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Performance Anxiety:
The nature of performance management in the NHS under New Labour

Shana Vijayan
Thesis submitted for the degree of Doctor of Philosophy
Department of Science and Technology Studies
University College London

0

Declaration

I, Shana Vijayan, confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis.

1

Abstract

This thesis explores both the proliferation and prominence of ‘performance’ in the NHS, focusing on the New Labour years from 1997-2010. The research’s main objective was to

understand how performance policy impacts the work-place experience: to understand the nature of work undertaken by performance managers, the tools used and the effect of these techniques. The secondary objective was to understand the goals of performance management.

The introduction and rise of performance saw a change in expert authority. A new set of professionals had arrived in the NHS: regulators, auditors and performance managers.

This thesis looks at the performance managers’ body of expertise, drawing upon several

forms of qualitative research. The primary research tool used was institutional ethnography, which included focused interviews, a case study and experiences and notes gathered during a period based as a participant in NHS organisations.

Documentary analysis carried out in the first phase of this thesis revealed that the principal rhetoric employed by politicians concerned the function of performance management in reducing risk and harm to patients. However, further research based on interviews and ethnography suggests that performance was experienced as a process of rationalisation and stigma, with risk rarely mentioned in the same way as in policy documents. In particular, various aspects of rationalisation, including measuring, quantifying and tabularisation, were deployed, these processes being a means for state surveillance. Performance, it will be argued, was part of the bureaucratic machine by which efficiency and effectiveness were judged in areas where the state previously had little knowledge or information.

The research draws heavily on approaches in Science and Technology Studies to consider ‘performance’ and audit as a form of socio-technological intervention as well the Sociology of Health to inform issues of organisational and work-based stigma.

2

Acknowledgements

“Our doubts are traitors,
And make us lose the good we oft might win
By fearing to attempt.”

"Measure for Measure", Act 1 Scene 4

My brother humorously refers to my thesis as my memoirs and to an extent he is right. It has taken up a substantial part of my life, at moments consumed me and at times almost defeated me. Yet, now I have reached the end, it seems appropriate to thank the following people. Firstly, the girls I met in Kenya whose enthusiasm for education reminded me that learning is an attitude to life and encouraged me to return to university. The three wise men, my supervisors, Brian Balmer, Graham Scambler and Charles Thorpe, have been central to this process; they see my potential and give me confidence in my abilities. Anne Coulson, a woman with a way with words, who edited this work and enabled me to find my voice to speak with conviction during my viva. Fellow students in the STS department helped sustain my enjoyment of my subject when it was on the wane. “Team Shana”- my support squad, friends who unflaggingly believe in me and cheer me on from the sidelines. My parents, who put up with me, pushed me to be better and ensured the completion of this research project. Finally, this thesis would look very different without the input of NHS staff who gave up their time to talk to me. To all of them a heartfelt thank-you.
London, August 31, 2013

3

Contents

Declaration Abstract
12
Acknowledgements Preface
39

  • Abbreviations
  • 11

Diagrams and Tables

 An overview of NHS structure as proposed in 2001  Models of accountability
35 43
 Ideal type contradictions: managerial / professional  Competence and caring in relation to building trust  Forms of trust relations
44 73 75
 Working relationships for Heads of Performance  Translation of strategy into action
97
124

Chapters

  • 1
  • Introduction
  • 12-20

  • 2
  • The History of NHS Performance Management

Formation of the NHS

21-53

  • 21
  • 2.1

2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9
The NHS under the Conservatives; the formative performance years The NHS under New Labour; performance becomes modernisation Reform of the NHS
24 30 38
The role of trust: the medical profession and the NHS Autonomy within the medical profession The New Public Management
39 40 42

  • Management as a new type of work
  • 45

  • Notions of Governance
  • 46

  • 2.10 Performance management: a tool for increased accountability?
  • 47

  • 2.11 The role of regulatory bodies vs. performance management as a regulatory instrument
  • 49

4

  • 3
  • Theoretical Background: Rationalisation, Risk, Audit & Stigma

Overview

54-90

  • 54
  • 3.1

3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9
Bureaucratic regimes and their effects The rise of the Public sphere
54 65
Historical examples of the State as a social engineer Understanding various approaches to risk The work and function of risk
67 68 69
Professional life in the Risk Society Trust within the Risk society
70 72

  • Accountability and Trust
  • 73

3.10 Audit as form of accountability and a tool for risk management 3.11 Language as work
75 77
3.12 The language of illness; its role in healthcare 3.13 Conclusion
79 83

  • 4
  • Methods
  • 91-119

  • 91
  • 4.1

4.2 4.3 4.4 4.5 4.6 4.7
Introduction and overview to methods Rationale for Chosen Method My role as an institutional ethnographer The use of in-depth focused interviews Sampling and data collection Coding and Interpretation
93 95 99
101 102 103 103 103 110 111 113 116 117 118
Using the 18 weeks policy as a case study
4.7.1 Introduction to 18 weeks initiative 4.7.2 Political background and detail to 18 weeks policy 4.7.3 Research Questions 4.7.4 Sources and Methods behind 18 weeks case study 4.8 4.9
Discourse Analysis on Department of Health Summary of Ethical considerations
4.9.1 Gaining informed consent 4.10 Applying for and achieving ethics approval

  • 5
  • Results - Risk: Solely State Rhetoric

Introduction of Performance to eliminate risk Performance managers as risk minimisers

120-160

  • 120
  • 5.1

  • 5.2
  • 122

5
5.3 5.4 5.5 5.6 5.7 5.8 5.9
The Balanced Scorecard: strategy into action Star ratings: encouraging success, marking out failure Planning: forecasting the future
123 126 132 135 139 141 142 144 145 149 151 158
Do performance managers increase accountability? Fundamental flaws: when disaster strikes it is neither new nor unexpected Seeking assurance or requiring reassurance Collaborative working: covering all bases
5.10 Lack of feedback and follow-up invalidates conducting lengthier reviews 5.11 Achievement of targets are dependent on organisational ownership 5.12 Ineffective measuring creates a false sense of security 5.13 The role of IT in reducing risk 5.14 Conclusion

  • 6
  • Results - Rationalisation: Statecraft Work

Organisational Rationalisation

161-206

  • 161
  • 6.1

6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9
Measuring, quantifying and evidence Arbitrary nature of targets and measures Tabularisation; its purpose and proliferation The rationalisation paradox
168 177 180 186

  • Transparency and Gaming
  • 189

Rationalisation and increased bureaucracy Economy, Efficiency and Effectiveness State surveillance
192 195 199

  • 6.10 Conclusion
  • 204

  • 7
  • Results - Stigma: Stigmatised Staff, Stigmatising State
  • 207-254

  • 208
  • 7.1

7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9
Defining stigma The discourse of Stigma and Organisational Change Four aspects of stigma: time, conflict, communication & tribe/community The discourse of Stigma and Policy Implementation The political imperative to policy
209 210 227 236
The disenfranchisement of the consultative approach The language of stigma
241 244

  • A dictionary of terms
  • 247

  • Language applied: conversation decoded
  • 248

  • 7.10 Conclusion
  • 252

6

  • 8
  • Conclusion
  • 255-268

  • 256
  • 8.1

8.2
How this research advances our understanding of NHS performance management

  • Performance management post-New Labour
  • 259

8.2.1 Francis Inquiry 8.2.2 Francis Recommends 8.2.3 Keogh Review 8.2.4 Berwick Review
261 262 263 265

  • 8.3
  • Future directions of this research
  • 267

Appendices

 Appendix A: Roles of staff selected and interviewed
269

270 271 272 274 275 276 277 278
 Appendix B: Participant Information Sheet  Appendix C: Consent Document  Appendix D: Balanced Scorecard for PCTs  Appendix E: 18 Weeks Executive Dashboard for NHS Commissioners  Appendix E: 18 Weeks Executive Dashboard for NHS Commissioners  Appendix E: 18 Weeks: Executive Dashboard for NHS Providers  Appendix E: 18 Weeks: Executive Dashboard for NHS Providers  Appendix F: Glossary of 18 weeks terms

  • References
  • 281

7

“Reputation is an idle and most false imposition: oft got without merit, and lost without deserving”

“Othello,” Act 2, Scene 3
8

Preface

My interest in audit systems stems from working in NHS performance management between 2000 and 2010. I am interested in how the NHS is held to account and the means and methods of accountability.

My career in the NHS began within Patient Information at a hospital Trust, where I worked on Chapter 10 of the newly published NHS Plan. I ensured patients had access to clear and accurate information on all aspects of their care. This is one of the key documents I look at in more detail as part of my research. While New Labour were elected in 1997, the NHS Plan was not published until 2000, yet that intervening period of consultation and consolidation resulted in much of the foundation to NHS reform and set some long-term goals.

I moved from working in a hospital Trust to become the Senior Information Analyst in a Shared Services in 2002. A Shared Service organisation provided a number of services to local Trusts; it stemmed from the strategy of local centralization of ancillary services, usually IT, HR and Finance. While managing a team of analysts, who provided information for a cluster of PCTs, I became aware of the problems concerning information gathering to which national government seemed oblivious. Standard information requests by the Department of Health were difficult to deliver: numerous gatekeepers restricted access to information, different NHS databases held variations of the same data, and finally there was the time lag as data was cleaned.

My last role before beginning my research was as Head of Performance and Information for a Primary Care Trust. From 2004 to 2007 I monitored performance within the PCT using the newly established Annual Health Check Framework set out by the health regulator. The position I was in led me to consider certain issues, e.g. the direction of the NHS, the objectives of performance and how information was processed. However, no real reflection was possible while I worked in an organisation requiring answers immediately. I rarely got the chance to comment on these issues while at work; research seemed a meaningful way of developing my thoughts.

I moved from the PCT to a Strategic Health Authority in 2007 to lead on performance management for a geographical group of PCTs and hospital Trusts. Throughout this period

9
I continued my research with the consent of my employer. The emphasis here was to ensure sustainable solutions for improvement against national targets while holding organisations to account in these areas. Once again I found myself focusing on the purpose of performance: what it seeks to achieve both at a local and a regional level. Others in the SHA felt similarly. Their thoughts are considered in greater depth in the case study central to this research.

By 2009 I had taken on a position at the Department of Health in policy and performance. I now had the opportunity to watch the internal workings of government, to see how health policy was formulated and the tension between the political rhetoric of local responsibility versus national state accountability. During this time New Labour left office to be replaced by the Conservative-Liberal Coalition government in 2010. A decade had passed where I saw performance management dominate the NHS. This thesis is a reflection on that time.

10

Abbreviations

18 WEEKS 18 Weeks Referral to Treatment Standard A4C BMA BMI BSC CDA CHI CQC DH
Agenda for Change British Medical Association Body Mass Index Balanced Scorecard Critical Discourse Analysis Commission for Health Improvement Care Quality Commission Department of Health
DHSS GP
Department of Health and Social Services General Practitioner
HCAI HCC HES IE
Healthcare Associated Infections Healthcare Commission Hospital Episode Statistics Institutional Ethnography

  • Local Delivery Plan
  • LDP

LDPr MHT MIS MMR NHS NICE ORPI PAF PCG PCT PFI
Local Delivery Plan return Mental Health Trust Management Information System Monthly Monitoring Return National Health Service National Institute of Clinical Excellence Outcome Related Performance Indicators Performance Assessment Framework Primary Care Groups Primary Care Trusts Private Finance Initiatives

  • Performance Indicators
  • PI

PSA QOF RTT SHA SS
Public Service Agreement Quality Outcomes Framework Referral to Treatment Strategic Health Authority Shared Services

  • SUS
  • Secondary Uses Services

11

Chapter 1

Introduction

“When a bedpan falls to the floor in Tredegar Hospital, its sound should echo in

the Palace of Westminster.”1 Aneurin Bevan, MP, Minister of Health 1945-51

This thesis explores the proliferation of performance management in the National Health Service (NHS) with particular focus on the years from 1997-2010 under the Labour Government. My interest in this issue stemmed from working in the NHS from 2000 to 2010, a period which saw the rise of a defined performance culture. Deleting

The main objective of the thesis is to assess how performance management policy impacts the work-place experience; to understand the nature of work undertaken by performance managers, the tools used, and the effect these techniques have. The secondary objective is to understand the goals of performance management. This research set out to find why

performance management was pivotal to New Labour’s governance of the NHS and to

understand the impact and unintended consequences the introduction of these systems had on the NHS, its patients and the wider public. The rhetoric employed by politicians focused on reducing risk; my research suggests that performance was equally about rationalisation. The introduction of performance saw a change in expert authority; a new set of professionals had arrived in the NHS: regulators, auditors and performance managers. This thesis examines the performance managers’ body of expertise - unpacking the repertoires which served to legitimise their authority within the NHS.

1 Nairne, P., (1984) pp33–51

12
It is important to understand NHS performance management because there may be a difference between political rhetoric and how a policy works in practice. Government’s vision and aim can be distorted; daily performance management in the NHS may not necessarily be what was articulated and intended originally. This performance management culture is replicated in other parts of the public sector. I use as key research questions those posed by Jeremy Dent and Mahmoud Ezzamel in relation to accounting, with the latter substituted by performance management. The questions then are as follows:

“1) how does accounting fit in the totality of an organisation’s activities? How do such

observed abuses in accounting interact with other organisational mechanism? 2) What forces shape the accounting functions in organisations? Why do accounting practices evolve over time? Such questions should, perhaps, be addressed before deriving normative accounting propositions.”2 The substitution of performance management for accounting is non-contentious; performance management is already formally considered a subset of accounting. With its propensity for monitoring, providing external scrutiny and internal control, it is a form of auditing.

I aim to contribute to broad debates in STS on how knowledge is created and used, both internally by the NHS and externally by the wider public. I sought to understand how technologies and conceptual tools used in performance management originate and the manner in which these are diffused throughout the NHS. The benefits and deficiencies are considered in order to understand how these technologies are shaping and skewing our view of the NHS. Technologies are immensely powerful; their application and advantages, however, cannot be separated from their detrimental effects on people’s lives and labour. Therefore, assessing how performance technologies alter the way in which staff work was

an important aspect in my research. I concentrate on how performance management’s

focus, under New Labour, on measuring certain aspects of healthcare, presented a distinct view of the NHS which had a wider audience than those immediately concerned with health policy.

Performance management, through the technologies it utilises, is like a kaleidoscope. It attempts to view an array of what would otherwise appear as haphazard data and produce a coherent meaningful picture to the observer. It looks to shed light on areas that appear unknowable, magnifying and multiplying facets of the system. The viewer has the impression that what is seen are facts speaking for themselves, untouched, unrefined and

2Dent, J., and Ezzamel, M., (1995) p39

13 unadulterated. The formation of facts lies in a heavily enriched process of translations and transformations and yet they appear distinct entities, separate to all that has gone before. What is seen is only that which is allowed to be displayed, the authorised account. Performance managers therefore are not only actors, but witnesses to the birth of these facts and providers of the literary technology for the official narrative; indeed they are actors in the laboratory where facts are produced.3 The tools at a performance manager’s disposal that aid the production of these facts are actants, Latour’s term to describe nonhuman actors within a process.4 Actants are as necessary to the production of facts as the actors, the performance managers themselves.

Performance tries to emulate science, in both its practice and culture; in so doing, like science, it has its own community, its own rules and standards of behaviour.5 The New Labour government prided itself in how performance management underpinned the health service. Applying methodologies in a scientific manner, that is, in an unbiased, rigorous fashion, was a sign of progress and transparency.6 This research considers the credibility of such an assertion and whether it is justifiable. The intention is to look critically at how performance as an activity produces figures, data and evidence, how this frames perceptions of an organisation, and what it actually means to be a successful or a failing Trust. I consider how translated information is appraised and evaluated and what these assessments and judgements mean to organisations. I look at what the idea of uniformity and standardisation, a one-size-fits-all approach to healthcare, has on those that work in it and how regulation enables the State to gather information on otherwise opaque parts of the NHS. I seek to understand the process of classification and the role performance managers play as gatekeepers of knowledge as well as their role in producing evidence cultures7, epistemic cultures8 and epistemological cultures9.

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    Wheat Prices and Rainfall in Western Europe Author(s): William H. Beveridge Source: Journal of the Royal Statistical Society, Vol. 85, No. 3 (May, 1922), pp. 412-475 Published by: Wiley for the Royal Statistical Society Stable URL: http://www.jstor.org/stable/2341183 . Accessed: 25/06/2014 03:22 Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp . JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected]. Wiley and Royal Statistical Society are collaborating with JSTOR to digitize, preserve and extend access to Journal of the Royal Statistical Society. http://www.jstor.org This content downloaded from 185.44.77.40 on Wed, 25 Jun 2014 03:22:47 AM All use subject to JSTOR Terms and Conditions 412 [Alay, WHEATPRICES AND RAINFALLIN WESTERNEUROPE. By SIR WILLIAMH. BEVERIDGE. [Read before the Royal Statistical Society, April 25, 1922, the President, Sir R. HENRYREw, K.C.B., in the Chair.] I.-INTRODUCTION. II.-CONSTRUCTIONOF PERIODOGRAMOF WHEAT PRICE FLiuCTUATIONS. (With chart.) I lf.-INTERPRETATIONOF PERIODOGRAM. The four tests of periodicity. Thc periods found. Summary and Review (with table). IV.-COMPARISONWITH EUROPEAN RAINFALL, 1850-1921. (With chart.) V.-CONCLUSION. APPENDIX.-Harmonic Analysis of Wheat Price Fluctuations. I.-INTRODUCTION. THE paper which I have the honour of reading to you to-night is ill substance a sequel and supplement to an article on " Weather " and Harvest Cycles," published in the Economic Journal of December, 1921.
  • A Social Security Plan for Great Britain: the Government's White Paper

    A Social Security Plan for Great Britain: the Government's White Paper

    Government's proposals for compen• A Social Security Plan for Great Britain: sation for disablement or loss of life from industrial injury or specified The Government's White Paper * occupational diseases. The Govern• ment agrees with Sir William that the present system is "based on a wrong IN JUNE 1941, the British Government individuals have little or no control, principle and has been dominated by asked Sir William Beveridge to recom• Neither course alone is effective. A a wrong outlook." Instead of the mend changes in the existing pro• nation cannot avoid widespread pov• concept of compensation for indus• grams for social insurance and allied erty if earning power is impaired by trial injury as an employer liability, services. His report, presented in unemployment or inefficiency, and, the Government presents it as a social November 1942,1 outlined a social regardless of high production levels, service. Both employers and workers security plan for "all citizens without a nation has not solved its problems if would contribute, but the benefits, upper income limit—all embracing in it includes any appreciable groups paid weekly at fixed rates with sup• scope of persons and needs," based on who are in want because their earn• plements for family responsibilities, assumptions that the Government ing power is reduced by ill-health, un• would not depend on the contribution would take other measures to prevent employment, old age, or inability to record. The system proposed "is in mass unemployment, would establish provide properly for their children. many respects like that which is the comprehensive health services, and When the present proposals, modified basis of war pensions schemes.
  • The Microeconometrics of Household Behaviour

    The Microeconometrics of Household Behaviour

    London School of Economics and Political Science Department of Economic History Doctoral thesis The Microeconometrics of Household Behaviour: Building the Foundations, 1920-1960 Chung-Tang Cheng A thesis submitted to the Department of Economic History, of the London School of Economics and Political Science, for the degree of Doctor of Philosophy May 2021 Declaration I certify that the thesis I have presented for examination for the PhD degree of the London School of Economics and Political Science is solely my own work other than where I have clearly indicated that it is the work of others (in which case the extent of any work carried out jointly by me and any other person is clearly identified in it). The copyright of this thesis rests with the author. Quotation from it is permitted, provided that full acknowledgement is made. This thesis may not be reproduced without my prior written consent. I warrant that this authorisation does not, to the best of my belief, infringe the rights of any third party. I can confirm that a version of Chapter IV is published in History of Political Economy (Cheng 2020). I can also confirm that this thesis was copy edited for conventions of language, spelling and grammar by Scribbr B.V. I declare that my thesis consists of 62,297 words excluding bibliography. 2 Abstract This thesis explores the early history of microeconometrics of household behaviour from the interwar period to the 1960s. The analytical framework relies on a model of empirical knowledge production that captures the scientific progress in terms of its materialistic supplies and intellectual demands.