target could be met.  Similarly, The Healthcare Commission’s 2006-7 investigation into the death of 90 patients resulting from outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust reported “It took four months to establish an isolation ward exclusively for patients with C. difficile. In our view this was partly because of the pressure on beds and the trust’s desire to meet targets.”  In another example of ends and means confusion, an Observer investigation (17 February, 2008) found that patients were waiting for up to five hours in ambulances because A&E units had refused to admit them until they could guarantee to treat them within the target time limit.


In all of these cases, what had been lost was the trusts’ focus on ends – the reason for their existence.  Which, borrowing from an NHS trust that is implementing the Policy Governance approach, I might summarize as: to have people presenting to the NHS (which people) achieving best possible health outcomes (what benefit) at a sustainable cost (the required level of cost-efficiency).


Safety and quality are two major foci in the NHS world today but we need to recognize that that does not make them ends.  The NHS does not exist so that people are safe.  The NHS is not the Royal Society for the Prevention of Accidents nor the Metropolitan Police Force.  Certainly, the NHS cannot produce the outcomes it does exist for unless people are safe but that is not the same thing as saying that safety is the reason for its existence.  The public do not turn to the NHS to make themselves safe, they turn to the NHS for best possible health outcomes and assume that the system will keep them safe along the way. 


Turning to the concept of quality, it is important to notice that the word quality does not necessarily denote ends or means.  We can have quality ends and we can have quality means.  And focusing on quality means can quite easily result in having us defeat the quality of our ends unless we are really clear which is which and what comes first.


In other words, for the NHS to avoid defeating its purpose, we desperately need to distinguish means from ends in healthcare and to shift our focus from means to ends.  It would be nice to think that this could start from the top.  However, we clearly have a long way to go in the measuring of ends nationally as indicated by the Healthcare Commission’s report on Mid-Staffordshire under the heading “outcomes for patients and mortality rates”. 


I started this article by saying that the second thing I want you to remember is that the work of boards in healthcare really matters.  This is because I believe that the immediate hope for progress in terms of distinguishing ends from means lies with NHS boards who are the only people at local level who have the authority to require an ends focus and to hold themselves and their organisations accountable for the fulfillment of same.   When boards define ends they are defining their organisation’s real bottom line – the criteria against which everything they do should ultimately be judged.  When boards define ends they are providing meaningful leadership.  Yes they need to ensure that everything about the organisation is legal, prudent and ethical, but without ever losing sight of the organisation’s purpose.




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