Fantasy targets

NHS Management

Defensiveness runs through all aspects of the NHS.  To be fair it runs through most public services and quite probably a good deal of private ones as well.

Why are we so defensive in the work place, who is to blame?

Well, the short answer is everyone is to blame because defensiveness permeates at every level.  So pick your starting point and let’s go on a journey.  The CEO, you say,  it is all the fault of the CEO.  Ok, let’s start there.

The CEO of any major NHS Trust is responsible for oodles of people.  As an example Leicestershire Partnership NHS Trust  provides a range of health and wellbeing services mainly for people living in the city of Leicester and the neighbouring counties of Leicestershire and Rutland. The Trust serves a population of one million people, has a budget in excess of £250 million and employs almost 5,500 staff.    According to Dunbar, we can only know about 150 people with any real understanding of who they are and how they relate to each other.   So the CEO is basically managing a whole lot of people who are just numbers on a page.  Sending down orders and instructions with very little idea of how these policies will affect those who have to respond to them.  Not the CEO’s fault entirely as they are relying upon their middle managers who have only half an idea when few of them have risen from the ranks.

The CEO is also on the receiving end of targets set by someone who has no idea about the feasibility of these instructions.   Fundamentally, in the NHS everyone is asking for more delivery with fewer resources plus detailed data gathering to prove success.  So the CEO probably has targets that are not realistic and can’t be delivered.  No matter, it is the CEO’s job to deliver and pick up the pay cheque.   So they pass the buck down and now the middle managers have the problem of delivering more from a service which is underfunded and quite likely understaffed.  Do more with less is all that is asked.  Oh by the way when you are not squeezing the lemon can you write me a data report outlining how you are meeting your targets.

So the front line now have the problem and they just know it won’t work.  To put it simply they don’t have two pairs of hands or eyes in the back of their heads, but to come even close to meeting their targets they need both.

So who should speak out and report back up the line that the blood simply cannot be extracted from the stone?

Well, if it is a front-line staff member they will be accused of not being a team player, not pulling their weight or being a poor practitioner.   If they persist they become a whistle blower with all the ramifications for their career.  So the message won’t come from there.  Middle-management have their own targets to think of and the implications for their career prospects.  They can’t admit failure to deliver.  So no-one says a word and life goes on.

Except that the targets can’t be met; it is not humanly possible to get more for less and so the inevitable incident will occur.  At that point the front line staff are defensive, trying to keep up the pretence that they have been delivering all this time.  The manager, if they find out, is also in a difficult position.  Unable to report up for fear of career suicide they simply apply damage limitation downward.  When the repeated failures pile up so that the CEO gets to hear of the potential scandal they order an immediate clean up of evidence.  Can’t have widespread failure invalidating your neat charts and data sets.  What would the minister say?

Everyone becomes part of the cover up because there is no opportunity to say ‘it can’t be done’.  

And that is it.  The model we work with and have done for some time.  Totally dysfunctional, based on fantasy targets and kept afloat by pretence.   One simple solution could be for the CEO to pull into his team some of the front line staff.  If they are able to say, in a safe space, that a new proposal just cannot be delivered, then perhaps the targets coming down would be more realistic.  Or let’s have an upside down model where the targets come from the bottom up in the first place.  Or let’s just have some honesty and decency and stop blaming people for knowing their limitations.

We all know what happens to stretch targets – they break!  

First published on phsothetruestory