Last week, we received a report from the Care Quality Commission that showed that cancer care records at Colchester hospital had been tampered with. Inspectors went into the hospital in August and September, and found 22 of the 60 records that they looked had been compromised in some way. It seems that senior managers were alerted last year (2012) to what was going on, and carried out an internal review, but this did not stop the practice. By way of context, Colchester was one of the 14 hospital trusts with high mortality rates that was included in the Keogh review, and although 11 of those trusts were subsequently put into special measures, Colchester was not. It is worrying that, even under increased scrutiny, the tampering with care records was not picked up earlier. It also seems that Unison and the RCN were trying to raise alarms, but that managers dismissed their concerns. The CQC only seems to have picked up the problems when – in the words of BBC correspondent Nick Triggle, they were told ‘exactly where to look’ (www.bbc.co.uk/news/health-24833412). The trust is now in special measures.
What does all of this tell us?
One view is that this is just what happens when you impose targets on staff in a particular way. Where staff have no ownership of targets, and will be blamed for not achieving them, then they have good reasons to try and ‘game’ them. I don’t know who the originator of the pithy phrase ‘hitting the target but missing the point’ is, but that seems to go on a lot in performance management systems. Targets make us narrow our focus, and the danger with that is, if we forget why we are chasing the target in the first place, we can end up behaving rather perversely. I can manipulate the figures to make it look like I have met the target (as seems to have been the case at Colchester) or I can hit the target and stop – saving my effort for the next time period or going to other activities instead. Or I can stop engaging with activities that don’t have targets attached to them, even if those other activities are worthwhile too. In other words, narrowing focus can be extremely useful, but it can also lead to problems where we forget all the other things that presently aren’t being measured, but are important in our job as well, or where we decide, for whatever reason, to simply lie in the statistical return for the target.
So, if targets cause problems, should be abandon them? There was an interesting discussion around this on twitter, where several people suggested that target-based systems are inherently flawed, and so we would be better off without them. I was interested to see several clinicians, however, suggest that targets are both important and can be useful. They made two main arguments.
First, that we need targets because without them we wouldn’t have seen the improvements that the NHS has achieved in recent years. Think of waiting lists – imposing maximum waiting time targets has meant that managers and clinicians have found ways of driving down waits, and surely that has to be a good thing. Provided that the reductions in waiting time are genuine, and that we haven’t ended up distorting clinical priorities, that seems a good argument. Effectively, we are saying that by finding a target that is in an area that is important, and focussing on it, then they can be a means of driving improvements. This can come through diverting resources into areas we need to improve, or by reviewing care pathways to find bottlenecks or efficiencies. Wherever it does come though, a target can be a means of focusing attention and driving improvements.
A second argument in favour of targets is that they can act as a means for clinicians to be able to challenge managers to provide additional resources. The logic is that, if a trust looks like it is going to fail to meet a target, then clinicians can go to managers to get more resources to try and improve performance against the problem target. If the point I raised above was about focus, this was is about diversion – about diverting resources and attention from one area to another – another area that looks like it has a target that won’t be met. Again, provided the diversion of resources is justified, this seems to me to be a good thing. But of course, if the target being chased is not as important as the area losing the resources, then this isn’t really optimal.
What I’m struck by is that you don’t need centrally-set targets to focus, and you don’t need them to allocate resources sensibly either. Surely it’s the job of our managers and clinical leaders to work out what the staff working with them need to be doing? Targets can help us focus on what is important, but do we really need them to be centrally-imposed us to treat them seriously? I would hope that clinicians are more than capable of working out what they need to do each year to make things better, set targets for themselves to that end, and be held to account for them. I’m not clear why the government needs to be involved. Equally, if the health needs of an areas are such that resources need diverting, then surely we can expect clinicians and managers to work through that debate and come to sensible conclusions. This won’t be easy, as decision about what to prioritise are also as much about politics as they are about evidence, but the alternative, where government sets the targets for us, isn’t the right way forward either as this ignores the importance of local context. What health services in Durham (where I work) need to prioritise is very different from health services in York (where I live).
What I’m arguing for here is for targets to be decided in a bottom-up fashion, by clinicians and managers working out what needs doing, and then being held to account for doing it. And those targets need to be understood as goals rather than fixed measures that we can simplistically tick off once achieved. Patient care isn’t like that. If we get our clinicians and managers to agree goals together, and hold them sensibly to account for their achievement, then we have a way forward in improving services that people will have bought into, and which will be about improvement rather than punishing people for things that they believe they have no stake in.