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‘The health service is wasting precious time fiddling figures to hit performance targets’

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The continuous pressure of NHS league tables is creating a management culture focused on meeting targets rather than providing services, argues Blair McPherson

A staggering 68% of public sector organisations in the UK admit to being aware of data being ‘massaged’ to make their performance look better, according to a recent survey on public sector performance management. This was higher than the rates reported in the US, Canada and Australia.

The pressure of continuous improvement, the publication of league tables and the focus on measuring success by performance against targets is leading some to cross the line between presenting NHS trusts or social services departments in the best possible light and ‘fiddling’ the figures in order to hide poor performance.

While there has been the occasional scandal, this survey, carried out by the Advanced Performance Institute, a leading independent research organisation, would indicate the practice is widespread.

I know of one director who changed the returns for the then Social Service Inspectorate before he submitted them. When challenged, he said he was not prepared to submit a figure that showed a deterioration in performance from the previous year.

He has since retired. How did he get away with fiddling the figures?

The authority was a two-star coasting directorate at a time when inspectors were focusing on those with one star. The director had no ambitions for the authority to have three stars as he believed there was only one way to go from there – down. So he did not overinflate the returns, just smoothed them out. Since then, the problem of coasting authorities has been recognised and more targets introduced.

The NHS has been subjected to the same performance culture. The assumption is that hospitals and PCTs cannot be trusted to deliver the government’s agenda without nationally set targets, national league tables and the threat of naming and shaming.

An example of this is the 18-week waiting time for an operation. The government’s aim was to cut waiting times across the board. Even 18 weeks can seem too long to a patient but it’s preferable to two years.

Managers had to put systems in place to ensure targets were met because it seemed nurses, doctors and allied professionals could not be relied on to deliver – they tend to base treatment decisions on clinical need rather than arbitrary targets.

Once the aim becomes meeting the target, as opposed to reducing the time patients wait, people start trying to devise ways to get round the system.

This doesn’t have to involve changing the figures. It could be as simple as finding ways of delaying patients appearing on the list.

I may be being cynical but, if within 12 months most hospitals are reporting that 100% of patients are seen within 18 weeks, then either the target is too easy or managers are finding ways around it.

The public sector survey indicates plenty of people are prepared to fiddle the figures to keep the pressure off. This may explain why performance management is a way to produce figures for an external audience rather than a useful management tool.

Of course, boards are supposed to identify where performance is not hitting targets or is not as good as that in other organisations.

But it is all too easy to be overwhelmed by the sheer volume of statistics. It’s often difficult to identify which are important among hundreds of performance indicators, and it requires a detailed knowledge of the business and some sophisticated analysis to identify what is a reasonable reason for a variation and what is an attempt to pull the wool over your eyes.

Besides, what use is this statistical information if everyone does not have total confidence in it? No wonder the emphasis is shifting from targets and indicators to satisfaction ratings.

I can’t help thinking that the problem is creating a fear of failure where public sector managers are treated like football managers – only as good as their most recent results, their position in the league table and their relationship with the board and chairperson.

Blair McPherson is director of community services Lancashire County Council

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