Drawing the right comparisons

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The course leader on a training session I attended many years ago made the dramatic assertion that anyone who claims to have more than three priorities actually has none. Whether ‘three’ is the right number in this statement is open to discussion, but his basic point was that having too many priorities leads to a lack of focus on what is really important. What brought it to mind was the changes to NHS targets in England, which highlighted just how many targets the NHS is actually trying to meet. And a huge problem with a target-based approach is that people end up managing to meet the targets rather than to deliver the best outcomes.

Another example which comes to mind is a time when I sat through a meeting of a local authority committee which was seeking to find what are euphemistically (but wholly inaccurately) referred to as ‘efficiency savings’. The work overseen by this particular committee was subject to, as I recall, 97 different ‘key performance indicators’. Most of them set, apparently, by the Welsh Government in Cardiff. One of them concerned dog fouling, and more specifically the percentage of incidents cleaned up within a defined period after receiving a report from a member of the public. The authority concerned was achieving a clear-up rate of something like 95% against a target of around 80% (my memory of the precise figures may not be entirely accurate). Anyway, the point is that the officer leading the discussion pointed out that the council got no extra credit for achieving such a high level and could make an ‘efficiency saving’ by deliberately reducing the level of service down to the targeted level. The target was effectively being presented as an absolute, not a minimum, service level to be met, and the targets were being used to make comparisons between different authority levels, in a situation where spending more than strictly necessary in order to exceed the target was as big a sin as not spending enough to meet it. It’s a petty example, of course, but it underlines the dangers of trying to manage large and complex organisations by setting large numbers of targets.

People sometimes assume that the private sector, motivated by an exclusive focus on profit, is somehow different, but my own experience suggests otherwise. Whilst there might be an overarching profit target to be met, large and complex organisations often end up splitting that target down into divisional and departmental targets. I have in the past found myself obliged to argue about whether my department or another should carry a particular cost (which was actually rather less than £1,000) when I thought my time might be better spent trying to increase income.

Whatever, and back to the NHS, it seems as if the English Health Minister is more concerned with demonstrating that the English NHS is doing better than its Welsh and Scottish equivalents than he is with achieving satisfactory patient outcomes. And he’s not afraid of using invalid comparisons (because the figures are collected on different bases) to support his argument. He did call for ‘more transparency’ from Wales and Scotland (translation: keep your statistics on the same basis as England or else), but the English numbers aren’t exactly transparent either, and keeping the numbers in a format specifically designed to enable the English Health Secretary to attack his Welsh and Scottish equivalents doesn’t look like the most attractive option for Wales and Scotland. More importantly, neither does it actually help to improve outcomes.

The health service in Wales is far from perfect, we all know that. And comparisons are an important way of learning, of course they are. But if I wanted to assess comparative Welsh performance, I wouldn’t choose England as the best, let alone only, comparator for everything. There are many other places which do some things better (as well as some things worse); learning from them and applying those lessons where applicable is a sensible exercise. But it’s about a lot more than reporting numbers against arbitrary targets and using the results for political point-scoring. It’s not a point that I’d expect an English nationalist like Barclay to understand – if you start from the unshakeable belief that the English NHS is the best health service in the world and has nothing to learn from anyone else, trying to force others to do as you do is the natural default. It is not, though, a default into which Wales and Scotland need fall. We have the opportunity to be more open to doing things differently and should take it. Ignoring Barclay is a good starting point – it’s not as if he’s going to be around much longer is it? My bigger concern is that Starmer seems to see managing NHS performance in the same terms.