Select Committee on Public Administration Appendices to the Minutes of Evidence

Memorandum by The Royal College of Surgeons Edinburgh (PST 43)



  1.  In principle how can public service targets assist in:

    (a)  producing useful management information;

    (b)  ensuring public accountability?


  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)?


  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?


  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)?


  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?


  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.


  6.  Is accountability adequately provided for by the Government's current reporting of targets?


  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?


  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?


  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?


  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?


  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.


  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?


  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?


  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?


  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.


  14.  What benefits and costs have targets brought to public servants—and do they know enough about them?


  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?


  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?


  The answer is yes in that targets and league tables are treated with great suspicion by all involved in service delivery in the NHS.


  17.  What resources do Government departments need to set and monitor appropriate targets? How best can they be organised to achieve this?


  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?


  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?


  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?


  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?


  There would at least be ownership of the target.


  22.  What criteria should be used to assess whether targets have been successfully met?


  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?


  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?


  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?


  No, because of inadequate IT and financial resources allocated for this role.


  26.  Are there useful lessons for UK departments in the way that overseas governments, devolved bodies or the private sector use targets?


  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).


  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?


  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?


  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?


  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?


  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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