Fact or Fiction? Declining hospital performance is down to a few ‘bad apples’

Can the recent decline in national average performance be explained by a minority of failing hospitals? Holly Dorning explores.

Blog post

Published: 13/03/2015

This blog is part of a series called ‘Fact or fiction?’, where experts from the Nuffield Trust give their take on the data and evidence behind some of the current perceptions of what is happening with the NHS.

We know national performance in many key NHS hospital targets has been declining for a while – indeed it’s nearly impossible to go a day without hearing about the pressures facing A&E and its ‘four-hour target’. Recently, this apparent deterioration has spread beyond A&E to problems in treatment waiting times.

While we know targets viewed in isolation can be misleading, they remain an important marker of hospital performance and help us to understand how front-line NHS services are holding up. In the past, it’s been reported that poor hospitals are to blame, and ‘a few bad apples’ are bringing down the rest. For example, writing in the Financial Times in 2010, before becoming the Chief Executive of NHS England, Simon Stevens claimed: ”according to the independent regulator [Monitor], a sizable minority of hospitals are clinical or financial basket-cases”.

It’s inherent in our system that hospitals are individually punished for poor performance in some way. Indeed, since the early 2000s, performance management and a financial drive has continued to push for achievements on access targets. But can the recent decline in national average performance be explained by a minority of failing hospitals?

What do we know?

The latest briefing from Nuffield Trust, published today, analyses six key hospital targets (shown in Figure 1). We looked beyond national average performance to try and understand what’s happening at a hospital level. We wondered if performance against targets clustered in certain hospitals – for example if hospitals missing their A&E target were also missing the others such as inpatient treatment.

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A simple way to look for any differences is to use a heat map. Figure 2 shows whether or not hospitals achieved their targets in 2013/14. In this figure, each row of the horseshoe is an access measure and each slice is a hospital, with squares coloured green where a target is met and red where it was missed. Hospitals are ordered by the number of targets met, from left to right.

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Our analysis shows that many hospitals are struggling to meet targets in the same services – A&E and inpatient treatment waiting times – rather than a few hospitals failing to meet all or many hospital targets. Failure to meet, for example, the four-hour A&E target appears to have very little bearing on performance against other measures.

Is it really all down to a few struggling hospitals?

The reasons for changes in national performance are complex and, in the past, certain dips could be attributable to a few hospitals. For example a national dip in inpatient treatment performance at the end of 2011/12 was due in part to three poorly performing hospitals. However, the analysis we’ve conducted suggests this is not always the case. What we actually see is that problems meeting targets are more systemic – especially across A&E and inpatient treatment – and not due to certain hospitals failing across all target indicators.

To address the declining performance and ensure people get the services they need, it’s important to look at why targets are being missed. Finding solutions fit for the problem is key. For example, national pushes to improve hospital cleanliness and reduce healthcare-acquired infections in 2007 lead to huge gains . What we’ve found in today’s briefing suggests that punishing individual hospitals (with fines or other sanctions) would not help: the problems are seen in many areas, making it difficult to attribute these to the hospitals themselves. What we need are national programmes to improve services in key areas – A&E and inpatient treatment times being the clear examples.

Of course, performance against hospital access targets only provides us with part of the picture. The other big story about the long-term sustainability of the NHS is the financial picture. The cracks have been showing in hospital finances for a while, as our previous work suggests. The fact that now almost three quarters of Foundation Trusts – those hospitals we would expect to balance their books – are in deficit , suggests that these systemic problems extend far beyond a few targets and a few hospitals.

Fact or fiction?

It is a fiction that a few ‘bad apples’ are driving declining national performance.

The fact that we see certain targets being missed in a number of hospitals rather than a few hospitals missing many targets is a clear symptom of the system-wide challenges facing the NHS. These include flat finance, a growing and ageing population and increased morbidity. As these challenges intensify, some hospitals will cope better than others. What is certain is that we need system-wide support.

Suggested citation

Dorning H (2015) ‘Fact or Fiction? Declining hospital performance is down to a few "bad apples"’. Nuffield Trust comment, 13 March 2015. https://www.nuffieldtrust.org.uk/news-item/fact-or-fiction-declining-hospital-performance-is-down-to-a-few-bad-apples