Sunday, 20 November 2011

Missing the target and still missing the point

The announcement this week that NHS waiting time targets are to be reintroduced was hardly a surprise. You don't need to be a health economist to have anticipated that the effect of removing the target when budgets were being squeezed harder than at any time in the history of the NHS and when massive change was being unleashed on all parts of the system would be to see greater rationing of the available services. That is a rational response by a system under strain.  

What this does reveal though is that the debate about targets remains frustratingly polarised. At the risk of annoying a number of former colleagues, the truth is that there is a strong case for national targets when there is a need for a general shift in focus or performance and the targets are simple and well designed. The use of targets by the last Government in health and in education on basic issues such as literacy and numeracy was in my view entirely appropriate even if there was some collateral damage at the margin. 

The case against the target culture is also well understood: perverse incentives from badly designed metrics; micro-management when there should be more discretion for managers; poor data quality; gaming by professionals to get management off their backs; adversarial relationships which ruin co-operation. One could go on. 

So the present Government had some good points to make about the way that the McKinsey inspired delivery chain culture instituted under the Labour administration with performance metrics coming out of the ears of everyone involved had gone way too far. That critique was shared by many people working in public services frustrated beyond endurance by the amount of time and effort spent on useless activity and by the immense lack of trust that it implied. 

Badly designed performance metrics were the bane of existence. When I worked for a London borough our frequent refrain was that either we or someone else would be 'hitting the target but missing the point'. 

The removal of a top down bureaucratic performance culture may be something that superficially brings together central and local. But in practice it’s a blunt instrument.

Where we are now is another depressing example of binary views of the world which refuse to accept that neither one nor the other might have all the answers.

The positive aspects of performance measures and targets - such as minimum requirements, making strategic shifts in focus and performance; providing comparability between organisations to allow them to see where improvement is possible - are being under-valued (see the frankly ridiculous decision to remove the Audit Commission at a time when the pressure to improve cost effectiveness is greater than it has ever been).

The negative effects of an obsession with a 'freedom from' culture and a hollowing out of those parts of organisations which had focused on performance because of the demise of LAAs, the NPI set etc. is increasingly clear whilst the single data list reveals very clearly that the Government has no coherent or consistent view about what should be solely local and what is genuinely national; nor any clarity about what the appropriate response will be if the data starts to go in the wrong direction.

So it’s also hardly surprising that we have a purported localism which doesn't feel remotely localist. That's because the Government is still driving the whole thing just on the basis of a different set of ideological parameters.  

What we never manage to have is a more sophisticated discussion about the place of different approaches to performance. That would be greatly aided by some real engagement with the question of what organisations like local authorities are actually ‘for’, a proper examination of the implications of principles such as subsidiarity and a recognition that wholly binary views of the world are not going to take us very far.

In short, it’s hard to have a sensible discussion about targets before having a sensible discussion about roles and responsibilities. As the Government has found, targets do have a role. They need to be well designed, they need to be determined by the relevant body and they need to be backed up by an understanding about their place in the system. There are ways of sensibly approaching these questions such as outcomes based accountability. They don’t have all the answers but they do at least offer an intelligent way of trying to think about the issues.

A couple of years ago we may have been hitting the target but missing the point.

Sadly now, it seems, we can't do either.

No comments:

Post a Comment