Treasury tells incoming Minister to learn from Mid Staffordshire tragedy

13 November 2014

Treasury highlights the "critical importance" of focusing on patient safety and not just narrow government targets, in its briefing to the new Health Minister.

It tells the Minister in its 41 page briefing notes released yesterday that the Mid Staffordshire NHS scandal* in England provided a "deeply tragic illustration" of what can happen when governance and management fails.  And it also advises new minister Jonathan Coleman to avoid "political expediency" and "short-termism" when deciding how to measure the health system's performance.

"There were multiple drivers behind this (Mid Staffordshire) failure, but one of the key issues highlighted in the public enquiry (Francis Report) was an overly narrow focus on meeting national access targets and achieving financial balance," says the Treasury briefing.

"These goals were given priority at the expense of the quality and safety of care, which ended up causing immense suffering to many patients and their families."

It goes on to say the Francis inquiry highlighted the importance of focusing on quality and safety indicators alongside financial performance and government targets as a "well-rounded performance measurement framework is critical for ensuring good outcomes and patient safety".

The Treasury also points the Minister to the principles set out in former Treasury official and Health Funding Authority head Graham Scott's expert advisory group report earlier this year including: "an important principle to avoid is political expediency or short-termism in systems design, performance measurement, indicators, data gathering and the use of data."

Rheumatic fever and 'waiting time' targets have trade-offs & risks

The current six health targets and 'better public service' results can be "useful" as part of an overall performance framework but are not without risks, warns the Treasury.

"The risk of using narrowly defined targets is that they have unintended consequences in terms of the trade-offs that managers and clinicians need to make to achieve them," says the briefing. "For example, waiting time targets shift focus to patients who have been waiting the longest, rather than those who have the greatest need of treatment."  And it points once again to Mid Staffordshire saying "too much focus on targets leads to failures in care quality and safety".

The rheumatic fever "better public service" result was another example given that may not "provide a particularly reliable indicator of the effectiveness of targeted health interventions" because rheumatic fever cases were few in number.  And the incidence of rheumatic fever hospitalisation had not been reduced.

"There is also a risk that a focus on rheumatic fever alone may divert resources away from more prevalent conditions which share many of the same socio-cultural determinants, including skin infections," says the briefing notes  "We see a case for broadening this result to include other childhood diseases"

It adds that more detailed advice on that suggestion – and the possibility of introducing a new result "targeting reductions in obesity" – would be included as part of Central Agencies wider advice on the Better Public Service result areas.

DHB at risk of favouring hospital over community care

The new quality and safety markers developed by the Health Quality and Safety Commission (reduction in falls and infections) are pointed to as a positive measure.

Also introducing the first stage of the new integrated performance and incentive framework (IPIF) in July is seen as a step in the right direction for measuring and monitoring the performance of primary health care across district health boards (DHBS) and primary health organisations (PHOs). 

But it warns that without a broad range of performance measures there is a risk that the DHBs' dual role as 'owner-operators' of the district hospital as well as funder of primary health care would lead to an "overweighting of resources to secondary care".

Download here: Treasury brief to incoming Minister of Health 2014

Ministry of Health briefing to incoming Minister of Health 2014

*Mid Staffordshire NHS Foundation Trust Public Inquiry chair Robert Francis said the trust’s ignoring of warning signs and putting “corporate self interest and cost control ahead of patients and their safety” lead to “appalling and unnecessary suffering of hundreds of people” including elderly and vulnerable patients left “unwashed, unfed and without fluids”. In his report, released in February, he said there had been a “lack of care, compassion, humanity and leadership” and made 290 recommendations designed to change the culture and ensure patients came first.  The full 2013 Francis Report can be read at:

An analysis of the Francis report by NZNO and its implications for nursing in New Zealand can be read at:



Health Targets and Better Public Services (BPS) results

The six health targets:

  • shorter stays in emergency departments
  • improved access to elective surgery
  • shorter waiting times for cancer treatment 
  • increased infant immunisation
  • better help for smokers to quit
  • more heart and diabetes checks

BPS Result 3: 

  • Increased infant immunisation and
  • reduced incidence of rheumatic fever.