Targets, metrics and outcomes: Bah humbug!

UBC snow

As Christmas looms, I have some time to sit and reflect over my festive sherry (while I ignore the paper that’s due January 4th). I realise that as I grow older and grumpier* I get annoyed about things at work that would have previously passed unremarked and/or ranted about. One example is the culture of measurement that stalks our health care system. I confess I raised my voice slightly last week as we discussed whether a 10 point scale was “enough” to gauge satisfaction. My “why don’t we just ask them” did not go down well. Over the last decade or so, we’ve shifted how we work. It seems increasingly that everything is reduced to an outcome, a metric or a target. I am reminded of that famous quote about the dangers of overly “measuring stuff” by William Bruce Cameron:

“It would be nice if all of the data which sociologists require could be enumerated because then we could run them through IBM machines and draw charts as the economists do. However, not everything that can be counted counts, and not everything that counts can be counted”

We’re living in a political environment that increasingly privileges economic competition, and governments are overtly or covertly abandoning the post-WW2 commitments to the welfare state. This “neo-liberalist**” (doctoral word alert!) environment is the sea we swim in but approaching the work we do with the language and values of economic output and quantification is often at odds with our health care professional practice. We know that a person isn’t reducible to a set of numbers – hence the push back with “patient centred care” “patient engagement” and the alarmed attention being paid to the (arguable) lack of empathy in medicine. At a recent patient engagement meeting it was suggested that all health care professionals should listen to patients’ stories, whenever and wherever they chose to tell them. This was immediately followed by a “quality” meeting (a seriously abused word in modern healthcare) – where all the outcomes were either times (less being better) or costs (ditto). Time to listen to patients didn’t make the cut. There is a serious disconnect between meeting 1 and meeting 2, unless Santa brings everyone a real-life Harry Potter time turner and we can increase our working days by magic.

As professionals we are taught to put the patient first, to exercise autonomy and judgement. In a very eye-opening article, the sociologist Julia Evetts examines the conflict between this idea of occupational professionalism and our organisation’s definitions of professionalism (which include standardising work, quality measures, targets and competition…) Evetts calls this “commercialised professionalism” and suggests that our places of work have co-opted the term. So instead of meaning “patients first”, professionalism has become defined and assessed by organisations run like “quasi markets”. The consequences of these organisational techniques on how work is viewed and prioritised “leads to subordinating or neglecting other, less measurable tasks ….time which might arguably be devoted to clients and professional tasks (p.260)” Hmmm, sounds familiar!

So – my grumpiness is vindicated! Social services like health care are increasingly frayed as governments move away from their commitment to the welfare state. The devolving of responsibilities to organisations means economic efficiency so we’re counting a lot of stuff – with our dashboards, performance walls, standard work and quality indicators. Our measurement culture is spinning out of control. But we’re also realising we’re starting to slide on the things that can’t be “enumerated” like a few minutes asking a patient about their daughter’s wedding or some time to read the social history of the new patient coming at 10 o’clock. Basically having the time to treat people like individuals – that’s what we should be asking for Christmas! It’s on my list after a large bottle of gin and the new Stephen King.

time turner

*This is an actual thing…I am now climbing back up from the sad trough of middle aged misery to a new dawn of elderly contentment, apparently

**Political governance emphasising economic efficiency, competition and minimal government interference (think Thatcherism, Regeanonomics)