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How do staff know they are doing a good job? Developing performance
measurement and management in a Primary Care Trust
Michelle Farr, (michelle.farr@banes-pct.nhs.uk), Peter Cressey and John Purcell,
University of Bath
A Knowledge Transfer Partnership between a Primary Care Trust (PCT) and Bath University
was developed to improve processes of performance management and measurement, using
staff conceptions of performance as its basis. Using a case study methodology interviews
were conducted at the PCT to explore perceptions of performance in everyday practice. For
front line practitioners individual patient outcomes are found to be the critical indicators of
performance. However these are not managed or measured by the organisational performance
regimes and staff instead “use their own measures”. Devising such outcome based measures
for the organisation from this tacit knowledge is complicated by the diverse and intangible
nature of the outcomes. Aspects of reward are also considered, both from a financial
perspective with the introduction of Agenda for Change and an intrinsic perspective; the
satisfaction felt by staff in delivering high quality services that meet the needs of patients.
Knowledge Transfer Partnerships are designed to encourage joint working between
universities and organisations to address areas of strategic concern to the organisation. An
Associate works within the organisation; conducting applied research designed to produce
specific solutions to organisational issues. A Knowledge Transfer Partnership between Bath
University and a Primary Care Trust developed to explore and compare organisational and
individual conceptions of performance. Using the question “how do staff know they are doing
a good job?” the study considers how individuals within the organisation understand and
reflect on their performance in everyday practice. Staff perceptions of performance are then
contrasted with organisational performance management systems. It is found that there are
differing notions of performance which are grounded in divergent logics. Implications of this
are considered for the development of performance management systems.
This article begins by charting definitions of performance; looking at academic concepts of
organisational performance. Government policy toward public service performance is
explored and details are provided of how government strategies have been implemented
within the health sector; presenting the specific context within which Primary Care Trusts are
operating. Performance measurement within health services is then assessed and the current
government performance framework for the NHS is critically examined. Through this review
it is found that organisational performance management systems tend to operate a within a
unitarist, rational goal model. Such models ignore intangible aspects of performance because
of the difficulties in measurement; nor do they acknowledge trade offs and contradictions that
may be inherent within different aspects of overall organisational performance. Studies which
have explored performance of health services at the front line begin to illustrate some of these
trade offs between different aspects of performance. Despite the extensive literature on
performance, relatively little is written about performance from the actor‟s viewpoint. Using
a case study methodology this study examines how staff themselves understand and reflect on
their performance. These findings are compared with the earlier review of organisational
systems of performance and the consequences for the development of performance
management systems are reflected on.
Approaches toward performance
Although historically, organisational performance has been defined in financial terms,
critiques of this financial focus have grown and wider definitions of performance have been
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sought (Hendry et al 2000; Kaplan and Norton, 1996). However in many studies there is still
an understanding that financial measures are the best indicators of organisational success and
sustainability (Boselie et al, 2005). Within management literature performance is often
defined within a unitarist framework (Winstanley and Stuart-Smith 1996); however the
meaning of performance itself is relative and value laden; whose values and perspectives are
used in the definition of what performance is (Pollitt and Bouckaert, 2004)? Where there may
be divergence of opinion in the nature of performance, some authors (Winstanley and Stuart-
Smith, ibid; Williams 1998, Simmons and Lovegrove 2005) have advocated the use of
stakeholder analysis and synthesis in the development of performance systems. A number of
studies have developed performance management systems from stakeholder perspectives
(Boland and Fowler 2000, Wisniewski and Stewart, 2005) although strategic integration of
different stakeholder views can be an issue (McAdam et al 2005). Within service
management literature there is an emphasis that performance must be related to customer-
defined and customer-focussed issues rather than to internal, bureaucratic matters
(Korczynski, 2002: 27). Korczynski (2002) illustrates how performance within service
organisations is oriented around two different logics; the need both for efficiency and
customer service. Korczynski‟s (ibid) model of the “customer oriented bureaucracy” (COB)
illustrates how these logics can be contradictory; there are trade offs between the different
aspects of performance.
Performance management in public services
Performance management can be seen as a tool which “directs employee‟s behaviour toward
objectives and tasks that deliver approved organisational performance” (Hendry et al, 2000).
Performance management was initially implemented in the public sector by the Thatcher
government of the early 1980s (Pollitt, 1990). It can be seen as part of a wider series of
reforms within public services which have been labelled new public management (NPM); the
aims of which are to increase accountability of public services, produce efficiencies,
economies and higher quality and effective services that are centred on the user (Ferlie et al,
1996). NPM imports management techniques from the private sector; taking a managerialist
approach which considers organisations in a rational, scientific way; assuming a unitarist
perspective which disregards politics and power issues (Pollitt, 1990). When the Labour
government came into power in 1997 it became clear that far from NPM being a managerial
fad, it was here to stay. Modernisation through managerialism continued through a top down
approach with new forms of organisation, quasi markets and contracting out, benchmarking
and an intensity of reform (Pollitt & Bouckaert, 2004). Performance management systems
have proliferated manifesting through principles of strategic focus, extensive auditing
systems that consider both finances and comparative performance indicators, individual
performance appraisal and performance related pay.
Whether performance management is applicable to the public sector is debatable; Solomon
(1986: 256) noting that channelling sanctioned goal directed behaviour is more difficult in the
public sector due to the pluralistic nature of policy implementation networks and the fact that
the public sector confronts political and value laden issues. Professional issues may make
alignment and goal congruence difficult in some public services. It has been suggested that
NPM principles focus on servicing organisational goals rather than those associated with
professions (Hood, 1995). The strength of professional values and beliefs about how work is
to be performed may conflict with organisational strategy and achieving goal congruence
may be a highly delicate matter manifesting different interests (Johanson et al, 2006).
McBride et al (2005: 44) account for this professional dynamic and in their analysis extend
the COB model in health services to include a third tension at the front line, that of
professional logic where staff “seek to retain its commitment to a distinct body of knowledge
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and peer group control”. Thus there are two schools of thought within public services
performance. The win: win approach is depicted by NPM political rhetoric where “citizens
enjoy services that are high quality yet low cost, easily accessed and responsive” (Pollitt &
Bouckaert, 2004: 103) whilst staff reap greater job satisfaction alongside organisational
efficiency gains (Department of Health, 2002). The contrasting perspective is based on the
customer oriented bureaucracy win: lose approach where trade offs between customers led
services, efficiency needs and professional issues are encountered.
New public management principles within health services
Within health services recent modernisation initiatives have included the reconfiguration of
Primary Care Trusts with the separation of their provider and commissioner roles
(Department of Health, 2005a). This has introduced contestability within the provision of
community based services and there is now a strong need to develop performance indicators
in community services; an area which has previously been neglected. Alongside these recent
structural changes there have been severe financial restrictions following end of year deficits
within the NHS (Department of Health, 2006). This has increased pressure on issues such as
productivity, efficiency and the need to meet national performance standards within budget.
These specific developments take place within an enormous change and modernisation
agenda which focuses on: health promotion and preventative work; partnership working with
local authorities; patient-led services; patient choice with a diversity of providers; and
community based services (Department of Health, 2000, 2004a, b, 2005b, c). Other
developments include Agenda for Change; the largest pay modernisation scheme in the NHS
since 1948 (Department of Health, 2005d) and a new development review process based on
the Knowledge and Skills Framework (Department of Health, 2004c). This has introduced a
performance appraisal system which links to incremental pay systems with the possibility of
staff‟s pay being held if they are unable to demonstrate the level of skills necessary to
perform well in their jobs.
Performance measurement within health services
Public services have faced a strict regime of performance measurement through NPM; these
systems operating through rational goal models with the achievement of targets equating
good performance. Performance measures have focussed on what is easily measured, and
have not been successful in capturing complexity (Johanson et al, 2006). Health service
performance has focussed on process measures, such as waiting times and accessibility,
which has had the benefits of being tangible, instantaneous, attributable to the provider of
care and indicative of remedial action needed (Hyde et al, 2006). Prior to the current health
service performance framework, Standards for Better Health (Department of Health, 2004d)
the performance system was based on a target driven, star ratings process. This was originally
designed to extend definitions of performance and was philosophically based on a balanced
scorecard (Radnor and Lovell, 2003). The star ratings framework was found to have several
major flaws; it failed to take local issues into account, was based on a methodology that was
not easily understood and was prone to errors (Davies, 2005: 59). Neither was the system
particularly welcomed by staff; whose perceptions about such target driven performance
systems can be illustrated by a headline in a Royal College of Nursing newsletter “Never
mind the targets, feel the quality!” (Cooper, 2003). Standards for Better Health, (Department
of Health, 2004d) the current performance system introduced in 2005, replaced the star
ratings scheme in response to some of its criticisms. It moved away from targets to standards
and local priorities. However several criticisms of this framework can be made:
The performance framework is based on a rational, managerialist approach; such
methods can fail to capture intangible drivers and processes such as feelings, values,
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beliefs and relationships; alienating employees from the system (Johanson et al,
2006).
Many of the standards concentrate on processes and do not show the impact and
effectiveness of services. There is little focus on the outcomes of the service.
The framework does not acknowledge inherent trade offs in different aspects of
performance. There is “no apparent architecture (policy, structures, procedures,
resources) or hierarchy (to differentiate between standards and criteria)” (Shaw, 2004:
1250).
Each of these criticisms is now explored in further depth and their implications considered.
The intangibles of performance Performance measurement systems can exclude many
unobservable, unexplainable and immeasurable phenomena which are essential parts of
clinical practice (Wilson and McCormack, 2006) e.g. the understanding of social and
emotional needs of clients and carers. The complexity of performance in health care services
therefore demands consideration of both its tangible and intangible aspects to enable a fuller
understanding of its intricacies.
Outcome measurements Process measures do not illustrate the overall effectiveness of
services whereas outcome measures would begin to quantify the overall objective of the
NHS; to improve patient‟s health (Appleby and Devlin, 2004). In the age of patient choice
and plurality of provider outcome measures would also give commissioners and patients
greater information to differentiate between the performance of providers (ibid).
Measurement of public service outcomes are complicated by the fact that they are often
multifaceted, they may be achieved in co-production, the period between intervention and its
eventual effect may be long, the causal effects of an intervention may be difficult to prove
and outcomes intangible (De Bruijn, 2002; Audit Commission, 2001). In spite of these
difficulties Appleby and Devlin (2005) propose that by measuring health related quality of
life, data could be provided to assess the effectiveness of health services; currently there are
no routine measurement systems for quality of life outcomes. Generally within the public
sector outcome measures seem to be the exception rather than the rule, Pollitt and Bouckaert
(2004) finding that out of the public services in twelve countries that they researched there
was no study that linked actions with positive and attributable final outcomes.
Trade offs This criticism highlights an issue already introduced in the concept of the
customer oriented bureaucracy. Different aspects of Standards for Better Health may involve
trade offs; many health service performance indicators cannot be “added up” to form a single
measure of overall performance of a system, because of paradoxes between different aspects
of a system e.g. access times and quality of care (Hyde et al, 2006: 53). Different groups may
hold different views about which aspects of performance to prioritise. The Standards for
Better Health framework provides no acknowledgement of such different interests and the
trade offs that may be involved in the implementation of the system and the delivery of health
services. The concept of “balancing” these different and sometimes contradictory aspects of
performance is illustrated well in a couple of studies that have explored performance at the
front line in the delivery of health services. Olesen and Bone (1998: 321) found the enacting
of the paradoxes of the COB in health services in the US where productivity and efficiency
pressures simultaneously diminished nurse‟s ability to provide emotional support, but
increased the emphasis on patient satisfaction as a quality measure. Despite the focus on
patient led services, rationalisation pressures may have greater force in front line service
delivery as a nurse in Bone‟s (2002: 46) study illustrates:
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“I feel a kind of impatience, like “Don‟t ask for too many things”; I keep saying
“Do you need anything else,” and I try to give it to them, but I have to get across
this unconscious message, “Don‟t ask for anything else.”
Such studies show the trade offs and dilemmas that can exist for professionals in the context
of fierce rationalising and efficiency drives.
To summarise, performance management systems can be seen as a process of “setting clear,
mutually compatible goals, translated into a set of operational targets, with management skills
and information harnessed to implement and monitor the most cost effective way of
achieving targets” (Pollitt, 1990: 120). They are based on a rational, managerialist
perspective with unitarist assumptions that define away tensions, contradictions and trade offs
between different aspects of performance (Pollitt and Bouckaert, 2004). Examining the nature
of performance however shows that it is a much more intricate phenomenon. Asking the
question “performance according to whom?” (Mannion et al, 2005: 58), begins to show its
pluralistic nature. Different stakeholders in health services may prioritise differing attributes
of performance; finances, productivity, effectiveness, clinical quality, empathy toward
patients. The actual performance of health services is multi-dimensional; social experiences
and the lived realities within the actual process of performance are likely to involve elements
and practices that are emotional, sentient, habitual, spiritual, routinised, sensory, locational
and many more (Mason, 2006). These intangibles in the delivery of health care can be just as
important as the tangibles. However due to the difficulties of measurement of these aspects,
they are often neglected in performance management systems. Despite the complexity of
performance, most studies explore the concept from a positivist, top down perspective. To
address some of the shortcomings of this approach, this study explores the concept of
performance from the bottom up; using an interpretivist approach to explore front line staff
perceptions of performance in everyday practice.
Methodology
This case study was based in a Primary Care Trust, which was established in 2001 with the
aims of planning, developing, delivering and buying health services for the local geographic
population. As well as being the commissioner for health services for the local community it
delivers a range of community based services and directly employs nursing staff, therapy
staff, medical staff, commissioners, administrative and support staff. The research took place
through a reconfiguration period with structural uncertainty for the PCT and was in the
context of severe financial restrictions following the announcement of NHS deficits. The
knowledge transfer project was based in the organisation through a period of significant
change and uncertainty. It used multiple sources of evidence; four annual staff surveys, semi
structured interviews, performance information, documents and data from the organisation
and participant observation. The Knowledge Transfer Associate, although formally employed
by the University acted as a member of staff of the PCT and was based in their Personnel
Department. Although participant observation was not a formalised method where notes were
taken from informed participants the Associate‟s position within the PCT meant that they
became familiar with the day to day issues of the organisation and to a certain extent “went
native”.
The project time frame ran from March 2005 to June 2007 and the data collection followed
the sequence of
October- December 2005 NHS National Staff Survey
April – November 2006 Interviews
October- December 2006 NHS National Staff Survey
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Data from 2003 and 2004 staff surveys was also available. The results of previous staff
surveys informed the structure and substantive issues of the interviews and their sampling.
However the results of the interviews were unable to inform the 2006 staff survey because
the survey was based on a national model developed by the NHS Staff Survey Centre (Michie
and West, 2004; Healthcare Commission, 2004). Interviews were specifically designed
around the research questions; the staff surveys provided additional longitudinal information
on general trends within the larger population of staff in the PCT. The rationale for using
mixed methods was one of completeness and enhancement (Bryman 2006). An initial 11
interviews were carried out with senior managers at the beginning of the project followed by
a further 22 in depth interviews with front line clinicians, administrative staff,
commissioners, personnel and development staff, line managers and senior managers with
overall responsibility for the departments in which the interviewees worked. Interviews
provided a hermeneutic dimension of performance; an in depth interview model was followed
(Johnson, 2002) to understand the practitioners lived experience, occupational ideology,
values and perspectives. Semi structured interviews were used but where appropriate the
interviewer attuned to who was being travelled with rather than setting out a precise route to
follow (Warren, 2002). Interviews were transcribed and analysed through the interviewing
process; themes that emerged formed part of further interviews; feeding back information to
participants and beginning the process of verification and interpretive validity (Johnson
2002). Data analysis followed an open coding and axial coding system (Strauss and Corbin,
1997?); this producing a multiplicity of codes which were then further structured iteratively
using the concepts of the performance management cycle (Armstrong, 2006).
Results
This paper first considers how staff construct definitions of performance, this is followed by
an exploration of how staff understand and reflect on their performance in everyday practice.
This is then compared with organisational performance systems. Key aspects of performance
that staff regard as important and prioritise are considered and their relationship to job
satisfaction and motivation examined. The nature of performance in health services is found
to be complex; individualised through the perceptions of staff and each patient‟s experience
and outcomes. Performance measurement systems and tools seem unable to capture these
intricacies. Implications of these findings are then considered with respect to performance
management systems and the influence of managerialism on health services more generally.
How do staff construct and define performance in everyday practice?
Front line staff that delivered services to clients tended to define their performance through
the impact that their work had on their client/ patient. The definition of client in this context
is the primary receiver of the service that is being delivered (in clinical roles this related to
patients and clients, in non clinical roles a client could be another member of staff, for
example an HR Advisor supporting a manager). When beginning a piece of work with a
client, staff would develop specific, situational objectives; making a professional assessment
of the situation in which they were working. “Every patient is different”, therefore using
one‟s own skill and judgement to evaluate the situation and assess needs was the first part of
the process of constructing performance. Good performance in the provision and delivery of
services included: engaging the client with the service; developing good relationships;
providing an unintimidating service; communicating and explaining the process of the service
to the client; understanding the needs of clients and developing effective responses; providing
a timely and effective service; developing a holistic picture of the client and the client
responding to the service. There was a sense of staff feeling that they needed to “do it all”.
Being able to deliver services promptly and meeting deadlines where they existed were listed
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as important areas of performance. Waiting times, prompt assessment and focussed, effective
services were all mentioned as important areas of efficiency.
How do staff understand and reflect on their performance in everyday practice?
Outcomes achieved were often spoken about as the key aspect of performance.
“I suppose a lot of the work that I do is based on outcomes really. So, if I don't get
the outcome that I thought I was going to get that can be quite difficult”.
The majority of outcomes were patient/ client centred; the client (primary receiver of the
service) was the central focus of performance as conceived by the front line worker. Staff
through their tacit knowledge and experience, determined how to use their skills to meet
client needs and developed their own measures of performance against the desired outcome:
“I use my own measures and my measure is have I made any difference. Have I
been of any benefit to (the client) and how have I measured that?”
The process of “using my own measures” was implicit within many professionals day to day
experience:
“to a certain extent because I have been doing this a long time you know…you just
know when what you have done is actually the right thing”.
“Using my own measures” became an important “in-vivo” code within the analysis; “my own
measures” were based upon the situation at hand, the desired outcome and the concept of
change. Change was related to the overall objectives of the job; for a Health Visitor it could
be a client coming out of a period of post natal depression; for an Occupational Therapist
enabling someone who had previously not been able to function independently to get safely
home. Tacit knowledge and professional experience were heavily relied on to assess one‟s
own performance. “My own measures” were also related to an individual‟s personal
standards, values, self efficacy and both professional and personal identity; staff spoke about
how they personally evaluated their own performance. This was associated with a sense of
achievement, “personal best” and satisfaction with work.
“I actually want to make sure that I can do the best that I can; that I go on in a day
and actually make sure that what I do is high quality; it is just in me that I am not
satisfied unless I feel that I have done everything. It is actually very hard to say
what it is that makes me motivated but it is to make sure that when I am an
Occupational Therapist I work like how an Occupational Therapist should and
ensure that patients are well and the care that they get is high quality.”
Although staff were using their own measures of performance, when they were asked how
they might evidence their successes, most responded that it was indeed extremely difficult to
measure.
“Showing evidence of something takes time and commitment to show that and it
can be frustrating because you think let me get on with the job, I can actually do it
far better and far quicker”.
Evidencing effectiveness, especially in prevention, proved an elusive vision. Evaluating one‟s
own work provided a useful assessment of one‟s own impact but it was acknowledged that
this could be based on personal, subjective judgement. Because of these difficulties feedback
from patients, peers and other colleagues was an integral part to evaluating performance.
“I think people have different perceptions of how people are doing a good job or not
but I think a lot of it for clinicians is based on the feedback that you get from
patients”.
The prominence of feedback in how staff evaluated their work suggests that performance has
a socially constructed nature. Feedback from clients was valued especially where there was
appreciation and gratitude from the client.
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“You know it‟s really, really good you get very good feedback…I mean I get loads
and loads of quite direct feedback; people phone up and say thank you”.
However feedback from clients was not always positive; some professionals spoke about
rarely getting a thank you from a client. One example is of a health visitor providing post
natal support where the client is struggling:
“They won‟t thank me for that because they don‟t want to think that they have been
there…If you get thanked, then that‟s even better. But it doesn‟t happen, not often”.
Rising expectations of clients may also elevate the levels of socially constructed
performance:
“The patients expect an awful lot more and so they‟re not necessarily the grateful
patient that we perhaps used to have and so I think it makes it much harder for staff
to really perceive whether they are doing a good job or not”.
Perhaps due to these inconsistencies in client feedback staff spoke about the importance of
peer discussions in enabling individuals to reflect on their performance.
However it was acknowledged that peer feedback was not always an easy option:
“I get feedback from colleagues; they can be quite cruel but also quite helpful and
positive. It is always quite difficult if you haven‟t got it quite right with a client.
How do you tell (someone) that she hasn‟t got it quite right? And we are finding
ways to tell people, tell each other and we get on … we are very loyal to each
other.”
Informal discussions with professionals suggested that issues of loyalty, friendship, and the
nature of the peer relationship made it difficult to sometimes give challenging feedback.
Senior staff spoke of the importance of peer discussions to enable newly qualified staff to
assess their own performance:
“I think it is really important for newly qualified staff to be as part of a team so that
you are in a surgery with other health visitors who say yes that‟s ok you‟re doing
that right, yes that is the best thing to do for that family, it is really important to
have that support. We all need that.”
Newly qualified staff themselves saw feedback from their seniors as an important source of
information in how they were progressing within their work. Tenure in post and professional
experience was seen as an important resource in evaluating one‟s performance:
“I don‟t know overall whether I‟m doing a good job at the moment in this role, I
think it is too new to really know”.
Feedback, although important, was a sometimes sparse process of understanding and
assessing performance within the workplace. Where there was little opportunity to get
feedback this restricted people‟s ability to assess their own performance. Management by
exception was often spoken about:
“I think you only really find out if you are doing a good job if you don‟t get
complaints or you are not called down to your manager.”
“Actually it is hard to know really in terms of staff and managers (clients of the
service) whether they are satisfied or not. I‟m sure if they were dissatisfied they
would complain but that‟s not really the best attitude to have in terms of managing
performance. You don‟t just lie dormant and think well they will let me know”.
The main procedural method of receiving feedback from managers was through the annual
review and personal development planning process (PDPs). Not all respondents mentioned
this as a way of getting feedback and where it was mentioned it had a variable impact on
people‟s understanding of their own performance:
“Unless I have my PDP you don‟t really get that much feedback”.
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“We went into our annual review feeling really scared and the feedback that we got
was the total opposite of what we thought so that‟s really important having a formal
meeting”.
“I mean these PDP things you are supposed to set aside an hour and a half my
god… all this set time aside and go through all this, it‟s a joke. How can you
possibly do that when there are real people depending on you? Would you sit and
get the paperwork looking pretty? You go to the people that need you. The children
that need you”.
“We get an annual …oh what‟s it called…review thing that we have with our
manager…but I‟ve only had one of those…laughter… so we have PDPs and that
was fine it was reasonably useful… pause…not necessarily that useful on a day to
day basis”.
Other organisational performance systems were less relied on as indicators of successful
performance. Generally staff did not use the organisation‟s performance measures to assess
their own performance because they saw fundamental flaws in them providing any detail of
the effectiveness and quality of their skilled interventions with clients. As an example, the
number and types of visits recorded for health visitors gave no details of the impact of the
visits or the outcomes. A well immunised baby may still have been on the receiving end of
poor parenting skills. The organisational measures that existed were poorly aligned with what
staff understood as the major aspect of performance; patient outcomes. It was the patient
outcomes that staff clearly valued and were proud of. Where these were not seen or measured
through the organisation, it could be argued that they were less valued because there was no
organisational emphasis on them.
Patient outcomes were highly important to staff and formed part of their own reward system.
“You are out there in the community, you come home and you think I made a real
difference to that person‟s life. Brilliant… that‟s brilliant.”
Patient centred care and teamwork were found to be important sources of motivation and job
satisfaction. The motivation of staff appeared to be fed by being able to provide the best
quality of care for patients.
“I like working with people. I love the interaction … my main passion is for the
actual building up of relationships with people, just seeing them progress”.
“I enjoy the job. I enjoy working with families. I suppose …I get a thrill out of
being able to help people with things… trying to do it in a way that doesn‟t make
them feel diminished.”
When staff had time to reflect and think about how they provided care and how they could
improve, this seemed to increase motivation.
“I did go through a phase when we were fully staffed and the team that I was with,
we had half a day a month, when we actually set aside a meeting and reflected on
our work…and that was the most fantastic time in my health visiting experience
when we were able to take time to think about what we were doing and reflect on it
and then say perhaps we need to do this or we need to do that or whatever or should
we actually be exploring this area, but it didn‟t last very long, I have to say.
Unfortunately it has all been to do with staffing”.
Where organisational efficiency drives stretched staff and compromised the extent to which
they could meet their envisaged outcomes for patients and were unable to provide the best
quality of care or use their full range of professional skills job satisfaction tended to go down.
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“I do get very dissatisfied if I can‟t do; give the support that I would like to...
because of the time pressures really.”
“with the number of patients you can‟t care as much with every individual as you
want to.”
“The priorities have changed; I keep going back to that it has changed. If I really sat
and thought about it I would probably get quite miserable that I don‟t give as a good
a service as I previously gave to lots of people.”
Results from the organisations staff survey confirmed that job satisfaction in the Trust
significantly decreased in the two consecutive years from 2004 - 2006. It was during this time
that the financial restrictions were at their greatest.
During this time new organisational reward systems were introduced by the Department of
Health. Agenda for Change was intended to develop a system of fair pay through a
“transparent and open system of reward” contributing to better morale and improved staff
satisfaction (Department of Health, 2005d). However there was a general feeling that the
process and outcomes of Agenda for Change did not live up to the espoused political rhetoric
which heralded its arrival within the NHS. After its implementation within the case study
organisation, the number of staff who were satisfied with the extent to which the Trust valued
their work significantly dropped from 49% to 32% from 2004 to 2005 after Agenda for
Change was implemented. In 2006 mandatory questions concerning Agenda for Change were
included within the National Staff Survey for the first time. Within the case PCT 53% of staff
felt that their Agenda for Change banding was unfair. The Knowledge and Skills Framework
(KSF) provided a new basis for annual development reviews, pay progression being linked to
these reviews. The KSF was intended to help staff develop their skills and improve links
between development and career progression (Department of Health, 2004c). However at a
time when training budgets were restricted due to financial pressures staff seemed more
concerned the prospect of being held at pay points and with restrictions in training than
feeling that this formed part of a reward system.
The rewards of performance for front line staff were found to be the actual outcomes of their
performance; benefits for patients and clients. Current dissatisfaction with organisational
reward systems suggested that it is the intrinsic rewards of performance that provide drivers
for staff. However as can be seen from earlier quotes, the pressure on resources means that
these intrinsic rewards were also getting harder to find.
Measuring outcomes
As discussed earlier, current performance frameworks within health concentrate largely on
processes rather than outcomes. In the course of later interviews, when it had become clear
that staff conceptions of performance were based on patient outcomes, outcome measurement
tools such as those cited by Appleby and Devlin (2004) were discussed in interviews, to
assess their efficacy and appropriateness. Perhaps using outcome based performance
assessments would align not only the mission of NHS, to improve the health of the
population with its performance measurement systems, they would also be congruent with
how staff assess their performance in daily practice. However further exploration with staff of
the use of these tools revealed their limitations.
“a lot of the health related quality of life outcome tools are all very well but actually
if you have got somebody with a degenerative condition they don‟t work… if
11
you‟ve got somebody who‟s dying or losing their skills. They are problematic
really these methods.”
“I think people need to be very careful about using some of those quality of life
measures as equalling good performance”.
Analysing the text and questions of health related quality of life outcome measurement tools
included in the report by Appleby and Devlin (2004) (SF-36 questionnaire, Medical
Outcomes Trust, 2002 and the EQ-5D, Euroquol) against the interview text of clinicians
discussing how they measured their own impact gave further concern that such tools would
not be sensitive enough to capture the intricacies of care provision to a diverse client range.
Implications of findings
Whereas organisational performance systems are based on rational measurements it was
found that individual members of staff‟s understandings of performance are based on tacit,
practical and experiential knowledge (Reason, 2003). Patient outcomes are the focal point for
the discernment of good performance for front line staff; these outcomes are situationally and
individually specific and to a certain extent value based. Due to the complexity of health
outcomes, generic outcome measurement tools seem to fail to capture the intricacies of health
service performance. Performance measurement systems are not easy to design around such
diversity, especially where outcomes are complex.
The different dimensions of performance are based in different logics which to some extent
mirror the different logics of customer oriented bureaucracy; the “rational” and the
“irrational” (Korczynski, 2003: 63). Clashes of logics are present within the performance of
health services; the logic of professionalism; the logic of patient centred services and the
logic of efficiency (McBride et al, 2005). Performance management techniques based on
rational goal models and managerialist techniques do not necessarily support the value and
experiential knowledge based work of professionals. Managerialism is blind to the
complexity of the process of performing, aspects of implementation and the real trade offs
that exist between different characteristics of performance. The unitarist approach of NPM
and managerialist principles seem to define opposing logics away insisting that higher
quality, more efficient and patient led services are mutually compatible and reinforce each
other. However a closer examination of the delivery of front line services suggests that the
relationships are not always compatible or complementary. Trade offs and contradictions
exist within the different principles of NPM. Future issues in health provision will make these
contradictions starker. Increasing pressures on health services due to an ageing population,
advances in medical care and rising customer expectations (Ham and Robert, 2003) all mean
that trade offs and contradictions need to be openly discussed and debated rather than defined
away through political rhetoric.
Practical implications
How can these different trade offs and logics within the system be managed? The purpose of
Knowledge Transfer Partnerships are to provide specific solutions to organisational issues.
What are the practical implications of these findings and what solutions can be suggested?
Mannion et al (2005) in their study of culture and health services performance suggest that
performance management systems in healthcare need to congruent with the nature of the
process being evaluated. Where performance is relatively unambiguous and measurable,
quantitative monitoring may be appropriate. Where outputs are difficult to measure controls
based on shared values and trust may be more effective. Through the data analysis it has been
shown that to a certain extent the nature of performance in everyday practice is socially
12
constructed. Ouchi (1980) suggests that organisations can rely on this socialisation as a form
of mediation or control. Perhaps by investing time in professionally led peer reflection and
performance assessment the value based approach of professionals can be supported.
Staff discourses of performing services maintain that “every patient is different”. In deciding
on a course of action with a patient, staff use tacit knowledge and experience to develop
appropriate clinical and interpersonal interventions. This process can be likened to the nature
of knowledge intensive work; “the practical use of tacit knowledge in novel circumstances”
(Swart et al, 2003: 8) where clinicians provide “bespoke services for customers with novel,
complex demands” (ibid). Examining the process of performance in front line health services
suggests that the work could be more akin to knowledge intensive work than to routinised
and rationalised work processes. Such a thesis is further confirmed in staff attitudes toward
their work which reflects those of knowledge workers who wish to be involved in work that
develops their skills and abilities. Performance management techniques in knowledge
intensive firms focus on techniques such as the encouragement of professional networks,
team based development and learning and developing performance standards that are
negotiated between workers (Swart et al, 2003). The application of these techniques within
health might begin to address the intangible characteristics of performance although there
may be difficulties in the implementation of these due to financial and time pressures and
force of top down performance systems.
Conclusions
New public management techniques of performance management approach organisations
from a rational perspective, making the assumption that it is both possible and conducive to
operate from a system of shared and measurable goals. This study set out to develop a series
of bottom up performance indicators; exploring aspects of performance in health service
delivery at the front line. It was found that staff understand their performance based on tacit,
experiential knowledge that operates through a different form of logic than that of the rational
approach. The heterogeneous qualities of health service outcomes resist a generic
measurement approach. Therein lays the challenges for the management of performance.
How can the organisation enable staff‟s tacit knowledge of their performance to be made
explicit? It has been suggested that due to the socially constructed nature of some
performance outcomes that performance management techniques may also need to based on
these different logics of values and professionalism. Here lessons can be learnt from different
sectors that share similar characteristics of knowledge intensive work. However
implementation of these techniques may prove difficult due to the external pressures of
government led performance regimes and tight financial pressures.
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