Next week, George Osborne will announce the result of
the triennial Comprehensive Spending Review (CSR). CSRs are the big brother to
Departmental Spending Reviews, where ministries consider their goals over the
short- and middle-term and match slices of the funding pie to policies which –
they hope – will be instruments to achieve desired outcomes.
In financial terms, DSRs aren’t truly zero-sum. Although
interest groups within any particular ministry will lobby for their pet
projects, there is always a little give around the whole pie. In the MoD, for instance, the media hype up tensions between the Army, Navy
and Air Force, but when the chips are down the whole lot can demand cash off
In contrast, the pie can’t really grow for the CSR. The
Treasury has no bigger hand to feed it, as it raises money direct from us, the
tax payer, and from the bond market. Neither is particularly forgiving when Mr
Osborne asks for more moolah, especially during a recession.
The Chancellor will this year sit in a Star Chamber to hear
Secretaries of State make their pitches for cash. To an extent he is balancing
apples with pears and bananas, aircraft carriers with housing benefit and
bobbies on the beat. The quid pro quo
for bearing the risk and getting the blend wrong, is that One Horse Guards can
set departmental public sector agreements (PSAs) – targets to you and me.
PSAs sound superficially attractive, and it is no surprise
then that they were introduced by Gordon Brown in CSR 1998. We all use targets
in our personal and professional lives – earn more, lose a stone in weight, run
a marathon – and it makes sense to set a yardstick by which financial efficacy
can be measured. An initial problem is that PSAs are widely-scoped and without
any formal mechanism for sanction. Departments are obliged to translate them
into their own metrics, and report these back to the Treasury and No 10.
One of the PSAs for the Department of Health, “Promote
better health and wellbeing for call”, is so bland and vacuous to be otiose.
But it spawned the infamous A&E target: initially 97% then 98% of patients
had to be seen within four hours. It was at first welcomed by medics as a way
of compelling hospitals to improve and ratchet up standards, but rapidly led to
skewed clinical decisions. Lots of ‘easy’ patients were seen speedily,
ambulances queued before disgorging the injured, and the
quite-sick-but-not-critical patients (often elderly) put on trolleys and parked
in corridors or medical assessment units.
The Conservative response in 2010 was to reduce to 95% the
number of patients to be seen within the golden time-frame, ostensibly giving
leeway to the clinical judgment of medics but triggering the recent rabid
headlines, “NHS misses A&E waiting time target, worst in nine years”, when
a particularly long winter caused more illness and only 94.1% of attendees were
seen within time.
The truth is bean counters are in no position to set targets
which depend on judgment, as practical policy delivery becomes skewed to
produce perverse and unintended effects. The Mid-Staffs hospital disaster was
caused in part when nurses and doctors ceased to be virtuous, autonomous
professionals and become box-ticking functionaries, with managers obsessed by
Whitehall dictat rather than seeing the bigger picture. The trend following the
Francis Review will inexorably be to turn targets with no or merely financial
penalties into ones attracting harsher sanction for their breach.
Rather, what ought to be happening is a
reduction in PSAs and micro-managed targets. Sure, political parties set out
objectives in their manifestos and it is right these become guiding principles.
But to fit more output into fewer civil servants and improve the ‘British
disease’ of low productivity, a renewed emphasis on trusting professionals
would be welcome.