Professionals need to be held to account by people whose understanding of data goes deeper than the ability to read a dashboard. Photograph: Kacper Pempel/ReutersEvery political initiative has its bogeymen – the simple caricature that sums up the evil that must be fought. For the architects of the New Labour programme to reform public services, it was the public servant who failed to see that his or her own interests were not the same as the public interest.
A favourite example was the feckless orthopaedic surgeon. His manner with patients was brusque. His attitude to safety was one of bravado. He (and it was definitely a he) regarded bureaucracy as irksome. And he thought his long waiting list was evidence of how much in demand he was.
From the publication of the new NHS plan in 2000, New Labour had an answer. More money would be put into public services. And an intelligent, data led bureaucracy with a democratic mandate would put the provider interest back in its box and champion the interests of patients. Don Berwick's report into patient safety is the obituary for that whole project. It is appropriate to remember the good as well as the bad that came from it. There is no doubt that it was conceived with the interests of the patient in mind. And, it led to significant improvements in standards of care from which many patients have benefited.
However, after reading the reports from Robert Francis into Mid-Staffordshire, from Bruce Keogh into high-mortality hospitals and from Don Berwick into patient safety there can also, no longer, be any doubt as to how corrupting it has been to the ethos of public services.
Part of the problem was the over-emphasis of a narrow range of key metrics – a feature of policy in both health and education. Huge political capital was staked on making certain numbers move in the right direction. A bureaucracy tasked with making this happen, did what it was asked. Increasingly, imaginative ways were devised to fiddle the data or change practices in ways that achieved nothing except to create the appearance of improvement. The metrics and indicators that populated the dashboards were selected on the basis of those that could be managed, rather than those that represented a genuine improvement for patients.
Most devastatingly of all, people began to believe that the performance on a dashboard really was the same thing as delivering high-quality care. The numbers began to count for more than anything else, more than the judgment of skilled professionals or the complaints and distress of patients. In extremis, it led to the suppression or dismissal of any information that seemed to contradict the official numbers.
Equally corrupting was the tendency it bred to treat professionals with mistrust. The response to the orthopaedic surgeon with the long waiting list was an unyielding demand from Whitehall that waiting lists would be shortened. It worked. Much of the NHS waiting list problem was fixed to the benefit of patients. But it also had the effect of removing from clinicians the authority to decide which patient they treated next. It created the fiasco of the manager in the A&E department telling doctors where to direct their attentions on the basis of performance targets rather than the needs of the people in the waiting room.
Don Berwick's report on patient safety in the NHS has been attacked for being "strong on platitudes" and lacking in clear instructions. That is the great strength of his report. He reduces it down to just four principles – focus on quality, listen to patients, be transparent and, most crucially, trust the staff. Instructions from on high are part of the problem, not the solution.
This does not mean that the NHS should row back on the use of measurement. Berwick recognises the central role that information, data and measurement have in understanding quality. But data is a means to understanding not an alternative to it. Professionals need to be held to account on the basis of open and transparent data. But they need to be held to account by people whose understanding of data goes deeper than the ability to read a dashboard.
Trusting professionals does not mean returning to a world in which they are unaccountable. As with all caricatures, the feckless orthopaedic surgeon may have been an oversimplification but it was not a myth. Berwick does not for a second suggest that we should be any less demanding either of our public services or of the people who work in them. The standards we aim for should be higher. But the mechanisms we use to achieve this must be built out of transparency and trust; professional pride and honesty. Not out of directives and targets.
Roger Taylor is director of research and public affairs at Dr Foster
This article is published by Guardian Professional. Join the Healthcare Professionals Network to receive regular emails and exclusive offers.
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