Accountability, Rhetoric, and Political Interests: Twists and Turns of NHS Performance Measurements

• Date: 01 February 2015
• Published date: 01 February 2015
• DOI: http://doi.org/10.1111/faam.12045
• Author: Li‐cheng Chang

Financial Accountability & Management, 31(1), February 2015, 0267-4424

Accountability, Rhetoric,

and Political Interests: Twists

and Turns of NHS Performance

Measurements

LI-CHENG CHANG*

Abstract: This study draws upon institutional theory to examine the extent to

which the political interests of New Labour influenced the application of NHS

performance measurements devised for accountability purposes between 1997 and

2007. This study adopts an interpretative perspective and emphasises the ‘ethos’

of New Labour’s policy initiatives to convey its beliefs and moral superiority to the

electorate. It argues that the performance measurements constituted by political

interests served as a source of power deployed by New Labour to strengthen

its credibility as being an accountable person. Where political interests were in

play, multi-dimensional performance measurements did not necessarily promote a

balanced pursuit of performance improvements but led to various distortions and

dysfunctional behaviour which hindered the stated aims of the NHS reforms and

undermined the ethos of New Labour.

Keywords: NHS performance measurements, accountability, institutional theory

INTRODUCTION

The field of accountability entails a power relationship between citizens, the

Government and local managers (Stewart, 1984). It encompasses the social

relationship between one party (the accountor) who is obliged to justify her/his

conduct or to render an account of her/his actions to another party (the accoun-

tee). In the public sector context, the accountability relationship is complex.

This study concentrates on two types of accountability relationships, namely

political accountability and managerial accountability (see Mulgan, 2003).

*The author is from the Kent Business School, University of Kent.

Address for correspondence: Dr Li-cheng Chang, Kent Business School, University of Kent,

Canterbury CT2 7PE, UK.

e-mail: L.chang@kent.ac.uk

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42 CHANG

Political accountability is the responsibility laid on political representatives to

give an account of their stewardship to the electors. Managerial accountability

is concerned with the success of managers within local units in achieving the

targets within the resource constraints set by central Government.

The trend of new public management literature has seen accountability

being underpinned by the increasing use of performance measurements (Hood

and Peters, 2004; and Pollitt and Bouckaert, 2011). Literature drawing upon

institutional economics or cybernetics theories tends to deem performance

measurements as a rational and neutral mechanism that can be employed by

central Government to improve effectiveness and efficiency (Kloot and Martin,

2000; and Hood, 2005). From a (neo) institutional theory perspective, however,

Pollitt et al. (1998) pointed out that performance measurements designed for

public management are employed not merely to maximize utilities but are

constituted by political interests to establish societal norms. Modell (2009) also

argued that the application of performance measurements might in essence be

for legitimacy seeking purposes and in fact hinder the stated aims of public

sector reforms.

Earlier research adopting institutional theory, however, has attracted in-

creasing criticisms, in particular that it paid little attention to the origin

of institutional norms and tended to shy away from the impact of interest-

driven behaviour upon the formation of institutions (Abernethy et al., 2007;

and Lounsbury, 2008). Scott (2005) pointed out that the Government plays

a significant role in defining societal norms and belief systems (see also

Zucker, 1987). The Government and its political representatives are not

without their own interests but strive to establish institutions to consolidate

and preserve their position (Meyer and Scott, 1992; and Clegg, 2010). This

suggests that formulation of performance measurements for constructing

accountability relationships may thus be constituted by the political interests

of the Government rather than be a neutral or rational mechanism (Thomas

and Meyer, 1984; and Brignall and Modell, 2000).

New Labour led by Tony Blair aimed to facilitate a pragmatic approach, or

‘third way’, to convince the electorate that what Britain needed in a modern

society was problem-solving leadership, instead of the ideological dogma of left

and right (Blair, 2010). In particular, New Labour’s election manifestos had been

dominated by the rhetoric of NHS reforms since 1997. Policies using slogans

such as ‘our healthier nation’ and ‘NHS Plan’ were articulated to demonstrate

New Labour’s ambitions to improve public health and reduce health inequality.

Waiting lists and waiting time targets were identified and imposed as a top

priority for local NHS organizations to deliver. These targets were set to coincide

with the timing of each election so that the electorate could hold the Government

accountable for their delivery (see Labour Party, 1997, 2001 and 2005).

Performance measurements played a significant role in facilitating New

Labour’s multi-faceted objectives espoused for the NHS reforms. Mechanisms

based on a balanced scorecard approach were employed to establish the norms of

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