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Targets can seriously damage your health

Sun, 4th Nov 2007

FIRST THERE were the truly gruesome events at Maidstone and Tunbridge Wells hospitals where, according to an official report, at least 90 patients died of the superbug Clostridium difficile because of deficiencies in the cleaning regime. Second was the strange embarrassment of the Surrey police chief at his force's top place in the performance league tables - an achievement, he confessed, that was undeserved. Third, the saga of the National Treatment Agency, which has been rewarding drug addicts who present clean urine samples with bonus drugs, and which last week revealed that a pounds 130m budget increase had resulted in just 70 extra patients kicking the habit.

What do these cases have in common? While the consequences were unintended, they were also no accident. Each was the unerring product of the management regime that ministers have propagated throughout the public services - and for which they, as much as the executives involved, should be in the dock.

At Maidstone, a report by the Health Commission said that the trust had been under such pressure to cut costs and waiting times that it took its eye off the job of cleaning. The drug administration regime is driven by the need to demonstrate that it is getting addicts into treatment, rather than getting results.

Most tellingly, Surrey's chief constable explained that, to meet government objectives to boost numbers of offenders brought to justice, his coppers were focusing on soft targets such as handing out warnings to shoplifters, instead of more serious and difficult cases. The result, the chief constable said, was that 'we are at risk of claiming statistical success when real operational issues remain to be addressed'.

Together these cases illustrate once more just why and how top-down target regimes have such baleful effects.

Targets, claim their defenders, are simple, they provide focus, and they work. Yes, they do. Unfortunately, these are also their fatal flaws. The simplicity is a delusion. As Russ Ackoff put it: 'The only problems that have simple solutions are simple problems. The only managers with simple problems are those with simple minds. Problems that arise in organisations are almost always the product of interactions of parts, never the action of a simple part.'

To focus on the individual parts and ignore the whole always makes things function worse at a system-wide level. Thus, to meet financial and waiting-time targets, Maidstone drove up bed occupancy rates. But that compromised cleaning. At the system-wide level, the cost was making the hospital more dangerous to patients than staying at home.

And if enough pressure is applied, people will meet targets - even if they destroy the organisation in doing so. As quality guru W Edwards Deming put it: 'What do "targets" accomplish? Nothing. Wrong: their accomplishment is negative.'

These are systemic faults, which is why such regimes can't be refined by setting 'better' or fewer targets. Deming added: 'Management by numerical goal is an attempt to manage without knowledge of what to do'. This is what makes it so attractive to bad managers. Unfortunately, in absolving them from the effort of thought, it is also junk management, which has the same effect on the consumer as junk food: obesity, flatulence, discontent and demoralisation.

Lack of method explains why the public sector absorbs so much resource for so little return. It also explains the stop-go, curiously disembodied experience of engaging with it: it's not reacting directly to you, the individual citizen, but to management's abstraction of you, as embod ied in the target. Hence the obsession with 'choice', which simply transfers the question of method to you.

Here's what I mean. On holiday near Aix-en-Provence in September, my mother had a fall. At the small, busy local hospital she was seen, X-rayed and discharged within two hours.

One phone call produced home visits by a local doctor and a nurse to administer a daily injection. On the last day, she showed my mother how to inject herself - a smart move, because the logistical feat of getting a nurse out for an immobile 90-year-old in Primrose Hill subsequently proved beyond the NHS. She also needed a blood test. Several days after the request, a nurse turned up without tourniquet, cotton wool or plaster. She severely bruised the arm, failed to take any blood and said someone would return with a 'longer needle'. Several weeks later, still no test.

So when Camden Primary Care Trust sends out a document on 'Improving Health in Camden' and asks for feedback, this is my reply. Stuff the targets and fancy extra services. I don't want 'choice'. I want competent professionals to give objective advice based on medical, not financial, considerations. What use is a health service that isn't personalised? If it functions properly, as in the wilds of Provence, it doesn't need personalising. If it works there, why not here?

The Observer, 4 November 2007


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