Examination of Witnesses (Questions 20
- 39)
THURSDAY 31 OCTOBER 2002
DR IAN
BOGLE AND
MR DAVID
HART OBE
Sir Sydney Chapman
20. I was going to ask about the difference
between waiting lists and waiting times.
(Dr Bogle) Yes, that is right.
Annette Brooke
21. I want to pick up something David said before
I get into my main questions. Do you not think that the targets
coming down from the EDPs and the agreements are likely to be
shaking up the rather cosy relationship with advisers employed
by the local authority and probably being teachers themselves
and headteachers who actually have been letting some of our children
down for quite a long time?
(Mr Hart) It has certainly shaken up the relationship.
Whether it is cosy or not I do not know.
22. I am suggesting it might have been in the
past.
(Mr Hart) It has certainly shaken up relationships
to the extent where headteachers now view local authority inspectors
or advisers whose prime responsibility is for monitoring standards
and for coming into schools doing the negotiations in a different
light. They do not regard them as being quite the adviser, the
supportive friend maybe, that they used to. Whether that is good
or bad I am not sure. I think the local authorities have a job
to do. It is one of their five or so strategic responsibilities
that they are going to have under the new funding system, to continue
to monitor standards. Let me give you a quick example of why I
think we have these tensions. Key Stage II 11-year olds: take
Southampton as an example. In 2001 in Southampton 11-year olds
achieved about 63 per cent level 4 and above in English and 66
per cent in maths. The targets for 2004—and that is only
about three years of tests, by the way—jumped to 85 per
cent in Southampton in English and 85 per cent in maths. That
is a massive increase in achievement being expected of Southampton.
It is that sort of major increase in performance which is expected
of individual local authorities that will bear down on our members
in Southampton and will lead to a bad relationship I guess becoming
more tense and more strained in the years to come.
Chairman
23. What would be helpful would be if you could
tell us in a nutshell, because it would help us across the board,
where a target like that comes from. By what process of negotiation?
Who is consulted?
(Mr Hart) The Department of Education and Skills civil
servants will arrive at that target and will discuss that target
with the local education authority. The local authority is under
a great deal of pressure to sign up. There is only one local education
authority in the whole country that refused to sign up to its
targets and that was Cornwall. Cornwall refused point blank to
sign up to its targets because it said the whole process was completely
flawed, and I congratulate the Chief Education Officer for Cornwall
for standing out, unlike his colleagues who I think should have
been much tougher in their discussions with the local authorities
about whether these targets that are being expected of them are
really realistic. Each Chief Education Officer has to go through
a negotiating procedure with regional offices of the Department
plus the central Department in London and, after a very tortuous
process, pretty well all of them bar one signed up in the end.
Having done that, they then go to the schools and say, "This
is what we have signed up with the Department. We have got to
get you to sign up to targets so that each school, when put together
as a totality, meets the target we have reached with the Department".
That is the process. Involved in that process, I said in my memorandum,
is a degree of coercion that includes monetary incentives being
offered or monetary penalties being suggested if they do not sign
up, and in the case of some local education authorities of course
they have been threatened with Ofsted if they do not sign up.
That is the negative aspect of the target setting agenda which
I think is in dire need of reform.
Annette Brooke
24. I want now to come to my main question.
I am carrying rather a lot of baggage and I actually believe that
decision making ought to be at local level. My question to David
was about the fact that I did see some benefits with one or two
schools being shaken up.
(Mr Hart) I agree.
25. But the general principle, as far as I am
concerned, is that it should be bottom-up and it should be local
decision making. You suggest, Dr Bogle, that this is rather difficult
because we get different expectations in different areas. My question
to you therefore is, could we not have more local decision making
without running into a problem of postcode lottery again?
(Dr Bogle) Like you, I believe in decisions being
taken at as local a level as possible. All I would flag up before
I specifically answer your question is that when you do that there
will be a variation in the provision of service across the UK
because there will be different priorities in different areas.
That is inevitable. One of the consequences of having that local
determination is that there will be variation. The variation will
be aimed at the needs of the people, if it is done properly, in
the particular area, so I can live with that variation. What I
would like to see, and I think one of the most difficult questions
is the one that was asked before,—pick a target and explain
why it is bad, because individually, when you pick a target, a
lot of them seem to be very good until you look at the unforeseen
consequences of implementing that target without any further discussion—is
the Government cutting down the number of targets that it is putting
forward. I think the Government, in the position it has now, has
every right to suggest target areas and to set targets, but there
are too many. Then I think that locally, through primary care
trusts, they should take note of those targets, they should form
their own plan in discussion with the public in a local area and
the professionals working in that area and produce a business
plan for that area that incorporates the Government targets and
the local targets and makes it clear which targets they find are
the more important for their area. They will need then to submit
that to the specialist health authorities so that there is some
co-ordination, but then to explain in their annual reports, where
they fail to hit targets, why they failed to hit targets and why
they gave priority, for example, to other targets that did not
appear to be the main Government targets. To give you an example
from my past in Liverpool, where smoking related diseases, particularly
chest diseases and chest mortality, were, certainly when I was
there, the highest in the UK. Smoking is one of the very important
Government initiatives but it does not figure as an absolute target
and I would have thought in Liverpool they would want to target
that above all for the illnesses that they see and so I would
expect the business plan to say, "This is why we do it. These
are the figures on which we base our targets", and then to
argue the case, if they cannot hit them because of staffing shortages
or whatever, and there is then some flexibility to debate how
a primary care trust can be helped to get back on track and to
hit the targets. At the moment it is, "There are the targets.
You have got to hit them. No matter how it is, I just want to
hear you have hit them". That does not help the patient at
all. It can be worked locally. I believe we have the structures
in place. It does bring with it some of its own difficulties but
I think we have to live with those.
26. That is interesting. I have not been involved
in EDPs in the last year or two but initially it was so constrained
in choosing the main priorities laid down by the Government do
you actually think there was enough scope for local determination
of priorities for a local education authority?
(Mr Hart) Yes, I think there. I think the problem
is that the by-products of the target setting process are such
that it is difficult to see some heads (not all; they vary enormously,
as you well know) using the autonomy/opportunity to be innovative
to best effect. We know perfectly well that it has distorted the
curriculum, certainly in the primary schools. We are losing music,
drama, sport and so on because of the relentless emphasis on literacy
and numeracy and yet this is one of the major achievements of
this Government, to improve literacy and numeracy levels in the
primary sector. It distorts to the extent where I am now getting
reports of primary schools having already started revision now,
in the autumn term, for next summer's maths and English tests.
That must distort the curriculum in most schools. I would like
to see schools freed up to be able to develop their autonomy,
their innovation, to demonstrate what the Government wants them
to have but a lot still feel very constrained by the relentless
emphasis on the test results that come out in the summer and the
league tables that follow those results, and there is the conflict
which we need to resolve in sensible discussions with the Government.
I respect the Government's democratic right, by the way, to have
targets. I respect its right to have public service agreements.
It goes to the country on a manifesto that says education is a
top priority. It wants to be judged at the next election in part
on achievements in education; I respect that. I just wish that
the dialogue was more open and that the Government listened more
to the responses it gets from the people representing the profession
about the realism of some of these targets and how they are driven
down at school level.
27. Would it actually matter if one authority
put music as a higher priority and another authority did not?
Do you need the unity across the country?
(Mr Hart) You certainly do not need it. The question
is whether the Department will let it get away with that since
each local authority has to file its education development plan
with the Department and each local authority has an EDP which
is supported by all the targets which the individual schools have
signed up to, at seven and 11 and at 14. The DfES has this whole
raft of information given to it and I suspect that if a local
authority kicks over the traces and says, "Sorry; that is
not our priority in our EDP", they would be smartly told
by the Department, "Go away and re-think it. It is not acceptable
to us".
28. If we had this balance of local and national
how could it be effectively monitored? I have had the case in
Dorset of the ambulance trust where there have been a few problems
with reported figures on targets and so on, so presumably the
management had a responsibility but who else is responsible and
how are they going to do the monitoring if we were to give more
local flexibility?
(Dr Bogle) From the health point of view and from
monitoring the clinical input and activity point of view, one
would expect the clinical governance lead at the primary care
trust to watch the clinical capabilities and aptitude of the professionals
in the patch.
29. How can they do it better? You have talked
about all this cheating. If the professionals are going to be
allowed to do their job then somehow we have got to have some
better monitoring, so not how it is now. How could it be better?
(Dr Bogle) That could be better, I believe, by allowing
more time for it to happen. It could be better if you had fewer
clearer targets and particularly from our point of view as doctors
those where we see benefit to patient care and something like
the national service frameworks for coronary heart disease where
there are targets for the provision of drugs, for the care of
patients, and the life expectancy and morbidity in that particular
group has shifted significantly, so professionals would like to
see targets that are fewer but by which they can easily measure
clinically the improvement. The main thing in the Health Service
would be the monitoring by the special health authority—of
course are new bodies—and the business plan of the primary
care trust.
Mr Liddell-Grainger
30. Who do you feel that targets should be used
for? Who should be the most important people to get the information
from target-setting?
(Mr Hart) First the school itself. You have to remember
that this whole target setting agenda is not being discussed in
isolation. We have a performance management system which now every
school has. Every school has a performance management policy.
Every school has a performance related pay system, of which academic
targets and other targets will to a greater or lesser extent form
part. The information which is generated by the performance management
system, by the target setting approach, primarily in my view should
be for the benefit of the professionals in the school to inform
them as to what action they should be taking to improve the standards
of education for individual pupils. Target setting for individual
pupils, by the way, is absolutely first class; it is absolutely
essential. You even start your target setting for individual pupils
if you are moving it up from the bottom. It is vital information
for the school and for the people working in the school. It is
vital information for the governing body upon which the parents
will be represented because the governing body has to make decisions
about the performance related pay of the headteacher and the headteacher
makes a recommendation to the Government about the performance
related pay of other members of the staff. I think it is very
important that the information does go to the local authority
as to how the school is performing against targets because the
local authority has a strategic role to play and is required to
monitor, and if it does not do its job properly it is going to
be sat upon by Government or by the Audit Commission and so on.
I think that the results should be fed through to central Government.
In Wales it is bottom up. In Wales the schools set their own targets.
The targets they set then pass through to the local authority
who pass them through to the Welsh Assembly, so the information
is not secret. That is in my view the order of priority.
(Dr Bogle) I believe that patients should be the ones
who are the first call on the targets, the first ones that targets
should be there to help, first, in providing information about
the services that are available and, getting more sophisticated
if you like, the safety and the comparisons between different
areas, the sort of thing we were talking about originally, and
also targets that would benefit patient care. Another example
of that would be coronary heart disease. Patients are the first
call on benefiting from targets in my view, or should be. The
second group is the professionals and the managers working in
the field and really as a management tool to see how you are doing
against set objectives. That is why it is important that the set
objectives are basically decided locally and have some meaning
and some ownership from the people using them. Last, but certainly
not least, fitting in with what David said, the Government should
be getting the aggregated information with their responsibility
for providing health services.
31. One of the things you say in one of your
documents is that there is a danger that the performance management
systems process could become more important than the outcome.
Do you actually believe that will happen? Do you believe that
is happening?
(Dr Bogle) I believe that is happening, yes.
32. And is it getting worse?
(Dr Bogle) Yes. The more targets there are the worse
it is getting. Ticking a box and saying that you have achieved
a certain level of waiting time or ambulance response is not the
point. The idea is that you should be benefiting patient care.
33. You also say, "One dilemma faced by
successive governments has been to reconcile local and clinical
autonomy with central control". That is basically what the
consultants have said now, is it not, that they want to have the
freedom to do it but outside a system which is constraining them,
making the decision that they are going to do private work or
work within the NHS, whatever they are going to do. Is it not
the target system, the end users of it, the target of information,
even though you would like it to be backed, that is not much what
is happening in reality?
(Dr Bogle) No, it is not happening in reality. What
we were trying to say in our memorandum was what we thought should
happen and where targets could help. That was the purpose of that
and I believe what the consultants were saying was that they,
as much as anybody, voting according only to targets, would mean
that we wanted targets to show benefit to patient care, obviously.
I have no doubt that the answer to your original question is that
in the Health Service the patient should be the one who will get
benefit from the setting of targets.
34. Can I come back to what you were saying
about targets and the way that they hit schools, Mr Hart? If a
headteacher does not hit a target and goes on not hitting targets,
should they be removed?
(Mr Hart) Eventually, if it goes on year after year,
they will be removed. That is a fact of life. They will be removed
but it has to take place over a reasonably lengthy period of time
because—
35. What do you call a lengthy period of time?
(Mr Hart) I will tell you. The problem we have got
at the moment is that people assume that as night follows day
your results must go up year after year; they must go up irrespective
of the fact that you can get a different profile of pupils coming
into your school which may well hit the results. We have got to
get away from what I think is excessive accountability. I believe
in accountability but I think this is excessive accountability.
We have to allow for hiccups. There will be hiccups in results.
That is a fact of life. Obviously, if a school has made a professional
judgment as to what its targets should be and it falls short of
its own targets, then serious questions will be raised, and if
there is no good reason for falling short of targets which can
be explained as a result of factors "in year". For instance,
you can get refugee children coming in in the middle of the year
or something of that nature which can distort the picture, then
serious questions will be raised. If that goes on, say, over a
period of three years or so, then I think the head will be at
risk. Certainly the head will not a get a performance related
pay award in the first year, that is for sure.
36. Because if you take it down to such a low
level, and I am not disagreeing with your answer, but if you go
down too low, could you not stigmatise schools in areas which
are finding it very hard to hit targets because of asylum seekers
or whatever? Could you not get to a position where a school was
finding it almost impossible to hit targets? You have got a local
education authority that is trying to hit their targets, you have
got the Government trying to tell them which targets to hit. Could
you not end up with a vicious circle where you just cannot win?
(Mr Hart) You could do, but if the professional responsibility
is allowed to lie with the school to decide its own targets, and
it will decide that upon an aggregation based upon the individual
pupil targets and then move them through the departments and the
faculties and so on, then it is signed up to a target which it
believes it can achieve at the end of the day. If there are good
reasons why that target is missed then those reasons should be
acceptable to the governing body and to the local authority that
is monitoring the situation. If there is no good reason for that
target to be missed then questions will be asked. All I am saying
is that there will be in-year reasons why the target has been
missed. If there are no in-year reasons for that then serious
questions will be asked and that is accountability. That is what
I am perfectly happy to sign up for.
Brian White
37. Do targets have a shelf life? Just to give
an example, in my area the cataract unit had a massive waiting
list which showed that there was need for investment. That investment
came along and there was a new unit put in, waiting lists disappeared,
with the result that GPs put more people through, waiting lists
reappeared but at a much higher throughput level, so do targets
have a shelf life to achieve a particular purpose?
(Dr Bogle) In general not in the Health Service. I
am trying to think of one where the shelf life might have expired
but no is the answer I will give to that.
38. And in education?
(Mr Hart) I guess, for instance, if you are going
to have targets for truancy reduction or for attendance improvement,
those targets might have a shelf life if we do achieve an improvement
on the truancy situation and the attendance situation, but the
academic targets certainly will not have a shelf life. They will
be with us ad nauseam, I guess. I do not say that, by the
way, negatively. I think they will be with us ad nauseam
because they are key targets.
39. One of the changes that has happened in
public services since Dr Bogle went into the Health Service is
that there was an acceptance of a standardised service in the
sixties before. Now people want individual service in a much more
focused way. Do we not have a problem between individual choice
and the efficiency of a service? In order to get choice you have
to have spare capacity in an organisation and the targets look
at the efficiency of an organisation and therefore tend to make
sure that schools are full and hospitals are running at capacity
operation?
(Dr Bogle) Yes, but there is a contradiction between
total efficiency and 100 per cent bed occupancy and patient choice
because a lot of patients choose to go somewhere where there is
100 per cent bed occupancy. I believe that the Government are
right to increase patient choice. One of the things that I would
like to go back into practice again would be to have this choice
of multiple providers that is now being offered, not just to be
stuck with your local district general hospital but to have other
choices, but you do need to free up some slack in the system.
I know you have also had our A&E report which refers to the
bed occupancy and even within a hospital unit, if you operate
100 per cent bed occupancy, you block your A&E. The idea of
patients being able to go wherever is at the moment more theoretical,
but I still think it is something we should be aiming for because
it is a choice patients should have.
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