This case study comprises a sample of six selected trust in London. There are four “low” performing (zero or one star) and “two high” (three star) hospital Trusts. In each case study I spoke to a number of staff at the Trusts and documentary analysis (e. g. CHI reports and internal clinical governance report). It should be noted that my analysis is based on the perceptions and subjective experience of individuals. Given the highly sensitive nature of the material I have sought to protect the anonymity of individuals and their organisations.
Quotes are attributed only and as much as is necessary for their interpretation while still protecting anonymity. There was a general view across the trusts that the performance star ratings as presently constituted did not represent a true performance of the organisation. In particular, staff in the “low” performing Trusts felt that many areas of excellent practice within their organisation, especially those relating to clinical practice, were either valued or missed completely by the ratings.
Several staff said that if these dimensions of performance were taken into account then their organisation would not have received such a low star rating. Staff across most of the Trusts reported a number of examples of where their organisation had used a number of “ruses” to improve their measured performance. These included cancelling operations on the evening before the operation is scheduled to take place, so that these cancellations are not recorded on the actual day, or re-classifying trolleys as beds on recording forms.
Indeed some staff at Trust D were of the opinion that their performance rating was to a large extent due to the accuracy of their reporting which may have placed their organisation at a disadvantage when compared to trusts that had not been as “truthful” in their data collection and reporting. Some staff, particularly those in the “low” performing Trusts reported that the performance ratings (and CHI visits) had been welcomed because they had “thrown a spotlight” on dysfunctional senior management team behaviour that had remained hidden, or unchallenged.
In addition, the two “high” performing organisations reported that their three-starred status had a very positive affect on the morale of their staff. “We cancel operations the night before so they are not recorded as cancellations on the same day. So there are many ways of getting around these things which usually are not in the patients best interests”. (Trust A) in addition to driving beneficial change, the performance ratings were also sometimes reported to have inadvertently induced a range of unintended and dysfunctional consequences for organisations and staff.
These included distortion of clinical priorities and bullying and intimidation Distortions to clinical priorities Many clinicians reported that their clinical priorities had been altered to meet short-term waiting targets. For example, in Trust F it was reported that the thirteen-week target for Children’s services had forced the Trust to concentrate on children referred to it by doctors rather than other professionals, even though the clinical needs of the patients may be very similar.
“I manage women’s and children’s services and apart from our contribution to the electives we don’t really impact on the star system. So as a result it seems that, a lot of the time, what we do as a directorate is not important to the management”. (Trust D) Bullying, intimidation, stress and anxiety The pressures to meet the performance targets wee reported to have led to the bullying, intimidation and harassment of staff in some of the apparently under-performing Trusts.
In Trust B for example there was a strong feeling that the emphasis on delivering measurable improvements in performance in order to 2turnaround” the organisation had contributed to a “culture of bullying” in which staff were “shouted and screamed at” and were threatened with the prospect that “heads would roll and desks would be cleared” if the national performance targets were not met.
In addition, I heard reports that in the “high” performing Trusts the desire to retain their star status was creating a demanding climate for staff which could sometimes extend to discomforting levels of pressure and coercion. For example in Trust E it was reported that the very high performance expectations placed on staff was generating a very heavy workload and in some case causing excessive stress and anxiety among staff.
In Trusts, which were “high” performing, there was a strong directional leadership from the Chief Executive and the Senior Management team setting out clear objectives for the staff in the trusts. In contrast, in the “low” performing organisations, all had a new senior management team inputted in the last two years including the Chief Executives. In the “high” performing trusts, meetings were held regularly within the senior management team on how to meet the targets of the performance ratings.
This again was in contrast with the “low” performing trusts where senior management did not meet regularly and where staff working at these trusts were not fully aware of the star ratings and what impact it had on their trust. High performing trusts were characterised as having an approach with working with their Strategic Health Authority and maintaining a strong relationship with them, whereas the low performing trusts had a poor relationship with their Strategic health Authority and hardly had meetings concerning performance star ratings.
From my information, which I gathered from the Trusts, I believe that there is a general pattern for Trusts, which have a high star rating, and for Trusts, which have a low star rating. Managerial competence is essential in all trusts to gain a high star rating as staff are aware of all the information of targets and work towards meeting their targets to achieve a high star rating. Trusts, which have low star ratings, are mainly due to the poor management team and leadership from that trust.