As I mentioned yesterday, I’ve never really believed that the “targets culture” would ever be replaced by my preferred “ahh, whatever, have a lie in” culture as the settled policy of any of the political parties.
It’s easy to say “ooh, targets are bad”, until you need to actually make something happen. Then targets become useful. Like zero tolerance policing, which politicians love more than they love their mothers. When you think about it, that’s a target.
So I was neither distraught nor suprised when the Conservatives announced this morning that they would be replacing the terrible, old distorting NHS targets with bright shiny new non-stick targets. It’s an accomodation with reality, and I’m all for that, no matter how grudging it is.
You see, what the Tories have apparently discovered is that targets are good, but only if they’re the right kind of targets. Outcome targets are good. That’s setting a clear objective. Process targets are bad. They’re top down state centralisation, see.
Now this is all very fine and dandy. Outcomes good, process bad. It’s catchy. The trouble is, well, that it’s silly.
The Tories specifically mention cancer care. They say something along the lines of “It doesn’t matter how hospitals and doctors choose to treat cancer, just that the cancer survival rate increases. So we’ll just say do that, and let them get on with providing the results”.
Sounds sensible, but the obvious truth is that it does matter how doctors and hospitals choose to treat. It does matter what they give priority too. It matters what they think is important. It also matters where you choose to put resources.
So someone, somwhere has to decide that you get more impact per pound spent on cancer survival rates by shortening diagnosis times than by buying new drugs.
To set top level targets without being prepared to set out the steps needed to deliver that target makes the whole process meaningless. By setting out those steps and measuring your progress, well, you automatically create a whole series of “process” targets.
In the case of cancer in the UK, the consensus was that the reason our mortality rates were higher was that our waiting times for initial diagnosis were far too long. In other words, if you got diagnosed with cancer late, you were more likely to die, ldo.
Once you have a clear idea for the reason for the gap you wish to make up, you then have to decide how you’re going to change things. So if your evidence is that waits for initial diagnosis is a major block to improved survival, you need to improve the time to initial diagnosis.
Hmm. But hold on, If a maverick health minister says “Dammit, I want priority for referrals to cancer diagnosticians, I’m going to make it happen and I don’t care who I offend in city hall on the way”. Guess what they end up creating?
Oh, right, one of those horrid old process targets. If you will the ends, you have to do something about the means.
So, in order to ensure waiting times for diagnosis reduced, targets were set and hey presto, mortality rates declined by 20%.
What would have happened without those targets? If the NHS had been told “well, we know that waiting times is a significant driver of mortality rates, but we’ll leave that up to you. No problemo if you don’t make it.” My suspicion is – not much.
Now once you’ve dealt with one issue, other come up. So, for example, Andrew Lansley is quite right to say one of the current issues in Cancer care is Radiotherapy treatment. here’s what he said about it on the Today programme.
“Let me give you an example related to cancer services, the governments target has been about time taken to first treatment… …where breast cancer was concerned this led to a serious distortion because the NHS was focused on breast surgery, rather than radiotherapy so the time to first treatment was measured but the time taken for radiotherapy was not targeted and actually got longer for years and the consequence of that is worse cancer services than would otherwise be the case”
I won’t get cutesy about his admission in there that if you don’t target something it doesn’t change. Well not much. What matters is that he’s right that Radiotherapy needs to improve.
The radiotherapists don’t quite blame the focus on waiting times the way he does of course. No, They say that the reason radiotherapy care is poor is that 15-20 years ago the NHS didn’t buy enough radiotherapy machines (technical term there, folks) and that when the machines did start being purchased from 2000 onwards, they needed to start training new radiotherapists to staff them and demand was growing the whole time.
Here’s what they say : “In addition to replacing obsolete equipment, the total stock of linacs had increased from 140 in 1997 to 215 by August 2006. By the time all deliveries in the current programme have been made, there will be 233 linacs (228 by the end of 2007 and a further 5 in 2008/09) providing 4.6 linacs per million population, exceeding the Royal College of Radiographers’s 1998 recommendation”
Still, he’s right to say it’s an issue – even with this expansion, the waits for radiography treatment are still too long and more staff and machines are needed.
So what do the radiographers suggest the Government do about it?
Rather embarrassingly for Mr Lansley they actually suggest that the government creates a new target for radiotherapy. Actually they recommend a whole bunch of new targets.
This is from the National Radiotherapy Advisory Group report “Developing a world class radiotherapy service for England”
“The National Radiotherapy Advisory Group therefore recommends that, as part of the Government’s commitment to go further on cancer waits, the 31 day target from diagnosis to first definitive treatment is extended to include all radiotherapy treatment”
and then there’s this…
“NRAG strongly recommends that NHS radiotherapy services should be developed to deliver up to 54,000 fractions per million population throughout the country by 2016 – a 91% increase on current activity.”
and this
“NRAG therefore proposes that the NHS takes a stepped approach towards meeting this requirement with an interim aim of delivering 40,000 fractions per million population by 2010/11. It is estimated that 8 out of the 39 radiotherapy departments that responded to the 2005 radiotherapy equipment survey are already achieving this interim aim. NRAG advises that these health economies should be challenged to deliver up to 54,000 fractions per million population ahead of schedule in line with local population projections”
These numbers look suspiciously like targets to me, Holmes. Is Mr Lansley going to abolish them all?
In fact, there’s a whole 180 page national cancer strategy looking at this stuff.
It goes from saying “we need to reduce cancer mortality rates”, to an analysis of why those mortality rates exist, to proposed solutions, to, you guessed it, ways to measure whether progress is being made. There’s huge amount of detail – from radiography to smoking to obesity to diagnostics to palliative care.
So here’s the question.
Are the Tories really saying that they’ll scrap the Cancer reform strategy, and replace it with “Do what you want, people. Just get the outcomes down”?
To tell you the truth I don’t believe it.
To do that wholescale would be so monumentally shortsighted I doubt it’s what they mean. Look at the questions they asked about it in parliament- what’s the target for this, when will you achieve that, how long until we get the other, what are the sanctions if we don’t hit this target. In fact, quite often they’re explicitly asking what the target is. You don’t get the sense that these questions are that the targets are worthless. In fact they seem to be calling for greater rigour, if anything.
Yet apparently now the Tory policy is to abandon all these targets in the Cancer reform strategy and replace them with an outcome objective that can only be measured 5 years down the line.
Bluntly, If you abdicate all responsibility for anything below the top line target, you’re not going to get anywhere. The Tories know this as well as anyone. So what are they up to?
I suspect that Lansley knows that he’ll need strategy after strategy and target after target to achieve the outcomes people want.
However, by only setting and therefore being accountable for, the broadest and most general targets, he can buy himself and the Tories time. He also can create a buffer for the inevitable criticism when waiting lists begin to start to sneak up, when there are calls for more Doctors, more hospitals and more investment.
It’ll be interesting to see if under questioning, Lansley explicitly promises to junk the “process targets” in the cancer reform stategy, which includes things like the specific radiography targets the radiographers are calling for.
If he is simply going to ask the NHS to be responsible for monitoring these “process” targets, then this isn’t a bonfire of the targets, it’s a good old fashioned political dodge.
21 Comments
June 24, 2008 at 4:17 pm
Now this is a defence of Brownism in its undiluted form he being Mr. Target.Targets are supposed to be a way of having an equivalent to real life failure in a system with no customers .
They do not work for any number of reasons but they will often have the appearance of having been met. For example exam targets lead to easier exams , nursing through the system with the result that exams no longer supply employers with information. You will hit your exam targets of course but you will actually debase the currency and dumb down the system.
You will notice the utter disjoin between public opinion and splendidly met government targets on this subject . On crime targets divert resources onto crimes that are easier to solve with all sorts of bad results and again the public see disaster and have now turned their backs on Brown and his statistics . Their instincts are quite right , look what a pigs ear Doctors targets have been,.
I begin to see the Hopi tactic you look for the point where the Conservative Party are trying to have their cake as well as eat it , the dissonance in the narrative . There is good reason for abandoning the Soviet /Zimbabwe method of running anything at all because it do not work On the other hand people are used to government being a busy bee and like the reassuring language fake thought it may be . You do not like them retaining the appearance of this reassurance . Others will want to fight their corner and appear busy bees we have them too , just less.
If you take the exam analogy the ‘outcome’ target is one that might not be reached. It would be a way of retaining light touch state monitoring without distorting and introducing inefficiency but it does mean that intervention is vastly less immediate and direct . The best exmaple is infakltion wheich the government does not directly effect , this outcome tyarget albeit informal has been a great succes just as John Major hoped .
So yes the language is designed not to frighten and the thinking is more radical than it looks and far from silly
Good .Soviets Russia failed Zimbabwe failed and Brownism has failed details aside this is the right idea
Good post though Hopi , I always understand more about what the Conservative Party are really thinking from reading your stuff.
June 24, 2008 at 4:19 pm
Surely there are ways, in some circumstances at least, of creating management priorities from the bottom up?
Wouldn’t this help some frontline service providers to meet the needs of users/customers?
In view of this contention, perhaps targets need to be replaced by responsiveness in organisation, and decentralisation.
June 24, 2008 at 4:34 pm
Miller- you’re absolutely right there are lots of ways of creating management priorities from the bottom up.
Indeed I’d say the Radiography example is a perfect example of that- people raise an issue that needs to be improved, “leaders” ask the professionals in the field what needs to happen to improve things, they say “you should do this” and then management commit to making it happen.
Bottom up can be vital – but it’s meaningless if there isn’t a top level commitment to making such bottom up changes happen.
June 24, 2008 at 7:09 pm
What on earth makes you think that proffessionals are going to tell you the truth ? Did it work with teachers ? Nope. They will just want more for them . Bigger empire shinier toys .. Why would they know what needs priority or will in the future. The information in the system has to exceed the information available to those in it , thats why the market works as do organisations allowed to grow and adapt to some extent.
You are trying to fill your bath using a sieve and it is an utterly doomed excercise . Seriously Hopi this is the very essence of the Brown error and it is a creed that will not in any case ever be tested any more so forget it .My humble advice is to start thinking about something that is not , ‘more of the same’ .I feel you are the sort of chap to lead Labour out of the Cul de sac but this is not the way .
…I mean really is it ?
really ?
June 24, 2008 at 8:31 pm
This is a very long post, but I got the gist immediately. I’m going to give a footballing analogy.
As I understand Labour’s NHS targets are related to what they consider proxies for success (e.g. possession, pass completion etc). Tory targets will simply be on success (e.g. goals scored, games won).
Your targets cause dysfunctional behaviour (defenders passing in the back of their half) ours promote creativity and real results.
June 24, 2008 at 10:16 pm
It’s a topical analogy, people!
But a flawed one.
If the entire NHS staff was 11 people, outcome targets with no process might be possible. But imagine trying to get a football team consisting of 400,000 players to score a goal. Incentivising passing would probably be a good way of doing it.
I like targets because they’re democratic. If we hadn’t had them, we wouldn’t have got waiting times down for diagnosis and for key operations – which is what the public wanted. If there is a disconnect between what the public want and what NHS staff left to their own devices would do, you need some way of dealing with that – and a top-down target is one way of doing that. The struggle to get GPs to operate at more accessible times is one issue where public need actually conflicts with the interests of health professionals.
I actually think that having fixed many of the Tory problems in the NHS we can scale back on some of the targets and keep the most important ones. I think the ideal situation is where there are a small number of targets whose progress is regularly measured. It is when progress is not regularly measured that targets distort behaviour in odd ways*, because we encourage people to do nothing for ages and then go for quick fixes at the end of the process. In fact, this is what the Tories’ outcome targets would do, by getting rid of the clearly measurable stages in the middle.
I expect Tories to oppose targets – they are part and parcel of a democratically planned economy. I would like to hear them talked about in these terms more often, instead of as part of a managerial process.
* I say in odd ways because clearly targets are meant to distort behaviour, so that it meets public need.
June 24, 2008 at 11:23 pm
I actually think that having fixed many of the Tory problems in the NHS…
Is that what you call flinging tax payers money at the problem and getting a poor return? Well I hope Mr. Hopi will not take offence with my vehement disagreement . I may at times be less than entirely serious but this is the crucial debate of our times fro provision of services and I am deadly( well fairly ) serious
.It is not so much detail of Hopi`s piece ,which is illuminating , as the direction such thinking would imply . It would, for example, imply an end to privatisation as this will respond to commercial pressure and elude top down targets .It would imply an end to independent or varied provision education as this is specifically designed to avoid the dead clammy hand of state . It is in fact all the public call Brownism and if you look at tomorrows ICM Poll you will see firstly why I say right or wrong you might as well forget it …Brown is dead in the water ; time to move on.
Let me explain something about targets . Mr Blair for placed a target for LA s to collect a certain quantity of recyclable waste ( or rather the EU did but I digress..) , Many authorities insisted residents separated their waste and thus met their targets . There was however a shortage of depots for such waste so some LA s ended up putting the recyclable waste back in with the waste whist collecting their bonus for having collected it .Or take the RAEs intended to justify University funding by measuring research. Well all the universities soon became adept at playing that game and made costly changes for the sake of funding , as the level remained uniform however no information was acquired by the system and the same pot was shared similarly but much waste has been caused . Targets for deaths in operation lead to an unwillingness to take on dangerous operations .and on and on it goes how tempting to imagine a better target and it would al lwork …this is the Brown trap.
Theoretically it might be possible in the NHS , say by the provision of a gigantic and costly data base , to get enough information and be reactive enough to fine tune at all times .The expense is prohibitive however and the complexity in itself soon reaches a point of negative return as no-one understands it . This is a common complaint of course it also erodes responsibility and devalues decisions by its nature
Or take the targets applied to safety in the workplace . On construction sites certain levels of competence are require and in order to escape Prosecution it is handy to be able to demonstrate that the Company provided the training and the employee was indeed trained . Such is the legal “Terror “ however that Companies are now able to buy software that automatically provides the training in accessible modules and the employee signs off his having watched and learnt. The soft ware logs what is in effect a ‘hold harmless’ from employee to Company.
The perverse result is that the sum of knowledge held by real people reduces as does the level of safety over time , the legal responsibilities of the Company will soon shrink to 19th century proportions . Again this is quite real and accounts for the rise in Industrial accidents of late ( not cuts in H and S funding as bureaucrats pretend). The FSA has had much the same effect on Financial services eventually and it was their hopeless tick box approach that allowed Northern Rock to sail unnoticed into trouble although the market had noticed some time before. This was a directly attributable to Brown reforms .
So Tim F has it exactly wrong in large complex systems targets cannot work. Now any private company would use models as aids but in real competition these models are themselves subject to cumulative evolution. The Conservatives as I see it wish to reincorporate human knowledge into systems . This need not be a market but might equally be something developing over time like Common Law.
What I think , Hopi objects to is that on the ground politicians of all Parties will be averse to advocating a sort of Laissez faire for health or education. It is so much easier rhetorically to bang your fist and talk about funds , targets and plans . Nonetheless we must move from the IBM mega computer into the PC age of interacting units and it is my belief that the people feel in their water that
Brownism has been tried and failed .
The Ministry of Agriculture Fisheries and food ( MAFF) in 2002 met 10 of its 13 targets . Sadly one of the three targets it missed was to prevent the outbreak of serious disease . Never mind it did all the easy ones .
And that my socialist friends knocks targets into a cocked hate unless I am much mistaken.
Ithenku
June 25, 2008 at 6:08 am
The Tories are as wedded to state control as Labour? The Tories want to use the government for social engineering, just like Labour?
Tell me something I don’t know.
June 25, 2008 at 7:47 am
The Tories are as wedded to state control as Labour? The Tories want to use the government for social engineering, just like Labour?
Tell me something I don’t know.
The list is endles and would appear to inlcude any of the developing Conservative Policies . Nick the drip on the other hand has been obliged to quietly drop the “Orange Book” under pressurre from the left which forms the Liberal Democratic Party , a Party on about 5% until it was boosted by centrist socialists during the SDP period .A Party who criticised Labour from the left in the 90s and continues to do so when it suits them and a Party whose tax plans are admitted by its own members to be tax raises and an utter mess
You simply cannot object to the size of the state and continue to support the Party of the Beveridge group and the Party who says the naswers “yes” now whats the question. The Conservative Party enacyed the onlt truly Liberal administartion of the post war period under Thatcher and the Livberals have not stopped bleating about how it hurt a bit since.
So if you are going to have that cake get it out of your mouth.Yes Cameron is commited to maintaining spending levels so was Thatcher just as Blair was commited to so tax rises.
The public , and Hopi will hate this , are not stupid and they know what they are getting with the Conservative party. A MOVE RIGHT ,slowly , carefully and thoughfully we hope but it is the only chnace of delivering this tormented land from the fearsome yoke of Brownite bondage.
I see I am going to have to start my own blog again and stop boring Hopi.
I have
June 25, 2008 at 8:46 am
A bit disingenuous here Hopi – if you’ve read the green paper it isn’t advocating the abolition of targets per se but a drastic reduction in those imposed from the centre and a shift in those that remain towards outcomes rather than process.
More here..
http://www.cassilis.co.uk/2008/06/why-target-culture-needs-addressing.html
June 25, 2008 at 10:49 am
Well, not exactly, Cassilis. There’s a lot of having their cake and eating it in the Tory proposals, which look pretty disingenuous to me. The green paper talks about the abolition of process targets, but it’s clear that there will be many process targets in place, just not imposed from Whitehall. This, incidentally, is the direction of Labour policy too, although with the difference that the Tories want to abolish absolutely all central “process targets”, whereas Labour just wants to reduce them – under Labour there will still be a small number of key patient guarantees, like the 18 week wait and the two week wait to see a cancer specialist, but increasing flexibility to allow local targets depending on local need – whereas under the Tories these will be abolished.
So both parties are committed to process targets, and both parties are committed to having more local process targets. Incidentally, the local targets will still have to be set at a relatively high local level, by NHS managers not individual clinicians, and will apply across whole NHS trusts, so the term “bottom-up” is a bit disingenuous. The main distinction is in the level of political accountability for ministers, and in the level of deniability if/when things go wrong. The key point, though, is that the Tories absolutely accept, given that they still encourage the setting of process targets in order to meet the national outcomes, that process targets are a key tool in incentivising and achieving results in priority areas. They just want to pretend they oppose them, by giving rhetorical emphasis to their (yes, real) distorting effects, and washing their own hands of the responsibility for those distortions.
Cameron’s speech yesterday also included the words, “Patient choice must really mean just that – so we’ll let patients choose any provider that meets NHS standards at delivers at NHS costs.” Whether that’s a good idea or not, it glosses over the fact that this is precisely – almost word for word – government policy, and has been in place since April this year. Again, pretending to distinguish themselves from the government, while following government policy.
June 25, 2008 at 12:11 pm
Thanks Tom – a couple of rejoinders.
“The key point, though, is that the Tories absolutely accept, given that they still encourage the setting of process targets in order to meet the national outcomes, that process targets are a key tool in incentivising and achieving results in priority areas. They just want to pretend they oppose them, by giving rhetorical emphasis to their (yes, real) distorting effects, and washing their own hands of the responsibility for those distortions.”
Not quite – again you’re confusing outright opposition to a target with a difference over who sets it. The Tory proposals are designed to make process targets subordinate to outcomes targets and make sure it’s the latter politicians are judged on. The distorting effects of the former aren’t the ‘fault’ of anyone per se, just statistical fact – but using them as a means of government control IS a political choice and something I think the Tories deserve credit for offering to forego. On my blog today I’ve quoted a piece from the Observer last year describing Whitehall targets as little more than restated producer interest when ministers should be advancing ‘consumer’ interest (patients).
“Whether that’s a good idea or not, it glosses over the fact that this is precisely – almost word for word – government policy, and has been in place since April this year. Again, pretending to distinguish themselves from the government, while following government policy”
That’s a fair point Tom but arguably not one Labour supporters should put too much weight on – over the medium-to-long term the accommodation Labour have had to make towards centrist or centre-right ideas about healthcare provision (a place for internal markets, patient choice etc.) far outstrips any Cameron & Co. are having to make in the opposite direction now. You only need to read Compass every other week to see the extent of that and so if Cameron is stealing back his hat & scarf Labour can hardly cry foul when they’re still wearing his jacket…
June 25, 2008 at 12:46 pm
Yes, but Cassilis, if you believe that a process target is needed to achieve your outcome target, it seems a little bit much to then say “but ministers should have no responsiblity for any intermediary steps”. That basically gives the government an opt out on any failing in the NHS for the span of a government.
This is even worse as, for example the cancer outcome target will only be known in 2020. Personally I think ten years is a bit long to wait to see if the NHS is going it the right general direction or not.
June 25, 2008 at 1:16 pm
I don’t understand where this idea of an opt-out comes from or how these proposals would somehow insulate the Tories from any blame in the future – quite the opposite in fact. A government minister who asks to be judged on health outcomes regardless of process can’t then claim it’s not their fault if those outcomes are missed – Labour would rightly retort “you devolved responsibility for the detail and asked to be judged on results – period”
It’s the current system that lets ministers claim (mostly) genuine successes in terms of all those intermediary steps and then offset any failings in outcomes against those success – ‘look I put all the process in place and tried my best…” This creates the situation at a local level where NHS staff are also judged on process rather than outcome so you get patients left in ambulances or corridors because bringing them into A&E risks breaching a target – clinical judgements are taking second place to political ones.
I agree that this Tory approach makes judgements difficult in the short-medium term but the priority in health provision isn’t which system better supports good soundbites for our manifesto – it’s which system better support the patients.
June 25, 2008 at 1:47 pm
Tom , how will this effect the Labour target for targets , are you going to miss it ?
Cas I would not take the Labour undertaking to get their hands out of the machinery any more seriously than the Lib Dem promise to reduce taxes .You cannot change your DNA but I am looking forward to listening to G Brown selling light touch government.
June 25, 2008 at 2:04 pm
Newmania: Who said satire was dead?
Cassilis: “A government minister who asks to be judged on health outcomes regardless of process can’t then claim it’s not their fault if those outcomes are missed – Labour would rightly retort “you devolved responsibility for the detail and asked to be judged on results – period”
That’s true, but if the results don’t come out for ten years then the Tories have two terms in which they can deflect such criticism. My guess is that, in the absence of any outcome results, poor process results like rising waiting lists would indeed be seized on by an opposition. I wonder whether, conversely, good process results would be seized on by a Tory government, or if they’d high-mindedly stay silent at a general election as waiting times dropped below 12 weeks and MRSA rates hit a new low. I have my suspicions.
On your earlier point about Labour making accommodations towards centrist or centre-right ideas while the Tories don’t have to move in the opposite direction: I think that’s much more open to debate than you suggest. For one thing, look at the enormous anger among the right-wing media/blogosphere (for what it’s worth) at Lansley’s commitment to match Labour’s spending on the NHS, and at Tory health policymaking being the victim of “producer capture”. For another, look at the Tories’ abandonment of their patient passport policy which they had in 2001 and 2005, successfully portrayed by Labour as a subsidy for users of private healthcare, and certainly a more “right-wing” policy than they now have. Finally, I’m a Labour supporter and I’m genuinely comfortable about patient choice. The fact that it makes Compass angry only strengthens my view.
June 25, 2008 at 2:16 pm
Thanks Tom.
I share your reservations about the probity of a Tory government staying silent should process results provide bragging rights – such is politics. I think my point holds that we shouldn’t organise the NHS around whichever system provides Ministers with the best information but whichever system best suits patients. It might be the case that those solutions do mean the government of the day get an easy ride for a decade but that’s no excuse to reject them.
On the other point I’m certainly not saying the Tories haven’t moved to the left – just a personal view that over the last say 30 years the Labour movement has moved MORE relative to its starting position than the Tory one. I’m aware that some disagree on that.
At least we share a certain joy in angering Neal Lawson….!
June 25, 2008 at 4:13 pm
we shouldn’t organise the NHS around whichever system provides Ministers with the best information but whichever system best suits patients.
If by ‘we’ you mean the state perhaps “we” should not organise it at all? Personally I`ll take our £400,000 health Policy which is about what the tax payer forgoes ( £200,000 each ) ,and live in BUPA luxury whilst pretty nurses anoint my feet with scented oils. ….
June 25, 2008 at 4:21 pm
See, Cassilis? There are Tories who think Tory health policy is much too left-wing.
June 25, 2008 at 10:00 pm
Newmania is a breed to himself and shouldn’t be seen as indicative of typical Tories.
You could say he’s a poor ‘performance indicator’…
December 2, 2008 at 11:16 am
[...] a different orientation for the NHS – patient choice. Moreover, observers have commented on the strategic nature of the Conservatives’ rhetorical emphasis on outcomes in their policy [...]