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Sunday, 20 November 2011

Targets... good or bad?

There was a quiet U-turn of sorts this week when Andrew Lansley decided to reintroduce targets to control hospital waiting times.  Why?  Because it turns out that more NHS patients are waiting longer than 18 weeks for treatment since the government scrapped targets in May last year.

Of the patients treated in September 2011, almost 18,000 more had to wait longer for treatment than in May last year.  In neurosurgery, there was an increase of 66% in patients who had to wait more than 18 weeks.

This raises interesting questions for a liberal blog, whose default position should be less central control, give power and responsibility to the doctors and nurses closest to the patients. 

In fact, Andrew Lansley has had to say that the Department for Health will now begin monitoring the numbers of patients waiting longer than 18 weeks.

You might draw the conclusion, as Labour is doing, that if you scrap the central targets then the quality of service goes down.  That their "top-down" approach, vilified by Tories and Lib Dems at the last election, does actually work.

For me, it sums up that you need to look beyond the rhetoric of "top-down versus bottom-up".  You can have a health service which delegates authority, responsibility and innovation to the lowest tier and still maintain central targets of an acceptable service.

Any business (public or private) delivering a service needs to measure itself against certain standards.  Setting those targets isn't a straitjacket that hinders innovation, since hospitals can always exceed the target or be named and shamed if they miss the target, just as a private business would be if it performed less well compared with its competitors.

I began reading Sir Michael Barber's book (he was Head of Tony Blair's "Delivery Unit") on what he calls "deliverology", what others call "top down targets".  It was hardgoing, but it convinced me that its central approach was a sensible one.  It's based firmly on the idea of reducing the layers of bureaucracy or chain of delivery between politicians saying what the service should look like and hospitals or schools delivering that service.

The coalition like Sir Michael's ideas enough to have exported him to try and sort out Pakistan's education system, something we're pumping tons of DFID money into.

And it seems to be wholly possible to have central targets, as long as there is freedom for service providers to have control of their own budgets and ideas to deliver that service as they see fit.  That's the important part of the "bottom-up" approach that we really need to get cracking with.

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