Each public service has its 'hot spots': high-profile areas, where important front-line services attract great public and media interest once problems appear. Examples include children's services in social care; asylum in the Home Office; and special educational needs in education.
Problems in these service areas - be they seasonal or ongoing - are not only reputationally risky for both providers and commissioners; they can adversely affect the lives of service users.
The NHS has its fair share of such areas. Over the past three years, the Department of Health's targeted support team has been able to achieve significant successes in two of these areas: healthcare-associated infections such as MRSA, and critical care – the high-dependency units of hospitals, where the most seriously ill are treated by high ratios per patient of highly-trained staff.
In 2004, the NHS was set a target to more than halve rates of MRSA (a bloodstream infection often caused by contamination of wounds, catheters and intravenous lines), using that year's rates as a baseline.
MRSA infection rates were halved in 2008, and the latest figures (covering July-September 2009) show a 36% reduction in MRSA infections compared to the same quarter in 2008. This is also a 76% reduction against the 2003-04 baseline.
A study of a project (which started in 2000) to transform critical care, published last month in the British Medical Journal, found that, "In the six years after 2000, the risk of unit mortality adjusted for case mix fell by 11.3% and hospital mortality by 13.4% compared with the steady state in the three preceding years".
It also found that these changes were cost-effective, involving "annual expenditure on critical care increasing in real terms from £700m (1999-2000) to £1bn (2005-6)".
To put these sums in context, the NHS budget grew from around £47bn in 1999-2000 to over £80bn in 2005-6.
The BMJ study concluded that "the government's considerable additional expenditure on critical care since 2000, combined with the modernisation of NHS services led by clinicians and managers, has greatly improved the survival chances of patients".
Not just policy priority
Both healthcare-associated infections (HCAIs) and critical care were of course given policy priority. This is an important first step to make these service areas into management 'must-dos'.
Success is, of course, about much more than one first step. The key lessons in both areas have been that engaging frontline staff in measuring the problems and developing and owning the solutions locally, rather than feeling that they are imposed 'from above'.
Another key element in engaging front-line practitioners is providing a clear basis in evidence for the changes. Professionals respond much more positively and strongly to evidence that an initiative can be effective than they will to a management diktat. Put another way, the incentive to follow good professional practice holds more appeal than preventing the boss getting a dressing-down, a warning – or their P45.
Ginny Edwards head of improvement support for the HCAI and Cleanliness Division, Department of Health, emphasises that key aspects to the success with infection control were ongoing measurement and monitoring; leadership at the local organisational level; and attitudinal change around patient safety, making it "everyone's issue".
Diligence matters
Edwards explains that beating HCAIs isn't easy, "but it isn't rocket science. Diligence matters – it's about doing things 100% right 100% of the time".
Locally, she adds, the key is leadership. "Trusts who succeed found that they had to make HCAIs a chief executive, management and leadership issue. And there are leaders at every level, on every ward and in every cleaning team."
"And keeping on doing it systematically, week-in and week-out, and maintaining the effort after you see a drop in infection numbers."
Effective performance management involves feedback, Edwards stresses: "not just telling people what to do. Firstly, it's giving them opportunities to improve, but making clear that if they don't manage that, then it will become about managing their performance".
Trusts had to put in balanced scorecards for boards and key performance indicators at ward levels, which were repeated frequently. Edwards notes that data time-lag cannot be countenanced: "you can't do an audit that you have to send to the clinical effectiveness unit who you don't hear back from for six months."
Renewing the connection between the board-level management and the frontline care deliverers of organisations was also crucial, she adds. "The story of the successful reduction in HCAIs is the story of building effective and regular assurance links from ward to board."
Andy Cowper is the editor of Health Policy Insight
