Holding each other in mind – an alternative to targets

The Royal Pharmaceutical Society’s chief scientist Jayne Lawrence gave an interview on the BBC on Wednesday 5^th November arguing that doctors needed ‘binding targets’ to reduce the over-prescription of antibiotics. Despite the fact that everyone knows we are becoming resistant to antibiotics, including and especially doctors, still the amount of antibiotics prescribed has risen rather than fallen both in the UK and across the world. It was unclear from the interview with the BBC journalist exactly how these binding targets would work – and Dr Lawrence was taxed on this very point by the interviewer. What happens when the annual target for prescribing antibiotics has been reached and yet there are more patients who need them? However, one of key her arguments was that targets help GPs keep the issue ‘in mind’.

This is a good example of what has become an accepted response to a general, population-wide problems. It has become taken for granted that the first recourse must be to set a target and preferably to make it binding. So we have the Millennium Development Goals (MDGs) for social development in developing countries, global emissions targets which are binding depending on whether a particular country has signed up to the Kyoto protocols or not, and a variety of targets for the NHS, Education and schools in the UK with more on the way (the Deputy Prime Minister Nick Clegg has just announced forthcoming waiting time targets for mental health patients). These are then backed up by apparatuses for scrutiny and control so that the targets can be enforced and made ‘binding’.

On this blog I have posted a variety of articles here, here and here where I have suggested that setting targets has become axiomatic in organizational contexts as a way of declaring seriousness of intent and sometimes moral purpose; as a way of exercising disciplinary control by ‘naming and shaming’, including and excluding when targets are taken up as cult values; and as an authoritarian theory of motivation (that staff in organizations will not do things unless they are forced to do them and then inspected to make sure that they really have).

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The loneliness of the dying

The Health Ombudsman in the UK, Ann Abraham, recently published a report documenting the ways in which some elderly patients over the age of 65 had been poorly treated in the NHS. These were some of the examples:

• Alzheimer’s sufferer Mrs J, 82, whose husband was denied the chance to be with her when she died at Ealing hospital in west London because he had been “forgotten” in a waiting room.

• Mrs R, a dementia patient, who was not given a bath or shower during 13 weeks at Southampton University Hospitals NHS trust. She was not helped to eat, despite being unable to feed herself, and suffered nine falls, only one of which was recorded in her notes.

• “Feisty and independent” Mrs H, who had lived alone until she was 88, was taken from Heartlands hospital in Birmingham to a care home in Tyneside but, when she arrived, was bruised, soaked in urine, dishevelled, and wearing someone else’s clothes, which were held up with large paper clips.

Abraham’s report prompted much hand-wringing on the part of the Royal College of Nursing,  government ministers and the press. The care services minister Paul Burstow saw the report as further proof that ‘modernisation’ of the NHS was needed, which presumably means the major ‘reforms’ that his own government is proposing. He added that ‘leadership’ was needed in the NHS to ‘drive out poor practice’, and mentioned a forthcoming initiative of the Health Quality Commission NHS regulator to carry out spot checks to identify malnutrition and dignity in older patients. Inspecting older patients for dignity is an interesting proposition.

Surviving in times of cuts

Increased competition, endless tendering for contracts, cuts to service, downsizing, paying people less: these are the things that a group of directors from a not-for-profit organisation supporting vulnerable people in the community  tell me they have endured during the last three or four years. Although contractors, usually local authorities or public health bodies, want greater and greater quality, they pay less and less money for it. This is what ‘efficiency’ in the provision of community-based services has come to mean. An experienced worker supporting many vulnerable people in the community with complex needs might take home £17k a year, and then might need a second job in order to earn enough money to support themselves.

So how had the directors of this particular organisation kept themselves going during the period? What did they think about the way they had been working?

Targets and Inspection

Recent press stories about low standards in some NHS hospitals, where up to 12 hospitals have been judged inadequate by the semi-autonomous body Dr Foster’s, have once again raised questions about targets, inspection and standards. We have been treating similar themes in this blog (see below The Tyranny of Targets and Performance Measures). The discussion has become much more animated in a context where standards of hygiene and care have more than just nominal implications, but can make the difference between life and death for patients. The debate seems to swing between two poles: on the one hand, the argument goes, it is no longer enough to rely on self-assessment, since some of the failing hospitals judged themselves excellent. Therefore the right approach must be more stringent, on-the-spot inspections. This is an argument for adding to the bureaucracy of inspection. The more free-market argument is to encourage the public to vote with their feet, and to stop using hospitals that fail to meet basic standards. As consumers we are encouraged to exercise our right to ‘exit’ the service. Neither approach seems to ask what kinds of work practices allow highly trained professional staff to ignore what must be very obvious to them in terms of low standards. To what extent does the practice of government ‘naming and shaming’ and the anxiety that this evokes in top NHS managers encourage them to prevent staff pointing out the obvious for fear of jeopardising the hospital’s reputation? How possible is it to speak out in hospitals even if what one has to say is unpalatable? Neither inspection nor consumer exit deals with the ethical responsibility of staff in situ, both managers and health professionals to find ways of talking about and dealing with the difficult situations they find themselves in together.

Targets and wholes

The following post is written by Rob Warwick. Rob works in areas of strategic change in the UK’s National Health Service. He is particularly interested in how policy makes its way from Government to the front line. This is currently the area of research for his doctorate with the Complexity Management Centre at the University of Hertfordshire.

There has been much talk in the UK press recently about spending cuts to curb public expenditure as a result of the recent economic downturn.  Politicians talk of 5%, 10% 15% cuts – conveniently rounded numbers.  What is absent is the detail of how this will or could play out.  Whichever government comes to power after the general election is likely to take these rough (but neatly rounded) percentage figures and turn them into targets, budgets, action plans and the like.  It reminded me of a book by Michael Barber called Instruction to Deliver, retelling his account of how he led Tony Blair’s “Delivery Unit” after the 2001 General Election.  A book comes with a new word “Deliverology” and a “Delivery Manual” at the end.  I don’t intend to write a book review here, but I would simply like to point out how little the actual experience of the practitioner (the teacher, nurse, or even the manager) features.  Take for example the then Health Secretary’s (Alan Milburn)  mission: “He was very clear what his task was –  to drive through the reforms, take on the vested interests, bring in private sector providers …and build on … choice … to ensure results were met” (Barber, 2007, p132).  No mention of what was valued by nurses or doctors as practitioners whose job it was to make people better.

The tyranny of targets and performance measures

John Seddon’s book Systems Thinking in the Public Sector is a well-written and powerful reminder of the limitations of targets and performance measures in public services. Targets, he argues oblige managers to pay attention to the wrong things, what politicians require rather than what local service users need and this leads to perverse consequences. Targets prevent staff from dealing with the variety of what they encounter by obliging them to serve inflexible and predetermined rules which have been set by someone else sitting outside the situation that local staff and managers are dealing with. Targets and performance measures arise out of an ideology of control and a pessimistic assessment of public sector staff: that if civil servants are not standing over them with exacting standards then somehow they won’t do their jobs properly. It has resulted in what he describes as an army of bureaucrats whose job it is to specify, inspect and report compliance on targets and measures which are driving public services away from what the public really wants and needs. In these ways this approach has contributed hugely to waste and cost.

He describes the difficulty he has had of getting many of his ideas accepted because setting targets has become axiomatic – to suggest that setting targets is the cause of many of the problems rather than the solution to the problems is to present oneself as being eccentric. Seddon points to the ways in which other ungrounded  idelogical obsessions, that consumer ‘choice’ is the best way to develop services, that IT is always a cheaper option, that the private sector will always deliver a better deal for service users, have come to dominate decision-making and management in the public sector.

Rules, advice and tips II

I have just been reading a chapter on clinical risk assessment in health care by a graduate of the DMan programme, Dr Karen Norman, which is published in the book  Complexity and the experience of managing in public sector organizations, London: Routledge (2005). In it she makes the helpful distinction between systems used as tools at work to help with things like work-flow, or risk assessment, and thinking about an organisation as if it were a system. As director of nursing a number of different hospitals, Karen has worked extensively with medical staff to identify and ameliorate risk to patients from medical mistakes.

So in terms of risk assessment it can be helpful to have a number of steps identified, or clear pieces of advice on how to mitigate risk in a particular area of clinical care. However, these are not enough on their own. She recounts how  clinical practice often improves following an incident when things have gone wrong, only to go awry again some time later when the focus is on something else. What proves important, then, is the quality of relationships between staff which sustain conversations and reflection about practice over time. It demands teams of staff paying attention to and describing how they are taking up these ways of working in their daily practice with others and what happens as a result.

What we really do at work: power, conflict and subversion

I have been working for a while with some health service managers and we have been discussing the Initiativitis that they suffer which is triggered on a daily basis by senior managers, local and national politicians. Some of these are well thought through and follow causally and coherently from the last initiative, others are whimsical, unintelligent or brutal. This leads to rounds of review, organisation and re-organisation. Things never stand still. Sometimes initiatives cut across each other, sometimes it looks as though drastic service reductions are being planned.

So in order to protect patients for whom they feel responsible, and colleagues whom they are managing, this group of managers I am working with try to take up each initiative, and as they do so find they are involved in acts of political lobbying and engagement, even subversion. One might make the case that they would not be doing their jobs properly if they weren’t. They get engaged in discussions about how this or that particular service ‘improvement’ might be carried out in practice, and they begin to steer it this way and that, according to their ability to influence the managers with whom they are engaged. Their ability to influence their manager will depend a lot on the way their manager manages them. So those who have shouting bullies as managers who demand that things are done their way, pronto, there is very little wiggle room. In these cases difference might only come about through defiance or lying. With more open, democratic managers there is usually greater possibility of compromise, of hybrid outcomes which can keep the spirit of what is intended at the same time respecting the integrity of what exists already.

As peer managers they discuss together what might be best to try and achieve, but these discussions are often hidden from the more public fora in which the explicit struggle is taking place. Equally, those provoking the initiative are themselves engaged in formal and informal discussions about what they intend, what they are prepared to say publically about what they intend, and how they will dress these ideas up for more public consumption. What actually transpires will be an interweaving of all these different intentions, with the more powerful having a greater effect on the outcome than the less powerful. Equally, there will be unintended consequences, both unwanted and unexpected, for which no single group will be responsible . Their are public transcripts about what is happening alongside multiple hidden transcripts.

On what basis is it ethical to engage in acts of subversion at work? What any group of managers brings to the service that they manage is a grounded understanding of what they are responsible for, which will have arisen out of their practice over time. They will usually understand their domain of service much better than the managers who manage them: what they might lack, however, is an understanding of the broader, more abstract thinking that is behind the wider organisational initiative. So by negotiating with peer managers about what would be best to try and preserve as well as change in their particular area of operation at the same time as negotiating with more senior managers about the broader implications of what is being proposed, managers are trying to make wider organisational generalisations, abstract propositions, more particular. And in doing so they can make the difference between a poor or a better implemented initiative. Their group of peers will exercise a discipline on the discussion about what they might and might not strive for. Together they try to work out how to engage, and the quality of this discussion will be critical for informing how managers then engage with the broader political process of change.

One might make the case that in order better to bring about better grounded organisational initiatives one should actively encourage political engagement and acts of subversion. This is an idea which would run counter to the dominant way of understanding politics in organisations which would suggest that politics and conflict should be ‘managed’. Perhaps managers would have a formal and informal job descriptions. The informal job description might read as follows: X manager is required to find ways of quietly or even actively subverting the worst excesses of senior management and government initiatives so that patients and colleagues can be protected from ill-thought out policies. In order to do so the manager will engage intensely in political processes within the organisation in order to find allies to work with, and will talk through with peers how best to work in difficult circumstances. In doing so they will recognise the need to change some practices as well as the need to preserve others, continuity and change arising in paradoxical relation at the same time.

Being scientific

Previously I described how I am working with a group of health professionals who are undertaking a research project to investigate inter-professional working. We have established that it is important to base our research on the day to day experiences of field workers, and the researchers, acting as learning set convenors, will help to intensify and bring out that experience in the learning sets. But if they come together as convenors after the learning sets to discuss their experience of convening, won’t this reflective processs then subsequently be taken back into the learning sets and contaminate the research data? If we were being scientific shouldn’t we, as researchers, be detached from the research we are undertaking so that the data, and field workers, speak for themselves? How can we reconcile this process of being active in the research at the same time as trying to be scientific?

If we were taking a strict view of what it means to be scientific perhaps we would be striving to be as detached and uninvolved as possible. So if we were looking for invariant properties of what we are observing as a way of producing valid  data which would be replicable elsewhere, we would try to have as little influence on what is happening as possible. But how possible would that be when we are encouraging practitioners to interpret what it is that they are involved with, and to intensify that interpretation with others? Intervening or not intervening in the process would have an effect on the outcome of the discussion in the learning sets. To this degree the learning set convenors are both researchers and particpants in the research at the same time.

The neo-Kantian philosopher Jurgen Habermas wrestled with the same set of problems and describes how interpretive social science methods inevitably compromise the idea of objectivity. By participating in interpretation of what is happening, Habermas argues, we automatically give  up the privileged position of the superior observer by becoming engaged in communicative exchange. The offering of an interpretation invites a counter-interpretation: we are obliged to give an account to one another of what we think is happening. And all of this can only be done within the particular context which we are discussing: it will be dependent upon this particular experience that we are having together.It can never be context independent.

Habermas’ ideal was to aspire to a power equivalence between engaged discussants so that each had an equal opportunity to be heard and understood. Less idealistically, one might take the view that such equivalence will never arise, since some people will always be more powerful than others, so we will never know whether a shared interpretation is fully shared.

The process of interpretation produces a different kind of knowledge to that of conventionally understood scientific knowledge, which is presumed to be value and context independent. Interpretive knowledge is leavened by the power relations that arise between engaged participants, and is intended to generate a shared world of significance. It may produce interpretations of what has been going on in this context between these particular people and may have value as a powerful example of a more generalised social phenomenon. Whether it is applicable elsewhere will be subject to further rounds of interpretation and power relations that will render the explanations useful or not.

So what interpretive social science methods have in common with a more orthodox understanding of science is that they can open themselves up to further rounds accountability: like conventional science, interpretative social science is still obliged to justify itself. There is a continuous dialectic of accounting and reaccounting for what one has learned and how one has learned it. However, there is never any pretence that those offering the interpretation somehow stand outside the process they are interpreting. They may be more or less skilful at offering an interpretation of what is happening, but they can make no claims to being ‘objective’. Although they might pay attention to how they are influencing the group, indeed this might itself become a subject of interpretation, they are unlikely to be able to give a full account of the way in which this is happening.

So, to reconsider the role of convenors of learning sets , would it be more helpful to think of them not as objective researchers but as co-participants in research, who have a particular responsiblity to support participation and interpretative conversation, and a particular responsibility to pay attention to how they themselves are affecting  interpretation. They are both researchers and objects of research at the same time.

Group processes and power relations

In a previous post I wrote about how the conventional way of thinking about meetings separates out task from process. Instead I offered an alternative way of understanding the patterning of human interaction, suggesting no separation between task and process. The way we choose to work together will directly affect what we achieve. There is nothing separate from what we are engaged in called ‘process’ that is other than what we are doing here and now.

Recently I was consulting with a group of health professionals on a project which is set up to research and develop inter-professional working. One idea that we’ve had, as a group of researchers, is to convene four learning groups of professionals already working in the community to meet once a month to reflect upon their experience of working daily with other professionals. We meet with the volunteer convenors of these learning groups as a way of exploring how they might work with the participants in the groups and how we might work with them. Since we’ve called them to a meeting we have a responsibility to explain what our thinking is so far, but beyond that our intention is to negotiate with them what they think they might be doing.

An interesting thing happens right at the beginning of the meeting, even before we get into this discussion, as one volunteer convenor tells us that she thinks that when they start working properly with their learning groups convenors should do  introductions with participants and then establish some group rules. As researchers we respond immediately to this suggestion realising that although we have been chatting in a friendly way before this meeting started we haven’t introduced ourselves in a more formal way in recognition of the task that we are undertaking together. After the introductions we researchers draw attention to this intervention  and it becomes an object of attention and discussion, and a good example of what it is that we think is central to the method we are proposing. Because one way of understanding what the volunteer convenor did was to challenge the existing power relations between us as researchers  who had called the meeting and the volunteer convenors, who had come mostly expecting to be told how to work. Perhaps one thing that she was implying with her intervention was that we weren’t running the meeting very well!

With this intervention we have already begun negotiating together and are exploring, in the here and now, what it means to work inter-professionally. This may feel like a direct challenge to role and identity: we might have felt, as convenors of this particular meeting, that it was our job to ‘keep in control’ and to steer the group towards what we thought should be happening. In most learning situations that is exactly what happens between the person designated as teacher and those designated as learners. And in some learning environments it may be appropriate always to try and direct. Interestingly, because of people’s expectations of what happens in these kinds of learning environments, it is often those designated as learners who are as likely as the teacher to try and keep the power dynamics as they have come to expect them. It is often very destabilising for learners to be encouraged to take responsibility for their own learning.

In our current situation we are more open to negotiate the way forward because we are about to work with professionals whose daily experience is to work with others, and we want to encourage them to articulate and explore this. We are joining conversations which are already going on.

However, our suspicion is that working relationships only change when we start to pay attention to the relationships of power that arise between us. And it is not as though anything goes even in this group. Although we gave way on this issue as it arose, we might not have given way on others. When groups of professionals come together to discuss their working relations they have to feel relatively safe in doing so. The purpose of the group is reflection on practice, it is not a therapy group, although it may also prove therapeutic for some. But being able to discuss what we are doing and to question the way of doing it enables participants in this group to experience what it is we intend in a way which no amount of grids, frameworks and powerpoint presentations would have been able to convey. We are already paying attention to the patterning of our engagement with each other as it emerges.