The NHS: balancing control and judgement in a climate of uncertainty

Delivering healthcare involves risk. Doctors, nurses and hospital managers have to make many judgement calls on a daily basis. But these judgements can be unpredictable due to the complexity of the patients they treat, and the health systems they operate in. This unpredictability makes it hard to standardise practice across all departments – and this variation can result in performance challenges.

So what should hospital managers do? On the one hand, greater standardisation should drive more consistent and predictable results. On the other hand, medical staff are highly educated professionals whose discretionary judgement is a key component of their job. Furthermore, it is through the continued exercise of this discretion that individuals learn, and that the practice of healthcare evolves and improves.

The obvious answer is, it depends. Clearly some standardisation is needed, but also some discretion is required. But how do we know where the line is? Whilst there is no simple answer to this, our experience across Trusts and other sectors tells us that there are a few principles we believe can help inform where to draw the line.

Be honest about your performance

Control and specifications are generally used as a performance management tool to handle under-performance. If departments are not performing, then an honest conversation is needed about the need for greater control.

Manage causes not symptoms

Hospitals face numerous pressures from regulators, commissioners, politicians and other providers. It’s really easy for the list of must do items to reach the hundreds. However, at the heart of this, sits a common root cause. Furthermore, that root cause may often be behavioural. Rather than controlling symptoms, the focus should be on the behaviours that drive those symptoms. The irony is that this involves fewer controls – rather than managing a list of a hundred must dos, the focus is on targeting key behaviours instead.

For example, at one Trust recently placed in special measures, the Care Quality Commission (CQC) found multiple specific incidents of medicine cabinets being unlocked, secure doors left open and emergency resuscitation equipment being absent or not properly stored. The list of individual, specific incidents ran to several dozen. However, the root cause was a single behaviour – namely individuals personally accepting poor standards because they didn’t see it as their job to fix. 

Share experiences

Hospitals are complex and there is no one-size-fits-all solution for improvement. So instead of seeking a single formula or model to apply uniformly, teams need to be given the space to both try what works for them in tackling these root causes, and also to discuss this with others. By developing pockets of expertise and learning how to share across them, hospitals can use the natural enquiring minds that many healthcare professionals have to their benefit. Indeed, a review of CQC reports for hospitals in special measures, shows that even in these organisations there are often individual pockets of excellence. Encouraging these departments to share what has worked for them and supporting others in trying this, may be more successful than mandating a long list of must dos.

Find the balance

Finding a balance between control and judgement should be a priority for any Trust leadership team. Applying the principles of an honest, informed focus on root causes with individuals sharing their experiences can help to find where that line sits. 

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