Iinnovation versus manipulation in the NHS

Targets came from Jeremy Bentham, in a labyrinthine journey via Robert Macnamara and Key Performance Indicators. They purport to provide transparency and accountability, and – in some ways, in the absence of anything else – they do.

The difficulty is that they never quite measure what they claim. They are indicators of the thing – success – and not the thing itself. And in that gap, so many difficulties follow.

I write all this because of a blistering attack by the influential NHS blogger Roy Lilley this morning about the effects of too close attention to targets is having on an NHS which feels itself embattled – and the tricks the managers are laying to avoid confrontation with the regulators, like delaying all operations to insert patients from the waiting list, or declaring a local emergency so that the targets don’t apply.

Many of us involved in Lib Dem policy in 2010 believed that the coalition would dump the Blair-Brown idea of targets altogether, and they did to some extent. But enough of the old edifice remains to twist the purpose of services and create waste.

Why didn’t they go further? I think because nobody had thought through enough – as they still have not in enough detail – how to provide accountability without some kind of target-driven inspection system.

But we have come some way. What we have left is the bones of the old Blairite, utilitarian design that dreamed that public services were giant humming machines, run outside politics by men in white coats, huddled over the dials.

That system remains because Whitehall has not yet realised how far the target numbers are from reality – cf. Goodhart’s Law – and how delusory their progress figures are. Or what to do about it. That is all now deferred for the next Parliament.

I thought before, and still think, that it was a wasted opportunity, but you can’t move until there is some consensus about what you do instead – and that remains elusive, though John Seddon’s work points in a pretty clear direction.

In the meantime, the NHS is still overseen in this bizarre system of management-by-numbers, which stands in relation to leadership as painting-by-numbers stands to art (see my book The Tyranny of Numbers).

You can see how targets might keep hospitals to the task in hand when budgets are increasing. But when they are shrinking, and demand is rising – partly because of the way contracts have tended to narrow services and spread costs – then targets just become ridiculous.

And in the midst of a crisis, like wartime for example, checking on the success of hospitals by peering at the target figures just becomes like satire.

The real question is this: who in the top eschelons of the NHS is watching over trusts and hospitals and supporting their leadership when they are providing innovative solutions despite targets? And who is holding them to account when they are meeting targets by putting all their energy and ingenuity into tricking the system?