Cassilis

Early responses to the Conservative policy green paper on the NHS seem to take issue with the Tory approach to targets. In yesterday’s Guardian John Appleby - chief economist at the healthcare thinktank The King's Fund – suggested that the complexity of healthcare provision is such that targets ‘will always play a part’ in improving the NHS and Labour blogger Hopi Sen was equally dismissive of Cameron’s speech introducing the green paper:

“It’s easy to say “ooh, targets are bad”, until you need to actually make something happen. Then targets become useful. Like zero tolerance policing, which politicians love more than they love their mothers. When you think about it, that’s a target. You see, what the Tories have apparently discovered is that targets are good, but only if they’re the right kind of targets. Outcome targets are good. That’s setting a clear objective. Process targets are bad. They’re top down state centralisation, see. Now this is all very fine and dandy. Outcomes good, process bad. It’s catchy. The trouble is, well, that it’s silly.”

Both John and Hopi are getting this wrong and subtlely misrepresenting the Tory position. Let’s get one thing clear that might not be apparent from these responses and much of the reporting on this – the Tories are not advocating scrapping measurement or the setting of targets in the day to day management of the NHS – they’re advocating a dramatic reduction in the number of centrally imposed targets from Whitehall and, for those that do remain, a shift (as Hopi says) away from fragmented process-focussed targets towards those focused on outcomes. The implication that a Tory-run NHS would use no internal measures or targets in day to day healthcare provision is nonsense and obscures the key change the Tories ARE advocating – that those targets and measures should, largely, be at the discretion of local management and Whitehall should be concerning itself with health outcomes on behalf of the public. It’s not about targets but a ‘target culture’ – a very different thing. ‘Target cultures’ divorce process and outcomes – they prioritise the minutiae of healthcare provision over and above its overarching aim of making people well. The stories of patients left in ambulances or admitted to wards to avoid ‘contaminating’ A&E performance stats are too common to be dismissed. Basic mathematics tells you it’s possible to meet a raft of targets and tick the boxes while failing the overall outcome every one of those targets was designed to support (and the other way round of course)

The reason this shift is so important was articulated well in the Observer by Simon Caulkin last month – it’s about a genuine break with ‘producer interests’ rather than the phoney break the target culture attempted:

“New Labour embraced the 'public choice' theory that had so excited right-wing intellectuals under Margaret Thatcher: basically, applying economic principles to politics. The problem was that civil servants, like any 'producers', tended to put their own interests above those of the public they were supposed to serve. Since they could not use the 'perfect democracy' of the market to tell public-service providers what to do, Blair and the delivery unit eagerly enlisted centrally set targets instead. Unfortunately, while they congratulatedthemselves on having disenfranchised one set of producer interests - the professionals - the ‘deliverologists’ neglected to notice that they were installing a more pernicious one in its place: themselves. Instead of making providers accountable to citizens, the new regime made them accountable to ministers and the burgeoning bureaucracy of performance management.

Do quotas and targets enforced by a regulatory bureaucracy remind you of anything Yes: they're called central planning and don't work any better in UK local government offices and police stations than in Soviet tractor factories.”

It's a very 'New Labour' attitude to believe that accountability to well meaning ministers and civil servants is a suitable proxy for accountability to the people. The relatively poor returns in terms of health outcomes on Labour's record investment in the NHS (for which it does deserve credit) suggest otherwise - anything that tries to correct that accountability has to be a good thing.