I was surprised to come across references to the King’s Fund research where they suggested that the new commissioning arrangements for GPs taking over fund holding might be managed using a “balanced scorecard”.
Frankly I was shocked. You see the NHS do not understand the balanced scorecard approach at all. Let me give you some examples. Here is a link to the NHS Institute for Innovation and Improvement and their definition of the balanced scorecard. Yes you have guessed it they are trotting out the 1992 crucifix model of a scorecard which is on page nine of the first book. The one never used by Norton & Kaplan again because it was misleading. They make no reference to strategy maps, the cause and effect relationship and using objectives before measures. All fundamental parts of the Balanced Scorecard approach defined by Norton & Kaplan and obvious to anyone who read beyond page nine. Oh dear. The NHS for Scotland duplicate the same information (which makes you wonder why they bother to have a separate site).
If this example of a “Balanced scorecard” for GPs from Southwark PCT is anything to go by it is clear that what they have is merely a scorecard that collects data across various aspects of the operation of the GP practice. eg Registration,
Opening Hours, 48 Hour Access, Advanced Booking, Telephone Access, Range of Services Available, Qof Achievement, Cytology, Imms 2yr, Imms 5yr, Flu, Smoking, Active Patient, Participation, Group NPS, Overall Satisfaction.
Looking at this list every single item is about the activity (processes) of the GP practice with the possible exception of the last one “Overall satisfaction” which, I would hope, is a measure of what their patients are telling them.
This is clearly not a BALANCED scorecard. There are no financial objectives or measures, only one customer measure (no objectives), (Hardly making it balanced) many process measures (not objectives) and no objectives or measures about the development, growth or capability (Learning and growth) of the GP practice. In summary, this is entirely from the perspective of the GP Practice’s operations. The purpose of a balanced scorecard is to get other perspectives.
What this is is an operational performance scorecard measuring the GPs activity with their patients. Now this is useful as in this case when you simply want to compare GP practice with GP practice. It is useful for an overall activity measurement. It is great for comparing practices. It is poor at driving underlying change in a practice or set of practices. It is also pretty clear from the red/amber/green scores that there are targets imposed on each of these practices for the amount of activity each is undertaking. What is very clear is that there are no connected outcomes for patients. there is only the assumed and hopefully positive consequences of the Cytology, range of services available, Flu and smoking activities.
So, I can imagine someone in the PCT (Primary Care Trust) looking at this data and waving a stick at those GP practices with 2 or 3 red scores.
However the essence of a “Balanced Scorecard” is to drive strategy and change. When we looked at the strategy map for an outpatient service within an NHS we asked
1) What financial outcomes do you want: Lower drug use, less operating cost,
2) What patient outcomes do you want: eg I understand what the consultant explained to me, I don’t need to come back again unnecessarily, I know what I need to do now.
3) What governance demands do you have: eg Statutory reporting on the clinic
4) The processes and activities
5) Learning and growth: What do we have to develop amongst our staff, procedures and ways of working to make the clinic more efficient and better for our patients? What do we need others to do better to help us (eg choose and book, or medical records).
The thing is when you look at the strategy and changes needed in a clinic or a GP practice, rather than merely the operational activity, you get a much richer picture. You set the agenda for change and improvement.
This GP Scorecard is merely an operational scorecard maintained by an external body to oversee activity statistics. It will not drive change except for beating them with a stick. In contrast the GP practices themselves do need an agenda for their change and improvement. So do not call this a balanced scorecard – it is merely an operational scorecard. Doing so might cause them to think they had actually implemented a strategic balanced scorecard that would bring about change when in fact this was still missing.