21 November 2019
A Mixed Blessing.
By John Watson
On Thursday the BBC website showed a number of bar charts comparing aspects of NHS performance against targets. They made uncomfortable reading for the Government. 83.6% of A&E admissions seen within four hours against a target of 95%; 84.8% of patients on the waiting list for less than 18 weeks as against a target of 92%, et cetera, et cetera, et cetera. Once upon a time these targets were being met but, if one looks at the bar charts, slippage occurred between 2014 and 2016 and the gap between performance and target has been opening slowly over the last five years or so.
Why the fall off? People say that it is at least in part a consequence of austerity. That sounds right. The whole of the public sector has been crippled by a shortage of funds and the result has been to mess things up in many areas. Look, for example, at the introduction of the universal credit, an administrative reform badly needed for years but bodged after the Treasury could not resist saving a little money on the way through. Yes, austerity must be a contributor to the slippage in the health targets too, if not because of insufficient funding for the NHS itself, then because the shortage of funding for councils’ long-term care programs has created bed blocks and gummed things up. But that isn’t all of it and the various political parties will each try to put their spin on the search for other causes. Was it Lansley and his unnecessary reorganisations? Is the NHS wasting money through its interaction with the private sector? How does the decline in performance tie in with the increased demands of an ageing population?
How will the various parties analyse the issues? By seeking to understand them or by choosing an answer which might serve them well in an election campaign? Well, we all know the answer to that, don’t we?
That is the trouble with targets. Of course you need to be aware how a public service (or a private one for that matter) is performing if you are going to manage it but figures do not always reveal causes and only tell you so much. Worse still, as any quantum physicist will tell you, it is impossible to measure something without creating a distortion. Thus imposing a target changes behaviour as well as measuring performance.
Take education as an example. Despite hiccups along the way, the standard of public education in Britain has improved markedly in recent years. That is partly because the introduction of more examinations, such as SATS, has enabled the public and the Government to see exactly what is going on and to push for better results. To that extent the targets and measurement did good. On the other hand some schools, anxious to maintain their score in the tests, have pushed out unpromising pupils rather than helping them, have narrowed their courses to match the syllabuses and have cut back on untested education such as sport and drama. That is not a good thing at all.
“To test or not to test” that is the question and the trouble is that there is no universal answer. When I was in school there were university admission exams and teachers had to find a way of preparing you for them. I remember one young man, three or four years out of university, suggesting that the best idea would be for him to take us through the maths he had learnt in his first year at Oxford. He thought we would find it interesting and we did. No set of targets and syllabuses could possibly have been as good.
On the other hand, take a sleepy school where the staff, having taught the same subject for many years, have lost their enthusiasm for it and so fail to inspire their pupils. Testing and targets may be just the incentive to get them all back on course.
It isn’t just education either. I attended a meeting recently with the social services department of a local authority. There are a lot of busy people there but, although a number of initiatives were agreed, none of it was really followed through. Not long afterwards there was a call from another body connected with the local authority suggesting that a meeting would be the thing. Why? So that the box saying that something was being done within a timeframe could be duly checked. Target met but nothing useful achieved.
That is the dichotomy. If you have targets, people will try to game them and energy will be diverted from what they really should be doing. On the other hand targets are sometimes necessary to keep everyone going. Sometimes targets are good; sometimes they are not.
Those of us who are instinctively bureaucratic will immediately start setting down rules as to when tests are helpful. Boxes to check in deciding which boxes to check, as it were. But that is the wrong approach. Whether targets are helpful doesn’t so much depend on objective criteria as on the people on whom the targets are designed to check. Lazy complacent organisations need targets. Ambitious and enthusiastic ones will be damaged by them. So how do you tell which organisations fall into which category? Not surely by using more boxes. It has to be a human decision and left up to wise and experienced officials to decide what targets and tests should be imposed. Train them up, give them authority, let them decide. Not a process we are particularly good at these days.
At election time, it is inevitable that target failures will lead to pledges and it may well be that the commitment of further funds is needed. It would be better, though, if how those funds are raised and applied could be worked out quietly by the professionals rather than becoming the subject of competitive bidding by the parties.