“You Can't Do Both—Something Will Give”: Limitations of the Targets Culture in Managing UK Health Care Workforces

• DOI: http://doi.org/10.1002/hrm.21701
• Author: Leo McCann,Edward Granter,John Hassard,Paula Hyde
• Published date: 01 September 2015
• Date: 01 September 2015

Human Resource Management, September–October 2015, Vol. 54, No. 5. Pp. 773–791

© 2015 Wiley Periodicals, Inc.

Published online in Wiley Online Library (wileyonlinelibrary.com).

DOI:10.1002/hrm.21701

Correspondence to: Leo McCann, Manchester Business School, University of Manchester, Booth Street West,

Manchester, M15 6PB, UK, Phone: +44 (0)161 2756490, E-mail: leo.mccann@mbs.ac.uk

“YOU CAN’T DO BOTH—

SOMETHING WILL GIVE”:

LIMITATIONS OF THE TARGETS

CULTURE IN MANAGING UK

HEALTH CARE WORKFORCES

LEO MCCANN, EDWARD GRANTER, JOHN HASSARD,

AND PAULA HYDE

Based on a three-year ethnographic study of four UK National Health Service

(NHS) organizations, we explore the everyday cultural experience of managing

clinical and administrative workforces. Although NHS organizations claim to func-

tion as enlightened HRM employers, we argue that the infl exible application of

metrics-based target systems to clinical and administrative tasks, including HRM

operations, can result in dysfunctional outcomes for patient care and workforce

morale. Reminiscent of the recent Mid Staffordshire health care scandal, the pri-

orities attached to NHS personnel meeting the demands of performance manage-

ment systems can prove incompatible with them also meeting the fundamental

“human” needs of patients. The everyday experience of health care organization

becomes one of employees reconciling competing logics of business effi ciency

and integrity of care. Trapped metaphorically between shrinking resources and

expanding targets, the inclination—on the frontline and at mid-management

level—is to extend the integrity of care, although this is sometimes impossible

and can prove problematic in terms of system accountability. In response to such

organizational tensions the behavior of many frontline and mid-management

staffs ultimately refl ects a form of “street-level bureaucracy”—a situation in

which traditional professional norms are reasserted informally in ways that often

transgress prescribed performance systems. ©2015 Wiley Periodicals, Inc.

Keywords: confl ict, health care management, National Health Service,

performance management, performance targets, professionalism, street-level

bureaucracy

774 HUMAN RESOURCE MANAGEMENT, SEPTEMBER–OCTOBER 2015

Human Resource Management DOI: 10.1002/hrm

Medically trained

professionals often

resent administrators

and managers who

have little or no

direct knowledge

of professional

practice, and whom

they consider

underqualified in

comparison to their

own occupational

groups.

1972; Wankhade, 2012). Such abstract systems fre-

quently alienate professionals, who are often con-

sidered “difficult to manage.” Medically trained

professionals often resent administrators and

managers who have little or no direct knowledge

of professional practice, and whom they consider

underqualified in comparison to their own occu-

pational groups. This is notably the case in health

care settings (de Bruijn, 2011; Theodosius, 2008)

where even if managerial staff have prior clinical

experience, they can be criticized as “remote

from” or having “lost touch with” the real work of

treating patients (Metz, 1981; Tangherlini, 1998).

Conceptually, abstract management systems,

and especially performance metrics, have received

significant criticism from a number of quarters.

Writers regularly point to their capacity for “goal

displacement,” whereby the political act of show-

ing that targets have been met assumes greater

importance than the practical completion of the

work itself (de Bruijn, 2007, pp. 17–19; see also

Hood, 2006). It is argued, further, that both the

definition and quantitative measurement of

“effectiveness” are factors that habitually remain

opaque (Talbot, 2010, pp. 144–147). Some have

argued that the excessive adoption and rigid

application of target-based systems can actually

foster dramatic organizational failures (Ordonez,

Schweitzer, Galinsky, & Bazerman, 2009). As we

shall see later, from the perspective of NHS junior

and middle managers, many chronic problems

with performance targets have surfaced in health

care management recently. In the eyes of many

frontline and mid-level health care employees,

these systems are part of the problem rather than

the solution to complex organizational challenges.

This is not to say, however, that the use of

numerical targets is wrong in all circumstances.

Commentators have described the effectiveness of

numerical-technical control measures in a range

of economic sectors. Heavily standardized and

metrics-driven systems—such as Lean Production,

Six Sigma, or Total Quality Management, for

example—can function effectively in automo-

bile manufacture or back-office processing, when

work is typically performed on inanimate objects

or digital information. But such systems may be

inappropriate for the management of health care

tasks, which often require complex interventions

and diagnoses, unexpected surges in demand, and

a general capacity for human care and compas-

sion (Theodesius, 2008; Waring & Bishop, 2010).

Nevertheless, successive UK governments have

pressed for the adoption of metrics-based perfor-

mance systems throughout the NHS (and in pub-

lic administration more generally, such as policing

and probation, schools, tax collection, and local

Efforts to reform and improve the man-

agement of work and human resources

in health care settings have increasingly

turned to abstract and numerical forms of

control. Such forms include the promo-

tion of “off-the-shelf” management information

systems, quality improvement techniques based

on standardization, and “Lean” organizational

philosophies (Adler et al., 2003; Gawande, 2010;

Waring & Bishop, 2010). In the UK National

Health Service (NHS)1 such technical-numerical

systems have often taken the form of rigid

performance targets; for example, the 18-week

“pathway” for outpatients, the four-hour waiting

limits for accident and emergency (A&E) patients,

and the eight-minute ambulance response time

for (category A) emergency calls

(Bevan & Hood, 2006; McCann,

Granter, Hyde, & Hassard, 2013;

Wankhade, 2012). Targets are also

becoming increasingly common-

place in HRM systems, with “hard”

HR policies in NHS organizations

(or trusts) stipulating objectives for

capacity utilization, roster comple-

tion, staff development, and sick-

ness absence. Performance targets

for patient care (e.g., waiting lists,

response times) and HR manage-

ment (e.g., sickness absence, staff

development) alike carry penalties

for their breach, hence the phrase

“targets and terror” (Bevan & Hood,

2006).

Many of those performance

metrics are derived from concepts of

systems analysis and “management

by objectives” originally developed

by the RAND Corporation and

the US Department of Defense in

the 1950s and 1960s (Hoos, 1972;

Talbot, 2010). Such approaches purport to place

objective “metrics” at the heart of the everyday

management of organizations. Targets, metrics,

and management by objectives are supposedly

“rational” and “systematic” approaches to mea-

suring and controlling aspects of organizational

behavior. The aim is to ensure efficiency, enhance

productivity and “effectiveness,” increase levels of

staff accountability, and avoid errors and failures.

In practice, however, such systems have long

been unpopular with professionals in any number

of sectors and settings. Professionals often regard

these managerial impositions as a form of depro-

fessionalization that drives out personal discre-

tion and weakens occupational control over the

delivery of work (Byrne, 1993; Dent, 2008; Hoos,