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Careful targets can help to achieve goals

  • 3 Comments

Management consultant and regular LGC contributor John Seddon is critical of performance targets and their “dysfunctional” effects. He is right.

My view is that all targets are flawed, but some are useful. People talk about the perverse effects of targets, but in fact they are not perverse at all. They are predictable consequences of a top-down performance management culture that encourages staff to prioritise an inevitably flawed target over service to the public.

It is wrong, however, to dismiss targets out of hand. That they have the potential to make people accountable and achieve change is evident from the perceived urgency for governments to commit to emissions targets to address climate change.

Another example is the NHS. It is not fashionable to be sympathetic to politicians, but in 1997 the new Labour government found that 175,000 people in England -about 1 in 280 of its population - had been waiting more than nine months for admission to hospital.

Changing

Ministers were prepared to invest in the NHS, but were aware that simply providing more resources would not by itself change the way people work - and the system definitely needed changing.

Moreover, there was a perverse incentive in the system, as the length of the waiting list was a prime determinant of the demand for private health care.

It is clear that performance targets were instrumental in cutting this figure to 223 people by March 2004 when you consider that waiting times in both Wales and Northern Ireland, which chose not to use targets, stayed high throughout this period.

The benefits - and limitations - of targets can be illustrated using the example of Liverpool Football Club, which recently set itself a target to be in the top four of the Premier League.

Because this is an outcome-based target, leading to entry to the lucrative Champions League, and challenging (Liverpool were not in the top four at the time), it has the potential to motivate players, fans and financiers alike.

Lessons

But suppose the chairman commissioned research which showed that the top four teams had at least eight corners per game and over 65% possession, and decided to introduce targets for these, too? That’s where the problems would start.

There is evidence that the regulators have learned some of these lessons. The Care Quality Commission allows NHS trusts to submit “extenuating circumstances” that might have affected their ability to meet a target.

The National Audit Office has reduced the number of public service agreement targets, while the Audit

Commission has provided more emphasis on supporting working across organisational boundaries with the introduction of Comprehensive Area Assessments.

But there is still a long way to go. The way forward is for organisations to take ownership of their own performance management within a culture of continuous improvement - not blame.

Scorecard

At the Sheffield Business School we have developed a ‘public sector scorecard’, an outcome-based service improvement and performance management framework for the public and third sectors. This focuses on delivering the outcomes that matter to service users and other stakeholders, including central government, through service improvement.

These include ‘lean’ and systems-based approaches, addressing organisational issues such as low staff motivation, poor partnership working, and resources, along with measuring the achievement of outcomes and evidence-based drivers of those outcomes.

The discussion on performance targets also provides insights on the potential hazards of performance-related pay. If performance-related pay is able to motivate staff to improve performance, then it can have a positive effect for both staff and the organisation.

However, if there is a blame culture, if staff do not perceive the system as fair, if it ignores risk, or if it is not based on the outcomes that matter to users, then ‘performance-related pay’ runs the danger of being more like its anagram … ‘mere end of year claptrap’.

Max Moullin is Director of the Quality and Performance Research Unit at Sheffield Business School and a Fellow of the Chartered Quality Institute and of the Operational Research Society

  • 3 Comments

Readers' comments (3)

  • Hi Max,
    While I can agree with some of the thoughts I can not agree with them all.

    Targets set as a prediction of the capacity of system, together with knowledge of where systems are, and what is to be done to them, within boundaries enables forecasts of outcomes within certain tolerances.

    Targets that say we will reduce waiting time on their own are like sky-writing, the change of out-comes in the NHS is a complex mixture of far more expenditure, investment in new hospitals and building, lean systems thinking applications, splitting up definitions to create a series of sub-targets, and straight forward data error and fiddling.

    Targets are almost just as often a demotivator as they are a motivator. As to Liverpool, they are not in control of their destiny, as Man City, Tottenham and Aston Villa all have the same motivators...

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  • Imposing a target may have cut the 9 month waiting list figure, but the real question is what effect did it have on health care received by patients?

    Even on the numbers alone this reduction could be meaningless, this figure could go down and average waiting time still go up.

    When we then consider the impact of this target upon clinical decision making it is almost certain it will have made the actual service being provided worse. We can see clear evidence of this at the Bradford hospital where 10% of patients are being moved at the last moment to avoid breaching the waiting time target:
    http://www.thetelegraphandargus.co.uk/news/4492367.___A_E_targets_put_patients_at_risk___/

    Do you have comparable stats for the 9 month waiting list reduction? How many patients were somehow moved off the list during the last week or two? And where did they go?
    How many people were denied more important medical treatment just so that someone could have their (less important) treatment within their 9 months?

    I think if we did the analysis thoroughly we could actually end up calculating how many people died directly as a result of this target.

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  • Thank you very much for these comments. I think the LGC’s choice of title with the pun on the word ‘goals’ may have given the impression that I am in favour of targets. My view as I say early on is that ‘all targets are flawed, but some are useful’. My reason for writing was that I felt that the debate was too much about targets are good versus targets are bad, when a more sophisticated approach is needed.

    I have been an outspoken critic of NHS targets for many years. In particular my 2003 article in the Health Service Journal ‘Until there’s a broader range of indicators for star-ratings system we need to say “No, Mr Milburn” rather than “Yes Minister”’ was influential in getting the government to produce a more balanced – but still flawed - approach. This article pointed out that a fictitious hospital featured on the BBC programme 'Yes, Minister' with 550 admin and non-clinical staff but no medical staff and no patients would score better than all other hospitals than 9 of the 10 targets for acute hospitals!

    Andy Nutter is correct to question the effect of the reduction in waiting time on health care received by patients. However his response ignores the fact that in many cases - cancer is not the only example - treating a condition before it gets worse leads to a better clinical outcome as well as reducing patient anxiety, pain, and frustration.

    Dave Gaster makes a very valid point that targets by themselves did not achieve the benefits. Indeed without investment, they would be what Deming calls ‘goals without methods’ which are always counter-productive. However my point is that investment by itself might have propped up a poorly designed system. It was a combination of targets and investment that empowered managers and clinicians to make those changes and also overcome the perverse incentive that long waiting times led to higher demand for private healthcare. I agree wholeheartedly that 'creative fiddling' took place, but this was in my view primarily due to the top-down performance management culture, based on blame rather than improvement.

    My reference to Liverpool Football Club was just to illustrate the fact that targets can be useful if they are based on agreed desired outcomes which are seen as fair and challenging but achievable. However if they are not – for example the number of corners or possession – then they will definitely be counter-productive. Yes, I agree that they are not in control of their own destiny, but as we have seen from the recent banking crisis, neither are those of us who work in the public sector!

    I believe however that we can do things differently – and in my view Local Government managers are best placed to come up with a solution to how we manage and improve the performance of public services. They have a dual role. They are recipients of the performance management culture provided by the Audit Commission and others, but they also need to be assured that the services they devolve to the third sector and the private sector are delivering the required outcomes for service users. My challenge to Local Government managers is to come up with a system that works in both directions. The aim of the Public Sector Scorecard is to do just that!

    Max Moullin, Sheffield Business School
    www.shu.ac.uk/ciod/pss

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