title: What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down governance in two clinical settings.
abstract: Top-down policy directives, such as targets and their associated protocols, may be driven politically rather than clinically and can be described as macro-political texts. While targets supposedly provide incentives for healthcare services, they may unintentionally shape practices of accommodation rather than implementation, deflecting practitioners from providing optimal care. Live work activities were observed for two six months periods in a UK NHS Emergency Department and a Mental Health Ward using video and field notes ethnography, with post hoc unstructured interviews for clarification and verification. Sixty-four practitioners were consented. Data were treated as narratives, analysed thematically and theorised using cultural-historical activity theory. The ideal text of patient-centred team working shaped by top-down, politically inspired targets was disrupted, where targets produced unintended consequences. Bottom-up strategies of making meaning of targets in a local context generated sub-texts of resistance, rationalization, and even duplicity that had paradoxical positive effects in generating collaboration and democratic habits. Throughput pressures generated both cross-team conflicts and intra-team identification. What practitioners actually do to make sense of top-down directives is not the same as the ideal expectation framed by targets. Team members pulled together not because of targets but in spite of them, and as a form of resistance to governance. Targets produce unnecessary stress as team members focus on throughput rather than quality of care. Those governing healthcare must look at the unintended consequences of targets.
authors.affiliation: Centre for Clinical Trials and Health Research - Primary Care Group, Plymouth University Peninsula Schools of Medicine and Dentistry, Room N21, ITTC Building Plymouth Science Park, Derriford, Devon, PL6 8BX, UK. Jon.allard@plymouth.ac.uk.
authors.forename: Jon
authors.initials: J
authors.lastname: Allard
authors.affiliation: Emeritus Professor of Medical Education, Plymouth University Peninsula College of Medicine and Dentistry, Plymouth, UK.
authors.forename: Alan
authors.initials: A
authors.lastname: Bleakley
mesh_terms: D000884:Anthropology, Cultural; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006801:Humans; D007407:Interviews as Topic; D016134:Organizational Policy; D010348:Patient Care Team / Q000458:organization & administration*; D061214:Patient Safety; D011567:Psychiatric Department, Hospital / Q000458:organization & administration*; D006113:United Kingdom; D014741:Video Recording
keywords: Emergency medicine; Mental health; Patient care team; Patient safety; Politics; Teamwork