The Warning Signs
The tragedy is that at the very same time that Evidence Based Management, or New Public Management was becoming a cornerstone of public administration – and was fending off criticism by touting its similarity to the revolution in medicine that Cochrane had begun – the medical profession was beginning to be concerned about the failings of Evidence Based Medicine. By 2014, the British Medical Association was so worried, that they published an essay asking whether the movement was in crisis. [1]
It is interesting to read the authors’ main concerns, because they map over onto Evidence-Based Management rather accurately. Indeed, one might easily substitute Evidence-Based Management for Evidence-Based Medicine and find the same issues.*
One of the main issues raised was that vested interests were corrupting the methodology. The more doctors depended on the evidence, the more important it was that the process of collecting the evidence was accurate and impartial. But since collecting and collating evidence could be very expensive, there was a tendency to turn to the drug companies – who were often willing sponsors. It was hardly surprising that having paid for the research, the drug companies frequently influenced the agendas, and chose which results to publish. **
Another issue was that the sheer quantity of evidence now available had become a problem. The authors of the study cited a 24 hour period in one hospital, in which a doctor looking after 18 patients was expected to read national guidelines relevant to her patients’immediate care consisting of 3,600 pages of expertise (an estimated 122 hours of reading).
Another significant issue was that in many cases, rather than being used as originally intended, to support a particular doctor dealing with a particular case, Evidence Based Medicine had become a tool for risk assessment, using “evidence based” scores and algorithms.
Critically, in their report Greenhalgh, Howick and Maskry describe the problems caused when evidence that has been gathered about one particular condition and its treatment is then used for treating a patient in the real world, where more often than not the patient is suffering from a complex combination of conditions. The treatment suggested by the evidence will most likely fail to take this into account and the consequences can be severe, even fatal.
The authors also found many cases where a series of bureaucratic rules had grown up to make sure that the evidence was being used. As these became less flexible, the tendency was for medicine to become more management-centred and less patient-centred.
Government was taking the methodology, terminology and reputation of evidence-based medicine, and turning it on its head as they turned it into Evidence-Based Management:
“As the language of Evidence-Based Management becomes ever more embedded in medical practice, and as bureaucratic rules become the accepted way to implement ‘the best’ evidence, its requirements for evidence are quietly attenuated in favour of an emphasis on rules.” [2])
The Origins of the Target Culture: A Summary
We began the journey with Archie Cochrane persuading doctors to use the evidence from data that had been collected from meticulously run trials, to use alongside their own experience and common sense, in order to make better clinical decisions. We saw how the success of this new and rational approach in medicine inspired a new breed of public administrators. They hoped to introduce a more rational way of decision making, and found in Herbert Simon’s work a philosophy of decision-making in public administration that took rationalism to an extreme, proposing that administrators use only numerically measurable, quantifiable data.
The young turks saw the old world of public administration as opaque, irrational and inefficient. These New Public Administrators wanted transparent and rational policy-making, marrying the collecting of evidence to the setting of targets, ‘performance indicators’in the jargon, which would be as much a spur towards efficiency in the public sector as competition is in the world of business.
This theory was first put into practice in the UK by Margaret Thatcher’s government, with new frameworks put in place to make it easier to collect data in the form that the government wanted.
What had begun with gathering of objective evidence to inform decision-making, became a process of measuring. Then the measurements were turned into targets. But as the banker Charles Goodhart said, “When a measure becomes a target, it ceases to be a good measure.”.
In the early days of this movement, when some aspect of a public service was not easily quantifiable, it was merely ignored. Later, when the administrators had difficulty in extracting nationally comparable data from the existing inspectorates, they changed the frameworks, changed what was being inspected, and if necessary changed the whole ethos of the organisation.
In the next chapter swe will look at some of the consequences of this in the NHS, in Policing and in Education.
[ Next: New Public Management applied (1) The NHS ]
* Perhaps the most significant difference is that few if any in New Public Management raised these concerns.
** In 74 trials of antidepressants sponsored by drug companies, when 38 proved positive, all but one were published. When another 36 trials showed the product failed, fewer than half of the results were published.
[2] idem
No comments:
Post a Comment