Putting on a performance

One of the things about going through a work trauma is that after the long process of soul searching and developmental growth what you end up knowing about the world can sound a bit, well, stupid. 

Simplicity is often confused with simple mindedness, as my twitter account @survivingwk can testify. I do psychosocial ‘lite’, unashamedly reclaiming the language of tips and solutionism that dominates our mental health debates to make some hard-to-hear points. 

Because of this, I’m often wheeled out at mental health events as the last speaker to cheer everyone up. I do this with varying degrees of irony aux power point as follows:

How to survive work:

  • Don’t blame yourself
  • Don’t stay calm and carry on
  • Don’t be brilliant
  • Don’t go it alone

Annoying eh. 

I do this for a number of reasons. 

Firstly, I genuinely believe all of that for deep experiential reasons. I actually think that Freud would have loved twitter and would have experimented with online technologies. There’s no point in believing in something, whether it’s psychoanalysis or anarcho-syndicalism, if nobody ever gets to engage with it. Hence this blog. Hence writing in short sentences. 

Oh OK, I’ll admit that the temptation to prod the beast of Noa’s-Arkism that dominates healthcare also comes into play here. As someone who not only knows they don’t have a place on the professional boat, and is coming round to the idea that there is in fact no boat, I don’t have any problem offering up the proposal that nothing will change through any of us being brilliant. This goes down very badly at professional conferences, but we don’t even get the off the starting blocks of compassionate care if we don’t challenge our tendency for heroics. 

In an age before the word ‘employability’ even existed, I studied philosophy at university where I learned that if you really understand something it can be said simply. No need to hide behind professional codes or pretension if you want to understand something. I’m a big fan of research and reading it, but I don’t think that you need to reference Foucault or Gramsci to make a political point.

Most of us are totally disorientated by our workplaces, unable or unwilling to stare into the abyss called The Future of Work. So this week we look simply at the advent of performance management and why a culture of fear and loathing has become installed in the public services.

The following section is from the new book Industrialisation of Care by PCCS books. Click here to view.

The strategic role of performance management

A wider context for health policy (and for the public sector more widely) is the New Public Management that was introduced across the public services in the UK in the 1980s as part of the shift towards introducing competition and privatisation into the sector. More recently, this logic has been reinforced by ‘austerity logic’, introduced in the period following the financial crisis in 2008 in an attempt to address the tension between budgets and clinical priorities.The New Public Management introduced a ‘results-oriented’ culture, and for this a performance management regime was needed in order to focus attention on reaching targets. Performance management has thus been a key mechanism for the reform of mental health services – and more recently for the introduction of the IAPT model.

New Management has gone alongside a programme of quasi-market ‘modernisation’ in healthcare: the decentralisation of commissioning and service planning has been in place since the late 1990s and is enshrined in the 2012 Health and Social Care Act. Privatisation has been encouraged through the introduction of ‘any qualified provider’ tendering processes – driven by the neoliberal idea that services can be run more efficiently by introducing competition, and breaking up monopolistic public-sector organisations into business units. This has involved a rapid decentralisation of decision-making right across the NHS, with the introduction of new localised structures at commissioning and contracting levels. There has been a mix of both centralising and decentralising tendencies within the NHS. There has been an increase in management control by virtue of its enhanced operational discretion, including in shaping the employment relationships; but there has also been an increased role for government in setting performance targets and performance data mechanisms, and in wider systems of auditing and regulation. 

The Health and Social Care Act was also part of the austerity programme: it sought to reduce management costs by 45 per cent. The impact of these cuts has been complex, but it has included a reduction in management jobs, which has in turn led to the ‘transformation’ of clinical roles to cover frontline management functions, a move that further embodies the tension between financial and clinical logics. 

In the context of austerity, performance management has also become an ideological and moral approach to managing public resources, as a response to ‘irresponsible’ overspending in the public sector. Performance data and management have been widely used to ‘evidence’ the value of public spending, and this has had the effect of narrowing the debate so that it becomes one about market efficiencies, rather than questions of quality care or meeting needs. Additionally, the model of performance measurement has greatly increased the bureaucratic workload within the NHS: management has increasingly become more a question of box-ticking, rather than an effort to base decision-making on a real understanding of performance within the organisation. 

The targets and measurements on which performance is measured in the NHS have led to some dysfunctional consequences, including misplaced incentives and sanctions that can undermine quality care. That is, performance measurements may not lead to improved performance, because of a potential ‘performance paradox’, where data does not capture either the strengths or weaknesses of the care system. For example, in the case of mental health, the way that recovery outcomes are formulated assumes a linear process of change and recovery, a far cry from the dynamic and complex experiences of patients engaged in the talking therapies. 

A further problem has been the NHS use of an inclusive measurement of quality of care – that is, it looks at quality of care alongside access to and cost of care. This combination of the three factors evades the tension between them: the question of whether increased access can be achieved with quality of care. The IAPT programme was set up precisely to increase access, at a low cost. It offers 4 to 12 sessions of cognitive and behavioural interventions, and can be provided by non-clinically trained staff. It is clearly therefore a relative cheap option, but, as we have seen, there have been concerns raised about the way that IAPT service outputs are measured, including waiting times, recovery rates and re-admissions. 

The way in which IAPT has been set up fits perfectly with a preoccupation with financial targets and performance indicators that reflect efficiency within the service rather than clinical outcomes. Financial concerns underpin the ‘evidence base’ for IAPT interventions, and these are made up of rigid performance data measurements (such as those noted above that claim that services offer a 50 per cent recovery rate for patients). 

Arguments for the effectiveness of the IAPT model now dominate policy decisions across mental health services; and the use of performance data has also been adopted for services outside of the IAPT programme, in order to provide ‘evidence’ of their value for money, and to secure funding and contracts. Clinicians consistently raise concerns about the ethics of the IAPT model, but the dominance of the IAPT performance data regime means that providers are forced to adopt these measurements in order to secure NHS contracts and continue to provide services.

One of the under-articulated consequences of this centrally defined model of performance data collection is the problem of gaming, such that organisations are forced to misrepresent outputs in order to achieve performance targets. The emergence of gaming as an ‘alternative logic’ within the NHS is one of the most serious problems with the current performance management system. Although there may be a distinction between a deliberate misrepresentation of performance and reporting data using an inadequate measurement, the results may be equivalent. In addition to misrepresenting the efficiency of services, the gaming of data can also lead to a lack of engagement with the consequences of poor services, such as suicide rates. Using the current measurements, it is quite possible for a service to be considered highly performing in terms of waiting times and discharging patients, as reflected in CQC audits, but at the same time to have serious problems with patient safety. In response to such problems, in 2017 the National Audit Office carried out an inquiry into the performance data of IAPT, specifically the measurement of waiting times and the claimed 50 per cent recovery rate. The report was not published, however, despite a high level of submissions raising their concerns from people working and researching in the sector. Despite repeated FOI requests no explanation for this decision has been given. It appears that there is little appetite to publicly inquire into the evidence base of the current mental health model.

A further consequence of the dominance of this model of performance management has been the establishment of a ‘command and control’ management culture. Research indicates that managers under pressure to deliver targets typically default to a command and control style, and become insensitive and defensive, putting a downward pressure on quality of care. This in turn is linked to the emergence of a culture of bullying within the sector, with staff reluctant to raise concerns for fear of victimisation – a concern that has been reinforced by the treatment of NHS whistleblowers. This management culture has led to a widespread silencing of staff, both within mental health services and more broadly in healthcare – and also to the establishment of the Freedom to Speak Up initiative, by the National Guardian’s Office.

This blog was originally published in an eBook UberTherapy: working in the therapy factory free to download here.

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