Intended for healthcare professionals


Supporting poorly performing NHS hospitals to improve

BMJ 2013; 347 doi: (Published 25 September 2013) Cite this as: BMJ 2013;347:f5830
  1. Chris Ham, chief executive
  1. 1King’s Fund, London W1G 0AN, UK
  1. c.ham{at}

High performing hospitals face obstacles and risks in providing support

Harvard Business School guru Clayton Christensen and his coauthors once famously described hospitals as “some of the most managerially intractable institutions in the annals of capitalism.”1 Recent reports on NHS hospitals in England failing to provide acceptable standards of care underline the simple truth behind this assertion.2 3 With other hospitals also likely to experience problems in delivering care of the right quality as the government’s new inspection regime for hospitals is implemented and financial pressures increase, how can poorly performing hospitals be helped to improve?

Health Secretary Jeremy Hunt’s answer is to ask high performing NHS hospitals to provide support to poorly performing hospitals to enable them to improve the quality and safety of patient care. Support will be provided initially to the 11 NHS trusts with high mortality rates highlighted in the Keogh review as requiring “special measures” to turn around their performance.3 High performing hospitals will work under improvement contracts through which they will be reimbursed for their time and rewarded through an incentive fund if they deliver genuine improvements in performance at the hospitals they support.

Hunt’s initiative is the latest in a long line of efforts by successive governments to tackle the problem of poorly performing NHS hospitals. Previous interventions have included appointing private sector managers to run hospitals for a limited time, franchising the management of challenged hospitals to private sector companies, appointing management consultants to advise on improving performance, and merging hospitals in the hope that this will deliver results. None of these interventions has fulfilled its promise, leading to the search for more effective solutions.4

What then are the chances that partnering high performing hospitals with those in difficulty will be more successful? The answer depends on how this initiative is implemented and whether an approach used in education, where superheads have been appointed to improve the performance of schools, can be adapted to the quite different requirements of the NHS.

Skilful implementation depends first and foremost on allowing sufficient time for hospitals to improve, particularly where their problems are deep seated. It is also essential that enough expertise of the right kind is made available to these hospitals to enable them to identify the causes of unacceptable standards of care and what needs to be done to tackle them. This will probably require support from experienced managerial and clinical leaders in high performing hospitals and a concerted effort to listen to the views of patients. Hospitals placed on special measures will probably be those where staff morale has been adversely affected by concerns about the quality of care, and engaging staff to improve ways of working will be a crucial step on the road to recovery.

One of the challenges of adapting an approach developed in education is that hospitals are much larger and more complex organisations than schools, and simply bringing in a new chief executive is unlikely to deliver the improvements sought. This is graphically illustrated by the experience of some of the 11 trusts in special measures, where chief executives have tried and failed to turn around performance, only to be replaced in short order by new leaders who have met a similar fate. The experience of these trusts underlines the importance of offering support through expert teams that combine the range of skills needed to bring about improvements in care, rather than through heroic leaders, who are almost bound to fail. It also suggests that changes in leadership may be insufficient if the problems facing poorly performing hospitals are caused by the requirement to provide services that are clinically and financially unsustainable.

To make this point is to emphasise the inherent difficulties in supporting poorly performing hospitals to improve, whatever the intervention used. As recent research has underlined, the focus must be on changing the cultures that give rise to poor performance in these hospitals.5 It will also be important to heed the advice of the Berwick report on the need to invest in staff to achieve necessary improvements in care and enable the NHS to become a learning organisation.6 In some cases, it may also be necessary to change how and where services are provided to ensure that the organisations placed in special measures are sustainable. Acting on these insights will not be easy, especially in an organisation that has relied heavily on “targets and terror” to improve performance, and when Jeremy Hunt is emphasising the role of inspection in avoiding a repetition of the tragic events at Mid Staffordshire NHS Foundation Trust.

All of this suggests that partnering faces some substantial obstacles if it is to succeed where previous interventions have failed. Not only this, but there is also a risk that standards in high performing hospitals may fall if their leaders are distracted by the work involved in helping hospitals in difficulty. An unanswered question is whether leaders who have succeeded in one organisation can do the same in another, especially where there is a history of poor performance. From this perspective, the impact of partnering may say as much about the leadership of the hospitals providing support as it says about the leadership of the hospitals receiving it, with obvious reputational risks for supporting hospitals if poorly performing ones do not improve.


Cite this as: BMJ 2013;347:f5830


  • Competing interests: I have read and understood the BMJ policy on declaration of interests and declare the following interests: None.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.


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