Targets. They hurt, but (sometimes) they work

A u-turn on NHS waiting times shows the Conservatives have realised how hard it is getting things do

The Guardian reports today that the government has been forced to re-instate something resembling the old target for waiting times. Labour imposed a limit of 18 weeks as the maximum amount a patient should have to wait for an operation. The target was scrapped by Health Secretary Andrew Lansley since it represented an "arbitrary", "top down" bureaucratic approach. This, it was imagined, would be unnecessary because reforms would deliver a newly efficient, ultra-responsive market in health care in which patients' needs would be accommodated by the profusion of competing providers. Clearly, things aren't quite working out that way and a modified version of the 18-week limit will be back in place in the New Year.

The Conservatives in opposition were routinely scathing about targets, which, they argued, skewed outcomes by creating perverse incentives. Plainly this was true some of the time. A target of holding down waiting times in accident and emergency wards, for example, sometimes resulted in patients simply being sent away. And there is no doubt that New Labour came to rely too much on targets across Whitehall as a way to force the civil service to deliver what had been pledged by ministers, which was demoralising for the departments and skewed priorities.

But the reason Labour used targets so freely was because there weren't many other ways to make civil servants focus relentlessly on the government's priorities. They worked.

Many Conservatives in opposition persuaded themselves that Labour simply liked being bossy and controlling because that is what statist lefties do. I remember a conversation with a shadow minister (now a minister) before the election who told me with pride how he had deliberately not written any performance measures into a policy green paper because the Tory way was to create incentives and trust people, not to regulate them with targets. And what if the incentives aren't taken up? I asked. "We'll come up with better incentives."

In the early days of the coalition, a number of senior civil servants reported being told by incoming Tory ministers that the kind of measurements and targets that had previously been used to check performance in the system were no longer required because "that's not how we do things." It was an ideological shibboleth.

18 months into government, ministers are now finding - as was predictable - that without targets and specific performance measures, policies and pledges get lost in the system. Crudely speaking, unless someone is leaning down hard from above asking hard questions about why targets aren't met, nothing seems to happen. The appalling word that Downing Street under Tony Blair used to use for this stuff was "deliverology" - the art (or science, depending on your point of view) of actually getting things done in government.

It is becoming increasingly clear that David Cameron, with his predilection for presidential floating above the fray, has neglected this area. Steve Hilton, his policy chief, is constantly exercised by it but he tends to think the problem lies in all forms of bureaucracy and civil servants not being dynamic, professional or generally enough like private sector entrepreneurs feverishly making change happen like a bunch of Berkeley graduates building a start-up social enterprise in a San Francisco garage. Maybe it would be nice if Whitehall mandarins were a bit more like that. But it isn't going to happen soon. So for the time being, it looks like it has to be targets.

Of course, this government isn't entirely hostile to the idea of setting arbitrary benchmarks for performance. It is committed to bringing annual net migration down to below 100,000. When the public get really cross about something, out come the targets. That tells us something about the u-turn on operation waiting times. Clearly ministers are very nervous about the growing backlash against changes in the NHS.

Rafael Behr is political columnist at the Guardian and former political editor of the New Statesman

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Inside a shaken city: "I just want to be anywhere that’s not Manchester”

The morning after the bombing of the Manchester Arena has left the city's residents jumpy.

On Tuesday morning, the streets in Manchester city centre were eerily silent.

The commuter hub of Victoria Station - which backs onto the arena - was closed as police combed the area for clues, and despite Mayor Andy Burnham’s line of "business as usual", it looked like people were staying away.

Manchester Arena is the second largest indoor concert venue in Europe. With a capacity crowd of 18,000, on Monday night the venue was packed with young people from around the country - at least 22 of whom will never come home. At around 10.33pm, a suicide bomber detonated his device near the exit. Among the dead was an eight-year-old girl. Many more victims remain in hospital. 

Those Mancunians who were not alerted by the sirens woke to the news of their city's worst terrorist attack. Still, as the day went on, the city’s hubbub soon returned and, by lunchtime, there were shoppers and workers milling around Exchange Square and the town hall.

Tourists snapped images of the Albert Square building in the sunshine, and some even asked police for photographs like any other day.

But throughout the morning there were rumours and speculation about further incidents - the Arndale Centre was closed for a period after 11.40am while swathes of police descended, shutting off the main city centre thoroughfare of Market Street.

Corporation Street - closed off at Exchange Square - was at the centre of the city’s IRA blast. A postbox which survived the 1996 bombing stood in the foreground while officers stood guard, police tape fluttering around cordoned-off spaces.

It’s true that the streets of Manchester have known horror before, but not like this.

I spoke to students Beth and Melissa who were in the bustling centre when they saw people running from two different directions.

They vanished and ducked into River Island, when an alert came over the tannoy, and a staff member herded them through the back door onto the street.

“There were so many police stood outside the Arndale, it was so frightening,” Melissa told me.

“We thought it will be fine, it’ll be safe after last night. There were police everywhere walking in, and we felt like it would be fine.”

Beth said that they had planned a day of shopping, and weren’t put off by the attack.

“We heard about the arena this morning but we decided to come into the city, we were watching it all these morning, but you can’t let this stop you.”

They remembered the 1996 Arndale bombing, but added: “we were too young to really understand”.

And even now they’re older, they still did not really understand what had happened to the city.

“Theres nowhere to go, where’s safe? I just want to go home,” Melissa said. “I just want to be anywhere that’s not Manchester.”

Manchester has seen this sort of thing before - but so long ago that the stunned city dwellers are at a loss. In a city which feels under siege, no one is quite sure how anyone can keep us safe from an unknown threat

“We saw armed police on the streets - there were loads just then," Melissa said. "I trust them to keep us safe.”

But other observers were less comforted by the sign of firearms.

Ben, who I encountered standing outside an office block on Corporation Street watching the police, was not too forthcoming, except to say “They don’t know what they’re looking for, do they?” as I passed.

The spirit of the city is often invoked, and ahead of a vigil tonight in Albert Square, there will be solidarity and strength from the capital of the North.

But the community values which Mancunians hold dear are shaken to the core by what has happened here.

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