Sunday, 10 February 2008

Targets kill, beware

This excellent Guardian piece succinctly dismantles the government's pathetically stupid target based culture that has been enforced across the whole of the public sector:

"What happens when bad measures drive out good is strikingly described in an article in the current Economic Journal. Investigating the effects of competition in the NHS, Carol Propper and her colleagues made an extraordinary discovery. Under competition, hospitals improved their patient waiting times. At the same time, the death-rate following emergency heart-attack admissions substantially increased. Why? As targets, waiting times were and are measured (and what gets measured gets managed, right?). Emergency heart-attack deaths were not tracked and therefore not managed. Even though no one would argue that the trade-off - shorter waiting times but more deaths - was anything but a travesty of NHS purpose, that's what the choice of measure produced.

As the paper observes: 'It seems unlikely that hospitals deliberately set out to decrease survival rates. What is more likely is that in response to competitive pressures on costs, hospitals cut services that affected [heart-attack] mortality rates, which were unobserved, in order to increase other activities which buyers could better observe.'

In other words, what gets measured, matters. Measures set up incentives that drive people's behaviour. And woe to the organisation when that behaviour is at odds with its purpose. Imagine the cost to NHS morale (one of Deming's unknown and unknowable figures) of the knowledge that managing to the measure resulted in more deaths - the grotesque opposite of its aims. Hospitals are the extreme example of a general case. As such, they allow us a definitive rephrasing of our least favourite management mantra. What gets measured gets managed - so be sure you have the right measures, because the wrong ones kill."

This thinking is based upon this article in the Economic Journal, whose abstract makes the situation rather clear:

"Our results indicate that hospitals in competitive markets reduced unmeasured and unobserved quality in order to improve measured and observed waiting times."

In other words targets are a complete waste of time, not only do they increase the bureaucratic burden but they result in the lowering of standards in anything that is not directly linked to a measured target. The government's answer to this has been to produce more and more targets, but you cannot measure everything, so anything without a target attached is still left to rot, while the system becomes more and more innefficient as the bean counters and bureaucracy proliferates exponentially. Targets need to be decimated.


Dr Xavier Ray said...

We have a wonderful example of this with facet joint injections. If they are done by orthopaedics there is a target for referal-to-treatment waiting time. If the patients need an x-ray there is a target for diagnostics but (and this is really clever) if they are referred to diagnostics for treatment (x-ray guided injections done by a radiologist - no target! Waiting time not even measured.

Anonymous said...

The real problem is that there's no free market in medicine in the UK. In a free market, if 'McHospital' was offering lousy service, people would go to 'Doctor Hut' for treatment instead; but with socialised medicine they have no such choice... they're forced to pay for the NHS, so unless they're rich they're stuck with using it no matter how bad it gets.

So without competition and consumer choice, governments impose 'targets' to try to ensure that taxpayers get something resembling decent treatment at a decent price (at least enough that they won't be pissed off enough to vote the government out). The problem is that the targets are set by bureaucrats and not Joe Public, so, as you say, management end up gaming the system to find any way they can to meet targets which bear little resemblance to what the taxpayers actually want them to do.

As Hayek and friends pointed out decades ago, central planners cannot manage a system better than a free market because they cannot, even in theory, collect and process the information required to do so; the current 'target culture' is a glaring demonstration of that... the more information they collect and the more targets they set, the worse government 'services' become.

Garth Marenghi said...

The 'free market' is no utopian vision.

The 'free market' sttle system in the US is more bureaucratic and inefficient that our system!

The best system must be well managed and sensibly regulated, and it must have a good balance between private and public sectors.

Targets set by joe public would be an even bigger disaster, as Joe Public is even less informed than the bureaucrats and targets do not work, even if they are 'sensible targets'.

There is no utopian system.

However we could build on what we do well, rather than engaging in rapid stupid ideological reform.