Reporting Scotland yesterday, nine times throughout the day, had much to say on the recent waiting time target figures for NHS Scotland. The 90% target was not met.
Today, however, the reservations shared by others about the effects of such an undue focus on targets, were reinforced by a report from the BMA in Scotland, which suggests such concerns are widely shared by GPs. While there are, as always, methodological concerns about the BMA ‘research’, they and BBC Scotland News have formerly had quite a cosy and even symbiotic relationship. The BMA report does not, of course, directly attack BBC Scotland’s reporting of targets, but it finds them diametrically opposed for what may be the first time.
Concerns about targets have been raised before. For example, from a 2015 report for the Health Foundation (p5):
- There have been instances where reported performance has improved without services improving for patients: ‘hitting the target but missing the point’.
Example: Cancelling procedures along parts of the pathway not covered by the target (for instance aftercare) in an attempt to direct resource towards the targeted area of referral to treatment, even though overall patient outcomes could be negatively affected.
2. [Targets] may lead to a disproportionate focus on areas which are measured at the expense of those which aren’t.
Example: Reports that the Quality and Outcomes Framework (QOF) had a negative impact on holistic care in general practice, with the targets skewing focus towards single-conditions or issues.
3. There have been reports of gaming and manipulation of data.
Example: Some ambulance trusts reported reaching patients in less than one minute (a near impossible time), suggesting manipulation of the data to meet the target.
https://www.health.org.uk/sites/default/files/OnTargets.pdf
Research from business schools, reported in Forbes magazine in 2013, suggests a wider and deeper problem with the whole idea of target-setting arguing that they tend to do more harm than good and that they often cause real damage to organisations and to the people who work in, or who use, them:
‘We argue that the beneficial effects of goal setting have been overstated and that systematic harm caused by goal setting has been largely ignored,” the researchers conclude. Bad “side effects” produced by goal-setting programs include a rise in unethical behavior, over-focus on one area while neglecting other parts of the business, distorted risk preferences, corrosion of organizational culture, and reduced intrinsic motivation.’
Where intensive national broadcast media attention to failures to meet targets is added to the above consequences, the effects must surely be even greater. During a recent one-month stay in hospital while at the same time writing this blog, I was able to ask 24 health practitioners about their reaction to the negativity commonly broadcast about NHS Scotland’s performance by BBC Scotland and STV. I had been especially interested in how their morale might have been affected but not one of the 24 reported watching or listening to Scottish news broadcasts other than by accident.
BBC Scotland’s weaponizing of the NHS, while potentially quite effective in scaring older and more vulnerable Scots into conservative mindsets conducive to voting against change, always risked conflict with those professional groups working in it and often otherwise aligned with their Loyalist mission.
Talking-up Scotland 
Targets have always been instruments for compliance and control of practitioners. They have some benefit in terms of identifying priorities and for evaluating and improving procedures. But, they are only one of a wide range of monitoring and evaluative methods, and, as the article indicates, they can become dysfunctional when they become instruments of blame. The media and some politicians see blaming as an end in itself – someone has been blamed, he/she must resign:and if the person blamed resigns or is sacked, the end has been achieved!
The BMA quotes provided raise a number of the key points about how the misuse of targets become dysfunctional.
However, there is, I suggest, another reason why the BMA is raising concerns and that is to protect its members. Although we hear a lot about NHS ‘Management’, almost the entire NHS service as it impacts on the public is delivered by BMA (and RCN and other NHS union) members. It is therefore a short step for these members to be blamed for shortcomings. On the whole, health service workers have a lot of good will from the general public and, in pursuit of claims for improvements to wages and conditions, the unions appeal to the ‘angels’ image with the general public. When failures to meet targets are explored, then there is a strong possibility that part of the reason might lie with NHS worker incompetence.
I am strongly in favour of accountability and for continuous monitoring and evaluation. However, these work best within a respectful and supportive context, which is directed at improving the service and the service delivery, which will include changing of procedures and retraining of some personnel. It will, in a few cases, assign culpability to an individual or individuals. When that occurs then a formal disciplinary procedure should follow.
An important part of this, not least in developing trust in the system, is that the judges themselves must be subject to judgement. In the case of the media, who is really able to call them to account? The complaints you and others have put to the BBC, for example, have received pretty swift dismissal, in most cases.
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