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 →
I found myself among a group of school governors talking about targets. Every year in the UK school governors have a statutory obligation to set targets for levels of examination passes for pupils taking GCSE examinations at 16. The governors cannot set a target below last year’s – it must be the same or higher, even if the cohort on the point of taking their examinations is deemed to be weaker.
So should we set the target in line with what the statistical predictor (a figure derived from past performance) indicates is realistic, or should we set something more ambitious than that? Additionally, there might be other areas of teaching where we might set targets for ourselves even though we are not obliged to do so. This would look good during the next inspection, that we as a group of governors are prepared invent more ways of holding ourselves to account and scrutiny.
Just as annual setting of targets is something of a ritual, so too is the debate that follows. Continue reading →
The British Conservative party has shown a lot of interest in the work of behavioural economists Richard Thaler and Cass Sunstein. In their book Nudge the authors argue that the choices people make are often influenced by unseen biases which cause them to choose less than optimally. For a variety of different reasons, because they are incapable of thinking for the longer term, because they are impelled by emotion, because they are lazy, people don’t always do what they ought or what they could. The authors recommend what they term paternalistic libertarianism, which they describe as a weak, relatively gentle form of paternalism to encourage people to make the right choices. This involves choice architects, that is to say those who have an interest in people saving for a pension, or choosing healthy food, creating the right choice environment so that citizens are ‘nudged’ rather than threatened or frightened into making better choices for them and for the state. Most theories of social change, the authors argue, are based on the idea of homo economicus so beloved of economics textbooks: that is an autonomous, rational individual who analyses the facts and draws the correct conclusion. They point out that experience tells us differently. But their own thinking rests on a similar rational fallacy, particularly as it is taken up by politicians in the Conservative party. Continue reading →
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.
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 →
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 →