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

Abstract

(2015) '"You can't do both -something will give": limitations of the targets culture in managing UK healthcare workforces.', Human resource management., 54 (5). pp. 773-791. Further information on publisher's website: Use policyThe full-text may be used and/or reproduced, and given to third parties in any format or medium, without prior permission or charge, for personal research or study, educational, or not-for-pro t purposes provided that:• a full bibliographic reference is made to the original source • a link is made to the metadata record in DRO • the full-text is not changed in any way The full-text must not be sold in any format or medium without the formal permission of the copyright holders.Please consult the full DRO policy for further details. AbstractBased 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 function as enlightened HRM employers, we argue that the inflexible application of metricsbased 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 healthcare scandal, the priorities attached to NHS personnel meeting the demands of performance management systems can prove incompatible with them also meeting the fundamental 'human' needs of patients. The everyday experience of healthcare organization becomes one of employees reconciling competing logics of business efficiency 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 behaviour of many frontline and mid-management staffs ultimately reflects a form of 'street-level bureaucracy' -a situation in which traditional professional norms are reasserted informally in ways that often transgress prescribed performance systems.

Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews

“…Interestingly, Newton et al, 116 in a study involving 374 acute care nurses, found that nurses often took independent action to address poor care rather than pursue official channels of compliant. McCann et al 111 observed a similar phenomenon, whereby, in response to more challenging performance targets amid a reduction in resources, both front-line and mid-management employees resorted to 'a form of "street-level bureaucracy" -a situation in which traditional professional norms are reasserted informally in ways that often transgress prescribed performance systems'.…”

“…Similarly, there was little attention afforded to potential variations in approaches to whistleblowing between the public, private and voluntary sectors providing health care, with the literature rarely making a distinction between these groups. The evidence from McCann et al 111 highlights the impact of austerity measures in the NHS on whistleblowing, and more specifically on voice: given the difficulties of meeting more challenging targets with fewer resources, the authors report that NHS staff often resort to 'under-the-radar' tactics to deliver the quality of care that they feel meets their professional standards, while avoiding the potential risks associated with 'speaking up'. Set against the backdrop of austerity in the NHS described by Hyde 137 and McCann et al, 111 it can be seen how pressure to meet business targets begins to undermine nurses' confidence in their judgement on what is an acceptable level of care, and thereby modify their behaviours in response.…”

“…The evidence from McCann et al 111 highlights the impact of austerity measures in the NHS on whistleblowing, and more specifically on voice: given the difficulties of meeting more challenging targets with fewer resources, the authors report that NHS staff often resort to 'under-the-radar' tactics to deliver the quality of care that they feel meets their professional standards, while avoiding the potential risks associated with 'speaking up'. Set against the backdrop of austerity in the NHS described by Hyde 137 and McCann et al, 111 it can be seen how pressure to meet business targets begins to undermine nurses' confidence in their judgement on what is an acceptable level of care, and thereby modify their behaviours in response. Given the increasing financial constraints in the NHS that throw job security into sharper relief, staff are less likely to blow the whistle when doing so brings them to the attention of management, which may result in retaliatory action.…”

Reviewing and Theorizing the Unintended Consequences of Performance Management Systems

“…gaming, lying) (Carmichael 1970). hospitals, schools, universities) and, when these relations are changed, perverse effects may appear (McCann et al 2015). In some contexts, gaming and low-trust environments are considered a 'price worth paying' (Berliner 1956) or 'part of business life' (Jensen 2003).…”

A Wicked Problem? Whistleblowing in Healthcare Organisations Comment on "Cultures of Silence And Cultures of Voice: The Role Of Whistleblowing in Healthcare Organisations"

“…In the face of increasing financial pressure, there is a need to examine the collective and cultural effects of discursive practices which use cost-effectiveness as a metric for decisions about healthcare provision. As austerity measures constrain the funding available to healthcare organisations, even as demand is rising, something must give 4 and whistleblowers are perhaps the last line of defence in raising the alarm that care quality is at risk.…”