Targets and standards
Targets and standards
There can be no doubt in anyone's mind about the significant changes that the UK Government wishes to bring about in its National Health Service (NHS). The last few years have seen significant changes in structures with tiers of management being eradicated or transformed; relationships have been built on the foundation of purchasers and providers; primary care has become pre-eminent at the expense of Trust hospitals culminating in an investment of no mean proportion.
Politicians have clearly nailed their colours to the mast of wholesale improvement in the performance of the NHS. Inevitably at the political level there must be some anxiety as to whether the promised vision can actually be realised by the time of the next general election.
To facilitate this realisation a number of bodies have been set up to ensure that progress is made; that money is spent wisely; that the service is "modernised";and that leadership is instituted.
Also to encourage mangers to "perform", a wide range of "quality"indicators have been established against which managers and their organisations are measured. These have resulted in a "star" system whereby those who achieve a (limited) range of targets are praised and rewarded with more freedom from centralised control. Those who gain no stars may eventually be dismissed and that Trust handed over to different managers. There can be little doubt that these "control and reward/punishment systems" have hadan effect. They have indicated the Government's serious intentions to the NHS and the public and have possibly led to improvements in aspects like waiting list management which might not have been achieved otherwise.
But they also have a side effect of highlighting a specific aspect of the service (such as waiting lists) which then focuses managerial and public attention on this aspect often to the detriment of another feature. It is relatively easy to reduce waiting lists by operating on the "easy" cases and putting off the more difficult and serious cases. Such centrally driven targets can overlook these knock on effects and distract attention to those aspects that may not be essentially important but are relatively easy to "measure".
What is needed now is a change on the process of identifying critical issues that really do need management attention. Just as there have been changes in structure, relationships and finance, there now needs to be a change in culture. This is also driven from the centre, where the management tone and style are set. Politicians have to learn how to collaborate with management rather than clobbering managers for not achieving improved targets.
In other words the centre should demand that targets and standards are identified by management who because they are self generated will have a greater commitment to achieving them. It does not matter that there will be differences from Trust to Trust. This reflects the state of development of each Trust. What is important is that each Trust's performance improves each year.
It could and should be the function of the "Modernisation" agency to ensure that every Trust management produces performance measures of quality and standards to be achieved. When Trusts appear to "lack ambition" the agency should be empowered to work with the Trust to produce more significant improvements and changes. The essence must be, though, that these are the Trust's own targets and standards to which it will commit itself.
Another aspect of the culture that needs changing is the idea of "winning and losing Trusts". This could come about by quite a simple change in introducing something similar to the Baldrige award – and perhaps also rewarding the Trusts that have made the most significant progress in the achievement for their targets and standards.
A side effect of this cultural change is likely to be that of more honesty and transparency in the management process. For example, a British Sunday newspaper (the Sunday Times) exposed the fact that the "centre"does not want included in the measure of how long patients wait for treatment,the time spent waiting for a diagnostic procedure. For a patient, this is a very real "waiting" time, but for the centre it embarrasses the pledge that waiting times are being reduced – whereas in fact they are getting longer if you take into account the time spent waiting for the diagnostic tests. Itis also not unknown for managers to "fiddle" the figures so they appear better than they are.
The difficulty with collaboration targets and standard setting is that it appears "soft". Yet we know enough from the behavioural sciences to indicate that participation in a process brings more commitment to the objective of the process. It also creates a "learning" and developmental culture where inadequacies are owned up to rather than concealed and fiddled away.
In summary, therefore, what we are proposing is that the centre, in addition to the other changes promulgated, should develop a strategy for gaining the commitment of all management (including clinical) to standards and targets setting through a policy of co-operation, support and reward, rather than by dictat, pillory and punishment.
Robin Gourlay
