Category Archives: health care

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 5th 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). Continue reading

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. Continue reading

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? Continue reading

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. Continue reading

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. Continue reading

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. Risk

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. Continue reading