Damned Targets?

“On Tuesday, the Healthcare Commission report revealed that between 2005 and 2008 there were 400 excess deaths at [Stafford] hospital – although it was impossible to say whether these had all been caused by bad care. The report said there were deficiencies at “virtually every stage” of emergency care and managers pursued targets to the detriment of patient care.” Report on BBC website (emphasis added).

The story of undoubted and appalling failure at an English hospital is being widely blamed in the media, by opposition politicians, doctors leaders and some academics, on the so-called ‘target culture’ in public services. But the truth is rather more complicated and harder to explain.

The critics claim that the “maximum 4 hour wait to be seen in Accident and Emergency” target set by the government for English hospitals is the primary cause of the tragedy at Staffs. Behind this criticism usually lies a particular view of human behaviour in public organisations and institutions which goes under the general name of ‘public choice’ theory – this assumes that everyone is a rational self-interest maximiser. So in this case health managers will respond to targets by meeting them (and maximising their own bonuses or cudos) regardless of the effects on patient services.

The supporters of targets claim this argument is obviously flawed – if the target was the problem then how come every hospital in England subject to the same target didn’t fail as spectacularly as Staffs? On the contrary, most hospitals have done reasonably well in meeting the target and still providing overall good patient care.

The real issue of course is why do some institutions and individuals respond to targets by ‘gaming’ them, and neglecting other aspects of care, whilst others both seek to meet the targets and to provide excellent care and really worry about their patients? There are several explanations, but the most fundamental one is that people’s motivations are more complex – and paradoxical – than simplistic economic theories allow. People are both ‘knights and knaves’ as Julian Le Grand puts it – or as I have argued we are all very ‘paradoxical primates’.

So some individuals and institutions respond badly to targets, whilst others respond well – the real puzzle is who, when and why do people and organisations respond differently?

And we should treat with some caution the claims of both supporters and detractors of targets (and other performance measurement and reporting systems). The supporters claim they always work and fail to see their weaknesses and problems. The detractors seize on any example of failure to damn the whole enterprise – whilst ignoring real successes. Whilst I would agree that top-down targets have probably been overused in England, and their associated problems down-played – we shouldn’t ignore their successes either. There are other – and better – ways of doing targets and performance measurement that are more collaborative and less confrontational than the way they have sometimes been done in the UK.

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