David Oliver: Stop naming and blaming hospitals for whole system problems

In advance of the chancellor’s financial statement, the UK press has trailed the government’s intention to protect NHS funding while pushing the health service to improve its performance and efficiency.1

This is nothing new for the Treasury, and both the previous and current health secretaries have pointedly highlighted major performance variations between acute hospitals. One figure doing several rounds of news recently is that just 15 of England’s 135 acute non-specialist hospital trusts account for 40% of ambulance handover delays outside emergency departments, with one large NHS trust experiencing one in 20.23

There’s also nothing new in highlighting variations in data on activity and outcomes. We’ve had national databases on variation for several years—such as the NHS atlas of variation,4 focusing on local level data, and the Getting it Right First Time (GIRFT) programme, which is more concerned with hospital services.5 A range of national clinical audits also show variations in processes and outcomes between trusts.6 The question is, having described and highlighted the variation, what do we then do to understand and improve it?

What I’m seeing at the moment from politicians and mainstream media offers more heat than light. Naming, shaming, and blaming the “poor performers” or “outliers” won’t help the staff working there, or the patients using their services—but it makes politicians appear to be taking tough action, holding the NHS to account for its use of public money, and acting as patients’ champions.

The Care Quality Commission has often compounded this by rating and inspecting individual hospitals as though they’re autonomous islands, not affected by their local context. But they very much are. I don’t doubt that there’s always more an individual hospital trust can do on leadership, workforce, morale, internal systems, and priorities—so their senior managers and clinical leaders don’t get a free pass. However, let’s think about those wider local contexts in which they operate, which give them very limited control over demand for care and put serious constraints on its supply.

Those factors include a local population’s growth, age structure, deprivation, inequalities, ethnicity, nationality, first language, education, housing and employment status, and help seeking behaviour, as well as proximity and access to the nearest acute hospital.

They include the funding of local government services, public health teams, alcohol and addiction support, and social care; the capacity and workforce in ambulance trusts, local social care, care homes, and primary and community health services; and alternative types of emergency care centre outside major departments—all of which are hugely variable around the country, with many gaps. They also include the proximity and behaviour of neighbouring acute trusts in urban areas, or a hospital’s status as a standalone provider many miles from the nearest alternative healthcare centre.

And they include the ability to recruit staff from the local community, against competing sectors, or to attract clinical staff from other regions or from overseas. Housing, rental costs, and transport links all play a part. Coastal communities7 with lots of retirees or seasonal holidaymakers, as well as rural hospitals with geographically large, low density catchment areas and long travel times, face particular challenges, as do hospitals in medium sized towns close to bigger conurbations with teaching hospitals.8 Progressive major reductions in general and acute hospital beds over the past three decades, with newbuild hospitals often smaller than those they replaced, also mean major variations in bed capacity between localities.9

None of these wider explanatory variables directly mirrors local needs and demands for healthcare. And it should come as no surprise that some acute hospital trusts have been on the “underperforming” or regulatory radar for decades despite numerous reviews, reports, special measures, and changes at board level. If these things weren’t easy to fix when the going was better, they won’t be fixable in the current context.

So, instead of naming and blaming hospitals for factors beyond their gift, let’s consider what would help us understand the reasons and allow them to improve, in terms of targeted resources and support. And let’s accept that this is a whole system and population problem. Soundbites and slogans won’t fix it.