Thursday 18 July 2013

Bankers, nurses and the way targets narrow language

"No nation has ever produced a military history of such verbal nobility as the British. Retreat or advance, win or lose, blunder or bravery, murderous folly or unyielding resolution, all emerge clothed in dignity and touched with glory. Every engagement is gallant, every battle a decisive action, every campaign produces generalship hailed as the most brilliant of the war. Other nations attempt but never quite achieve the same self-esteem. It was not by might but by the power of her self-image that Britain in her century dominated the world."

So said the American historian Barbara Tuchman about the British retreat into India in 1942.  That was the way we regarded things a generation ago - the military, our police, the NHS.  What changed?  How did we go from verbal nobility about the NHS to the corrosive vigilance that has led to the current panic about eleven dysfunctional hospitals.

Before, our ability to congratulate ourselves would over-shadow almost any local abuse.  Not now.  What changed?

The answer is the transparency, faulty as it is, that comes from measuring everything.  We pore nervously over the data, the averages, the bizarre conceptions of normality, and we appoint inquiries.  Then we sum it all up, pathetically, into Ofsted-style ratings (that is the future of hospital inspection apparently).

You can't un-invent this kind of measurement, and it does shine a light into the dark corners of the NHS which - let's face it - have always existed: the geriatric wards, the nightmares of psychiatry, the abusive cruelties of the system - as well as the brilliance of the vision in practice (sorry, verbal nobility again).

But there is a major downside if we turn these measures into a means of control, and the Financial Times journalist Gillian Tett hinted at it yesterday in a brilliant programme in the Radio 4 series Pop Up Ideas.

As a trained anthropologist, she talked about her journeys into the world of bonds and derivatives as the system overheated in the mid-2000s.  The obscure language reinforced the otherworldliness of the financial sector.  They believed that only they could understand it.  And what blinded them about the way the world really was, she says, was their narrow measures.

There is a vital truth here.  

I remember early in 2007, before a whiff of financial calamity had leaked out, I gave a talk in a bankers forum about new ways of imagining the future, and announced a new consultancy to do just that (which we never actually set up).  At the end of the talk, there was a rush for my desk by members of the audience.  But to my disappointment, they were not rushing up to offer to employ us - they were rushing up to ask for a job.

If I had understood the significance of it then, I could have predicted 2008.  But I didn't.  The point was not that the language of banking was so narrow that it took the financial world by surprise.  It didn't.  They all knew what was about to happen, but the language of 'verbal mobility' and groupthink prevented them from saying so publicly.

So here is the irony for the NHS.  Measuring everything drives out the verbal nobility that Barbara Tuchman revealed about the British military.  But measuring things too narrowly, and calling them targets, and trying to control people with them, blinds insiders just as effectively.  

It means they follow the target numbers for waiting times, or make the financial targets, even if it means cruelties and abuse on the wards.  It isn't that they don't know what goes on, when it goes wrong, but - like the bankers in 2007 - they lack the language somehow to describe it.

That is the problem of targets, which we still have in our services in abundance.  They narrow the language.  Those who are subject to targets come to think that they describe reality.  They are able to see outside the numbers, but somehow lose the ability to describe it. 

It is groupthink of a kind, but what it is really an example of the way that targets numb the brain, narrow the language to a comfortable two-dimensions and lobotomise us all. 


BruceK said...

I must admit I do not altogether follow the argument here.

Up until the bankers ask you for a job it seems to me that the argument is that:
1. The numerical targets are ultimately just a proxy for the performance of the system as a whole.
2. Once they exist they monopolise our attention
3. They may not be very good proxies.
Conclusion: They can blind us to failings in the system.

But then it seems that the bankers were not blinded to problems in the system, indeed far from it, but they wouldn't say anything to this effect publicly.

This, though, does not look like a problem with the proxies, but a problem of omerta, the cult of silence, which strikes me as rather different thing.

David Boyle said...

I'm trying to argue, not very well I fear, that there is some link between the narrowing of perspective and the cult of silence. In other words, that it is too simple to say people don't know - they know, but they can't articulate it.