The fine line between target setting and bean counting
RECENT reports that the UK Government were looking at abandoning the NHS target that 95 per cent of patients attending A&E should be admitted, transferred or discharged within four hours has attracted a lot of criticism. There can’t many managers in most industries who could do their job without accessing statistical data: everybody needs such information to pinpoint problem areas and then learn when/if their corrective actions have worked. But is the NHS really comparable with “an industry”? And given that its raw material (ie patients) is very variable and not always easily controlled, is it fair to expect the NHS to measure its “output” on a comparable basis across the country?
While accepting that few organisations (public or private) compare with the NHS in terms of size, scope and service delivery, it’s worth reviewing the development of target-based management that has evolved over the years. A few decades ago I liaised with Audit Scotland, which was preparing new “Performance Indicators” (PIS) for council cleansing services. We started with refuse collection and they wanted to measure how often councils “missed” bin collections at individual houses. I said it was pointless because whenever people forgot it was collection day, and heard the truck passing, they’d then put the bin out and phone to say it had been missed. Most councils would usually ask their crews to go back as soon as possible to empty the bin. I felt its proposed PI wasn’t a real measurement as it couldn’t be validated, and anyway, few people could survive with a full bin for long. But the civil servants had to come up with a PI measurement and it was their call.
They took a similar approach to street sweeping, a service that interests few members of the public these days.
The civil servants had to come up with a PI measurement and it was their call
At the time we lived in Ayr and one Saturday afternoon some youngsters ran down our street throwing eggs at our and our neighbours’ windows. My wife phoned the police who on hearing the rascals had fled, said: “I take it you’re reporting this matter for police information?” It then emerged that if they’d had to accept the report as a “crime” (rather than “for information”) it would then have to go into the system as such. Given the chances of arresting the miscreants were remote, it would then have to be recorded with all the other “unsolved crimes”, and reflect adversely on their Performance Indicators.
Supporters of the target approach often quote “if you can’t measure something, you can’t manage it” but if a lot of an organisation’s efforts are concentrated on “meeting the targets” then quality and service delivery can sometimes go out the window. It shouldn’t be just about getting your superiors off your back: there has to be other factors to evaluate service delivery and (in the case of the NHS) patient care.
So instead of targets (or Performance Indicators) being used as one of a number of management tools, we’ve created a demand for a new skills set for public sector managers: to “be able to ensure we meet the targets”, sometimes at the expense of other considerations that are just as important.
By all means, let’s use targets as part of evaluating performance in the NHS but there needs to be just as much emphasis on the quality of the services delivered and how patients’ expectations are met. Solely meeting the targets at the expense of other considerations is simply bean counting.
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