Can targets rebuild our NHS? An open letter to the Cabinet Secretary for Health and Social Care

June 8, 2021

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by Sarah Davidson, CEO, Carnegie UK Trust

Tuesday 8th June 2021

Dear Cabinet Secretary

Can targets rebuild our NHS?

On behalf of the Carnegie UK Trust, I offer you our warm congratulations on your appointment as Cabinet Secretary for Health and Social Care. As you yourself have already acknowledged, this is a moment of immense importance for these public services, when decisions taken in the short-term will shape the culture and pattern of health and care provision in Scotland for many years to come.

Most immediately, now that the election is settled, the business of rebuilding the NHS will begin at pace.

There are big choices to be made: which buildings and services to invest in; what technology to deploy; how to support staff through yet another change process. And critically, how will we know if these course-adjustments have the intended effect?

The culture of management in the NHS for a generation has been to focus on input and process targets: things like waiting times, sound financial management, and interventions that are singled out as being particularly important to the health of the nation, such as alcohol brief interventions and smoking cessation.

Many of these targets were deprioritised during the pandemic as the system pivoted to do whatever was necessary to respond to Covid. However, during an election period in which the NHS was rightly a key focus of debate, we noticed commentators and politicians of all parties placing a growing emphasis on tackling backlogs and ‘getting back to normal’.

Of course, there needs to be a plan to see and treat those whose care has been put on hold, especially where life-threatening or debilitating conditions are concerned. But before automatically reintroducing the plethora of previous performance management targets, we also need an open and inclusive conversation about what really matters in our health service – and indeed what is possible for a workforce that is still recovering from the physical and emotional impact of the pandemic.

For too long, input and process measures have exerted more power over public debate on health services, than have outcomes for people and the wellbeing of staff.

We know that there are challenges here. Reducing targets may be seen as retrograde by lobby groups who fight hard for them. But there are also costs in our current system: the cost of time; the effect of stifling innovation; and the underlying message of mistrust in professional judgment that is communicated to NHS staff.

If we return to a system in which healthcare delivery is guided too closely by narrow performance management measures, there is a very real risk of hitting the target but missing the point. How is it that before the pandemic we were able to meet so many targets, and yet make no impact on healthy life expectancy? Moreover, unless we build in space for our NHS staff to recover from the exhaustion, trauma and moral injury that has been experienced over the last 15 months, we risk inflicting further harm on the mental health and wellbeing of those who have given so much during the pandemic.

At the end of 2020, the Carnegie UK Trust published The courage to be kind, which drew on a series of reflective conversations with a group of medics involved in the healthcare response to COVID-19. Alongside a range of insights about what was changing in practice, these conversations also highlighted the critical importance of creating time and space to listen to people’s experiences.

Right now, in amongst all the many choices you face, there is a choice to listen. It is clear that what was happening before was not delivering the very best outcomes for patients or staff. By reducing the relentless focus on the metrics of performance management, we hope that space can emerge for a kinder culture within health services, which will in turn lead to better outcomes for patients and for staff.

The response we received to The courage to be kind indicated that this is a conversation which many people want to participate in, and to have their voices heard. We are therefore publishing this as an open letter as a blog on our website as a way of continuing the dialogue. We would also welcome an opportunity to discuss any of the issues raised here and in the afore-mentioned report directly with you.

Best wishes

Sarah Davidson

CEO Carnegie UK Trust