Memorandum by The Royal College of Surgeons
Edinburgh (PST 43)
QUESTIONS ANSWERED
1-31
GENERAL
1. In principle how can public service targets
assist in:
(a) producing useful management information;
(b) ensuring public accountability?
Answer:
In order to produce useful management information
and ensure public accountability, the correct targets must be
chosen in the first instance. The service involved and the public/lay
representatives working with that service should be involved in
choosing the targets.
2. In practice how well do different Government
departments currently use targets in terms of:
(a) the basis on which they set targets,
and
(b) the use they make of the information
produced in relation to targets (eg in planning the business of
the department)?
Answer:
In relation to the Health Service, it could
be contended that very often the wrong targets are chosen in the
first instance because of lack of service involvement when choosing
targets. In addition, the medical Royal Colleges should be involved
when targets involve standards of education and training of doctors.
3. Do current targets put too much stress
on the three "Es" of the economy, efficiency and effectiveness,
and not enough on wider public service concerns such as equality
and probity?
Answer:
While economy, efficiency and effectiveness
are stressed, there should be a wider acknowledgement that from
the patient perspective, quality of service would be at the top
of the agenda. How service quality is then measured becomes the
question for debate.
4. Why are some targets popular with the
public (eg those concerning reduction of greenhouse gases, or
the millennium development targets) while other targets are treated
with more scepticism (eg those concerning waiting list reductions)?
Answer:
The individual patient on a Health Service waiting
list does not believe they can influence change. The public at
large are also aware that the NHS and clinicians are struggling
to overcome enormous challenges while working in an understaffed,
under resourced and, in many respects, old fashioned service.
5. Is it always best to measure outcomes
rather than outputs? Is it sensible to have a mixture of both?
Answer:
Both output and outcome should be measured in
the Health Service context. In addition the efficiency of the
Health Service should not solely be measured on hospital outcomes—socio
economic parameters and returning patients to a full role in society
must be assessed.
The Health Service outcomes should also measure
disease avoidance and the promotion of good health.
TARGETS AND
ACCOUNTABILITY
6. Is accountability adequately provided
for by the Government's current reporting of targets?
Answer:
In the Health Service accountability is absolutely
clear and the management terms rest with the Chief Executive of
a Trust and above that, the Executive and the Minister. Consultants
are accountable for the quality of care of individual patients
working within the parameters of Clinical Governance, appraisal
and revalidation, and collegiate standards.
7. Are departments clear and consistent
in the way they report against their targets?
Answer:
Not always.
8. Would it be helpful for the Government
to publish an across-the board evaluation of how well it has performed
against it targets?
Answer:
This may help Government but it is doubtful
whether the information would be of help to individual services.
9. Should departmental Select Committees
make it a priority to take evidence on relevant draft targets,
perhaps set out by the Government in a White Paper and subject
to wider consultation?
Answer:
Only if the targets have been clearly set out
and agreed by all parties involved, including the "end users"
and "end providers" of a service.
10. Should there be a league table for the
performance of Government departments?
Answer:
How would this be measured? Would it be helpful
or relevant? External, independent quality assurance using the
National Audit Office would give to the public greater reassurance.
TARGETS AND
SERVICE USERS
11. Do league tables and publication of
information about targets really widen choice for public service
users? If so, how is this achieved and does it equally benefit
all service users, and others with an interest?
Answer:
In the Health Service context, it is dubious
whether league tables are taken seriously either by staff who
provide the service or by patients because they are rarely, if
ever, involved in setting the targets. Publication of league tables
based on information from organisations such as the Scottish Audit
of Surgical Mortality (SASM) may destroy individual clinicians
confidence in the process. Clinical performance hinges on a wide
range service, resource and staffing parameters as well as the
individual clinician. Performance of a service would be a better
approach, assessing all factors relevant to that services outcomes.
12. In 1999 the Treasury Select Committee
criticised departments for failing to "build quality of service
into the targets". Has the situation improved since then?
Answer:
If the situation has improved it is difficult
to find evidence for this from the perspective of the Health Service.
13. Could the process for setting targets
be improved, perhaps by involving service users more fully and
more effectively?
Answer:
To improve the process for setting targets would
require not only involvement of service users which would be welcome
but also service providers, ie clinicians, nursing staff etc.
TARGETS AND
PUBLIC SERVANTS
14. What benefits and costs have targets
brought to public servants—and do they know enough about
them?
Answer:
The answer to this question is dependent on
which group of public servants are being debated. The targets
set in the Health Service has frequently frustrated the provision
of appropriately prioritised clinical care.
15. Which targets are effective at helping
to motivate front line professionals and improve their performance?
In what way should front line staff be consulted when targets
are being formulated?
Answer:
I would doubt whether targets motivate front
line staff but they should certainly be consulted when these targets
are being formulated. Motivating staff requires ensuring they
are respected, consulted, recognised and rewarded.
16. Is there a change that targets and league
tables that are badly drawn up and crudely managed will destroy
moral and motivation on the front line—for instance by implying
that professional cannot be trusted?
Answer:
The answer is yes in that targets and league
tables are treated with great suspicion by all involved in service
delivery in the NHS.
TARGETS, CENTRAL,
REGIONAL AND
LOCAL GOVERNMENT
17. What resources do Government departments
need to set and monitor appropriate targets? How best can they
be organised to achieve this?
Answer:
There requires to be a well funded structured
approach to information systems in the NHS which to date have
failed to delivery good information but only large amounts of
poorly structured data.
18. Could there be a bigger role for local
and regional bodies in setting and monitoring targets? Should
those who formulate national targets be prepared to learn from
those who set local targets?
Answer:
The Clinical Standards Board for Scotland (CSBS)
and the Scottish Intercollegiate Guidelines Network (SIGN) are
good examples of clinicians working with service colleagues and
lay representatives to provide good targets based on standards
of care.
19. Should more local bodies be required
to set their own service targets instead of or in addition to
national targets, along the lines of the schemes already introduced
in schools and local authorities?
Answer:
Yes, provided the local bodies are appropriately
funded to do the work.
20. Do local organisations have the skills
and resources to set and monitor their own targets? Is there not
a risk of tensions between local and national priorities?
Answer:
Local organisations almost certainly have the
skills to set and monitor local targets but they would need appropriate
resources. Clashes with national priorities would only be a problem
if there was mutual distrust.
21. On the other hand, wouldn't an extension
of local target-setting encourage unfairness and inconsistency,
as with so-called "postcode prescribing" and wouldn't
local targets be a recipe for more bureaucracy?
Answer:
There would at least be ownership of the target.
MONITORING AND
EVALUATING TARGETS
22. What criteria should be used to assess
whether targets have been successfully met?
Answer:
Variable. Outcome measures based on cost benefit
to the community as well as the individual would need to be built
into the target.
23. In the United States, the General Accounting
Office make a substantive assessments of government performance
against targets. Should the National Audit Office be asked to
undertake an equivalent assessment in this country?
Answer:
We understand that the National Audit Office
and Audit Scotland are already involved in assessment performance
in the NHS. Given the current climate of concern in relation to
overall service provision in the Health Service it is doubtful
whether these organisations can assess the whole of the service
but a wide-ranging approach would be supported.
24. What sanctions should be applied by
Government when service providers fail to achieve targets? Or
is it better to use the "carrot" of greater autonomy
rather than the "stick" of sanctions? What real evidence
is there that either approach works?
Answer:
Staff facing difficulties respond to support,
provided active attempts are being made to identify solutions.
Ensure staff have been involved in setting targets and why the
targets were chosen. Failure to meet targets will then be a shared
responsibility and solutions can be sought jointly.
25. Do departments have good enough performance
data to monitor progress against targets, and do they make proper
use of that data?
Answer:
No, because of inadequate IT and financial resources
allocated for this role.
MISCELLANEOUS
26. Are there useful lessons for UK departments
in the way that overseas governments, devolved bodies or the private
sector use targets?
Answer:
No comment but the Swedish approach to shared
funding of inappropriately housed frail patients is an exciting
concept.
27. Please give an example of what is, in
your view, a "good" target (in the sense that its achievement
will enhance the quality of a public service) and one that is,
in your view, a "bad" target (in the sense that it might
make a (public service less effective and efficient).
Answer:
A patient who is seen within a short time-scale
likewise has an operation shortly thereafter which has a good
outcome. The patient must return to function normally within society,
or social services and the non-hospital authorities should be
involved in care that cannot be provided by the family or privately.
To achieve this will, however, require adequate funding and resourcing
from a non NHS budget.
28. Do public services need fewer and leaner
targets than they have now, and if so, how should they be thinned
out? How otherwise could priority targets be identified?
Answer:
Yes and involving "end users" and
"end providers" will help choose the key targets.
29. In the past, some targets have been
dropped between Spending Reviews; has this led to a serious loss
of accountability?
Answer:
No comment.
30. Is it really practicable to set and
monitor targets which are shared between departments? If so, what
is the best way to do it?
Answer:
No comment.
31. If you believe the use of targets is
a bad or flawed idea, what alternative approach would you advocate
which would help bring about real and lasting public service improvements?
Answer:
Targets provide a focus for service delivery
but they should be set in such a way that they are less vulnerable
to political manipulation.
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