Target setting and other strategies

Citation

Gourlay, R. (2003), "Target setting and other strategies", International Journal of Health Care Quality Assurance, Vol. 16 No. 7. https://doi.org/10.1108/ijhcqa.2003.06216gaa.001

Target setting and other strategies

Target setting and other strategies

In the UK "New Labour" – the party in government – is learning some painful (politically) lessons about the management of the larger, dispersed and complex institutions. New Labour came into office committed to improving public services including education, health and transport. Its initial approach was to define targets for institutions in these fields to achieve. This was backed up by the establishment of "inspectorial" bodies which would assess progress being made towards the achieving of the targets, publishing their analysis for all to see. Consequently such bodies have been installed for education, transport, and many utilities. In health the Commission for Health Improvement (CHI) was established. Initially it took a somewhat more facilitative approach, although many managers felt its teeth. The government now intends that CHI should be more "inspectorial" and audit-focused with a change of name to the Commission of Health Audit and Inspection (CHAI).

Obviously the government wants to see results in the shape of improved services for patients. It aims to do this by publishing targets for health organisations to achieve. The dilemma the government faces, though, is that, where targets are not being achieved, opposing political parties make political capital out of such failures. And it is the nature of the political processes for an opposition to concentrate on failures rather than on "government" successes. The government naturally wishes to shield itself from such public criticisms especially on such a hot political potato as health. It can do’this by adopting one or all of three strategies.

The first of these is to "lay the blame" for the non-achievement of targets at "management", accusing them of being system-driven bureaucrats. This clearly has a negative effect on management motivation and is contrary to the attempts to create an equitable culture in the management of health care. Nevertheless it is an easy strategy for governments to deploy and is reinforced by the more "critical" newspapers and media.

The second strategy is more complex than the first. In this approach the government divests itself of the responsibility for the performance of health-care organisations. This accountability is placed elsewhere. This is the strategy that the "New Labour" government wants to deploy with the creation of Foundation Hospital Trusts. Here the idea is to create an overseeing body of stakeholders to whom the hospital trust management would be accountable. Along with this, the management would have greater financial, operational and strategic freedoms. They would be far less constrained on such things as the raising of capital on the open market and the determination of terms and conditions of service for staff. The opposition to this approach comes not from the opposing "right wing" political parties but from the left wing of the "Old Labour" party, who allege that such an arrangement would create a two-tier service, as not all hospitals would be allowed to have "foundation" status. Those that did achieve such a status would be able to exercise more "muscle" in attracting staff and would also be able to acquire other expensive resources than non-Foundation Hospitals. Other criticisms of this approach involve the problems that would occur if a Foundation Hospital went "bust".

The third strategy focuses on the target-setting process itself. Currently the approach to setting targets is a "top down" "Theory X" style. Targets are imposed and penalties for non-achievement threatened. The consequence of this style is the creation of a culture of negative creativity, where the attempts are more concerned with finding ways around the targets than with their achievement.

The process of target setting needs to be more participative, so that the results are "owned" by the relevant management. The Government, on the other hand, needs demonstrable evidence that things are getting better. To satisfy this legitimate aspiration, targets should be to do with local improvements and should not be nationally imposed absolutes. With the proposed approach each health organisation would select up to 20 key areas for itself that would result in improvements in their patient care. Management would analyse current levels of performance for each key area and propose a percentage improvement for each such area over the next one to five years. This process would be subject to the oversight of the CHAI, which would need to be assured’that the targets were in key areas and did force management to have to "stretch" to achieve them. The result would be a "contract" between the relevant Strategic Health Authority (SHA) which would report to the CHAI annually on progress toward target achievement and each Trust.

Adopting the process would result in:

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  A range of defined improvement targets for each health organisation.

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  A commitment to each target by local management, because they have had a say in their development.

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  A positive recognition of Government's need to demonstrate real improvements in the service without the potential for distortion.

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  A fair means to hold local management to account.

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  An explicit contract between local management and the SHA devoted to continuously improving the process of health care.

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  No change in structural roles and responsibilities.

In essence what we are proposing are good management practices, which allow local management to manage in a positive fashion, whilst giving the Government a range of performance targets to which all are committed.

Robin Gourlay