Make the mind shift to unlock hospital performance

Performance management in the NHS is not working. It is time to abandon the assurance management mindset and trust hospital leaders. The industry must look at system performance and take a new attitude to risk.

Hospitals are under pressure

The health sector is struggling. It is responding to increasingly complex needs from an ageing population with constrained social care spending, inflexible infrastructure and pressures on capacity. The impact is felt most heavily in hospitals.

The management challenge in hospitals is significant. Politicians, regulators and commissioners have sought assurance from hospitals through detailed reporting on financials, operational performance and quality improvement plans. This has resulted in a ‘performance management’ culture, focused on managing down risk and controlling the likelihood of any failures in hospital. This is understandable, but it isn’t working because performance is not improving.

A positive response requires collaboration

Proponents of performance management argue that the problems would be even worse without a strict focus on holding hospital leaders to detailed action plans.

This may be true if the problems facing hospitals were the product of their own internal management and controls. The reality is that hospitals are the focal point for these system failures. Factors driving down hospital performance include:

  • the absence of accessible GP appointments
  • risk averse referral behaviours that send patients to hospital ‘just in case’
  • care bed shortages and insufficient care packages causing the long-term ill to remain in hospital or be frequently readmitted
  • the need to cancel operations due to these external pressures creating backlogs.
“Hospital leaders cannot simply performance manage their own organisation to success, so trying to performance manage them is doomed to failure.”

All of these factors combine to place Trusts under significant pressure and responding to these challenges needs leaders to influence across organisations and work collectively with primary, community and social care providers to develop collective solutions. Hospital leaders cannot simply performance manage their own organisation to success, so trying to performance manage them is doomed to failure.

Why performance management is not working

First, hospital leaders do not directly control their performance. Performance is a product of the way healthcare is organised in a system. It is not a simply product of their own failings.

Second, the leadership style that is needed is an influence model that encourages leaders to look upwards and outwards to the end-to-end impact on the patient. Performance managing (or ‘blaming’) the individual who is feeling the pain of system failure in their A&E department does nothing to encourage the system to fix these issues.

Third, individuals need to be empowered to solve problems and motivated to do so. By dictating solutions, plans and detailed trajectories top-down, politicians, regulators and commissioners take ownership of the answer. This causes hospital leaders to not own the problem and consequently they do not own the solutions.

Fourth, fixing these issues requires a different risk mindset. It requires moving away from detailed plans that forecast (incorrectly) daily performance trajectories. Instead risks need to be taken to see what works best in helping the system improve.

How to achieve trust

Fundamentally Trusts need to be trusted to do their job and given the space and freedom to own the challenges they face. This can be done in three key ways.

  • System performance, not individual performance: hold systems to account, rather than individuals who are merely feeling the symptoms of wider system failure.
  • New attitudes to risk: accept that there is risk in managing the care for a diverse, ageing complex population across multiple organisations, and tolerate that daily performance will not always be delivered as new solutions are attempted.
  • Abandoning the assurance management mindset: recognise that the role of performance management and assurance is very limited as the constraints and challenges it creates often outweigh the benefits, especially when managing complex problems across organisations.

Make the mind shift

Only when stakeholders are working together and trusting each other to put the focus back on patient care can hospital performance have a chance to recover.


Nick leads our health team at Gate One. He is passionate about working on the things that matter most in delivering improved, sustainable care to patients. He has worked with numerous providers and regulators to help rebalance programmes in favour of empowering teams to deliver lasting benefit and improved quality.