4 pie charts you won’t see in a performance report

I do performance reports for a living.

Here are the most important 4 pie charts that I will never be able to put into a performance report.



This entry was posted in all wrong, deming, systems thinking, targets and tagged , . Bookmark the permalink.

23 Responses to 4 pie charts you won’t see in a performance report

  1. “Frequency that targets cause gaming: 100%”

    Fine (I don’t see how you can be so certain it is exactly 100%, as a scientist I am never so certain of *anything*, but hey). However, targets do produce results. Let me take you back to 1997 when average waits for elective hospital treatments were 18 months. Then the (politically chosen) 18 week target was enforced and the result? Waiting times plummeted. Now, you’ll say there is gaming. I agree, but the vast majority of people now have treatment within 18 weeks rather than 18 months. That is an improvement.

    Frankly I care little about the pedantry about gaming, and while I would like targets to be flexible in a way to reduce gaming (because I care about the patients who do not have their treatment promptly because of the gaming, not because of the gaming per se), gaming is minor compared to the incontrovertible fact that people are being treated quicker.


    • ThinkPurpose says:

      Thanks for the reply!
      Re: Targets always cause gaming. From an academic study of targets in the NHS done by LSE, reference here , direct quote being “Target based performance management always creates ‘gaming’ “. As an article about this type of thing states, not sometimes, not frequently, always.

      Re. targets driving down waiting times in the NHS. See here, for another example of how an apparently “good effect” of a target, the 4 hour maximum wait in A&E, actually worked against purpose and made patients be FAR more likely to be admitted to hospital rather than breach the 4 hour target.
      So, regarding the 18 week target and the associated measure, we can only know if the target had a beneficial effect if we look at what actually happens to the patients, and whether the care they need is helped or hindered by that target.
      A very good place for reading about the actuality of targets and that in the NHS is here.


      • Well we can argue about whether gaming occurs in 100% of the times there is a target because, of course, you only need one single case to disprove that assertion! (That’s why I am always reluctant to be absolutist.)

        The 4 hour A&E graph, I think proves what I am saying. It shows that the vast majority of people are being seen before 4 hours! That is a good thing, right? The target says effectively “it is unacceptable to wait more than 4 hours” and the result is that the majority of people are seen before that time. (Incidentally, you are wrong to say that the 4 hour target has been abolished. It never went away. For example, here’s a recent case where Monitor intervened at a trust because it persistently broke the 4 hour A&E compliance target http://www.monitor-nhsft.gov.uk/home/news-events-and-publications/latest-press-releases/monitor-steps-behalf-patients-cambridge-univ)

        I also dispute your claim that trusts admit patients to avoid breaching the 4 hour target. That assertion would assume that there is an everlasting supply of hospital beds and staff. There isn’t, quite the opposite, the number of acute beds has fallen over the last decade. There simply is not the capacity to be able to admit a patient merely to avoid breaching the 4 hour target. High bed occupancy is a cause of numerous other things that are covered by targets: for example, hospital acquired infections (MRSA, c-diff) and mixed sex breaches. High occupancy also contributes to non-clinical bed moves which are bad for patients.

        Of course, a true comparison would be with the waiting times without a target, and I would be interested to see such a graph and see how many people are seen over 4 hours.

        There’s a couple of other things to think about. First, the Conservatives announced before the last election that they will get rid of all targets in the NHS. While they have relaxed (in terms of what is measured) some of the targets, they have actually added *more* targets. Why? Because of public demand. Lansley tried to get rid of the 18 week target and found that it would be extremely unpopular, so we still have it. Further, Lansley has even added a *new* target of long waiters – people who have waited more than a year (this is one of the downsides to targets, once the target is missed there is no longer any incentive and the patient is treated the same way as in the pre-target days, ie, they get dumped on a never ending waiting list). Incidentally, Denmark has a 4 week elective target, a fifth of what is considered to be acceptable waiting times in the UK, if the 18 week target is bad because of gaming, then 4 weeks would be hyper-bad!.

        I am an elected Foundation Trust governor so I make a point of finding out how the trust is run. Like any business (and these days, an FT is treated as a business) they have their own targets. The so-called compliance targets (like 18 weeks, or 4 hours or 2 week and 62 week cancer targets) are just a tiny number compared to the internal targets that the trust sets itself. Every business does this. So are you really saying that the entire business is “gamed”? If so, then they are kidding themselves.


        • ThinkPurpose says:

          Genuinely mate, thanks for the comment. Whilst I ABHOR a balanced view (see my reply to previous commenter) I will always approve on topic comments, but not necessarily argue back to them. My bit is above the comments, the bit below the post is [gestures dramatically with open arms] BELONGS TO THE WORLD!
          Oh look, here comes Red Blogger to do just that.


      • Red Blogger says:

        Dear Richard,

        very nice to see a governor engaging in meaningful debate, I think the Trust is fortunate to have someone like you.

        I work compiling target outcomes in a very large NHS organisation and I am more on our hosts side, there is likely to be some kind of gaming going on across the board.
        If you are allowed to, it might be instructive to look at a few you deal with.
        This is difficult because of the knowledge imbalance, you are unlikely to get very far.
        However, some detailed reports from your internal auditor is your best bet at picking up some “inconsistencies”.

        As far as the 4 hours is concerned, I will challenge to see if you were aware of the blog below and the discussions that have taken place around this topic.

        Your comment about everlasting beds is not well informed IMO, demand surges and ebbs and therefore admissions to preserve the 4 hours will happen in certain periods only.

        “But the focus on the 4 hour target feels inappropriate in the current context. Why? Firstly, because it puts all the focus on one part of the system (acute hospital), when a broader approach is needed. And secondly, because this pressure could easily lead to inappropriate actions being taken.”

        Targets have had some use, particularly whole system targets.
        The way they have been enforced has had many damaging side effects.
        The whole system needs to be considered.

        best wishes,



  2. stephen black says:

    I like the Pie charts (and I don’t normally approve of any pie charts) but they should be supplemented by others to give a balanced picture.

    Like “how often do you feel OK when customer services keeps you on hold for 10 minutes?” or “how many hospitals fixed their A&E processes to meet the target rather than gaming it?”

    The first is 0% the second is not 0% though, sadly, not 100% either. Besides, the very evidence you show (in the linked “targetitis” post) to demonstrate gaming is, in the hands of anyone supervising the system, a good way to spot gaming and poorly designed A&E processes and has been used as such by some of the smarter performance managers in the NHS.

    And it isn’t obvious to me that the large increase in waits since the government relaxed the targets has done any good for anyone, clinically or otherwise. I’m also fairly sure that there has not been a major change in admissions nationally related to changes in the target or otherwise. I’d need to see good evidence of that.


    • ThinkPurpose says:

      Thanks for the comment Stephen!
      I genuinely love it when people read my stuff and more so when people take the time to reply. I will always approve a comment if it is on topic, or just plain good. Funny is even better
      However I don’t do balanced pictures, or “striking a balance”, taking “a more considered view” or any of that fake conciliatory bollocks.
      I have to do that at work, here I make the rules, and I am a fucking God on this blog.

      Targets are THE number one arguing/sticking point between systemsy types and non-systemsy types. I don’t know why exactly, possibly because it is pretty black and white to a systemsy type. If smoking 20 cigarettes a day is bad for your health, and it is, then its not being moderate or “striking a balance” to say that person should smoke 10 cigs a day. Just stop. Its not extreme or immoderate to have that position. A bit like if I have my left foot in a bucket of freezing water and my right in a bucket of boiling hot water, I am not actually in some kind of temperate lukewarm balance. One foot is being scalded, the other frost-bitten.
      Sometimes there is an up and there is a down.

      Everything that I’ve read, and experienced and learnt from in the work, has shown me that the targets don’t work, and at best are irrelevant, but most of the time aren’t.
      I am not going to stop or alter what I think I should be learning from the workplace because it doesn’t appeal or contradicts or is absolutist and not in a fake balance to appeal to others sensibilities. This is what I and many many others have learnt when the right questions are asked in the workplace about purpose and what helps and hinders achieving it.
      I have provided my own evidence for me, in my workplace. If you want to, so can you too. This blog is certainly not an attempt to persuade anybody. That would be impossible. Lessons that completely turn around your whole mental model of work are generally not learnt from posts on a blog.
      Regards, and thanks for the commment!


  3. I am sorely tempted to put the first two pie charts in my next annual self-evaluation. In fact, I may not wait until then, and send them to my manager before our next 1-on-1. I think he’d appreciate it, but likely he would not send it to his manager where it really needs to be seen.


  4. After following your blog for a year or so, I’m curious. Why do you do what you do for a living if you are so opposed to it? Are you not interested in seeking work where you can embrace the value system, rather than despising it? Or is it just too hard to find such work?


    • ThinkPurpose says:

      Good question!
      sadly this probably won’t be a good answer though.

      A combination of the following, in different weightings at different times

      1: I’m lazy. I’m in a nice rut. Pleasant people, a view from the third floor over green things. flexi-time for picking up children, public sector pension. Bike-sheds.
      2: It’s really good material for the blog. The worse it gets, the better the material.
      3: It’s convenient. Only 4 miles away from where I live, an easy 18 minute cycle
      4: I enjoy arguing and posturing. Ideal when in a minority.
      5: THE ECONOMY
      6: I am practically skill-less. A keyboard rattling policy officer is NOT who you’d want in your fox-hole. Doesn’t mean I can’t do things, just not the sort of thing I see advertised that companies are willing to pay for.
      7: I get satisfaction from other things now. Not work. This blog, for a start. If nobody agrees with me at work, there are several thousand a week that do here. That is very pleasing.
      8: Recently it’s got a lot better, different atmosphere, and there’s a lot more opportunities for change as the Inspection system has practically disappeared. We can do what we like, performance-wise.
      9: It is incredibly interesting seeing how it all works. Even if I don’t agree with it, or it drives me mad. I think observing people interacting in an organisation can teach you so much about sociology, psychology, all sorts. Just read some good books to provide some theory, and then watch it all unfolding all around you , with you doing it too. Like being an amateur anthropologist.


    • ThinkPurpose says:

      One more thing. I want to CHANGE the value system. That’s it.
      Or rather, I would like to play a small part in helping others find a way for the system to help THEIR work get better by helping change the thinking.


  5. As someone who has written quite a bit about ‘gaming’ (Gaming the System, FT/Prentice Hall), I will avoid that subject, but I am wondering why you say you could never put these charts into a performance report. Granted, the chances of them appearing in a report are slight, but the reality is that if they aren’t talked about, the demonstrated behaviours that they exemplify will continue to be a curse on overall performance.


  6. ThinkPurpose says:

    Yup, the reality is they AREN’T talked about, and the behaviours DO continue.
    But then again, where do people read reports? In meeting rooms. What good happens in meeting rooms? Little.
    So in the end, doesn’t really matter. The thing to do is turf them out the meeting rooms.


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  8. For Richard Blogger, re your comment, “I also dispute your claim that trusts admit patients to avoid breaching the 4 hour target.” –

    I was admitted to avoid breaching the 4 hour target.


  9. Red Blogger says:

    well, well well
    who would have thought it, “discrepancies” rather than “inconsistencies” that I had mentioned above, in the NHS

    27 February 2013
    Data fears over septicaemia deaths at Royal Bolton Hospital

    Bolton NHS Foundation Trust said acting chief executive Dr Jackie Bene has stepped aside
    An investigation is under way into unusually high numbers of septicaemia deaths at the Royal Bolton Hospital.

    Bolton Clinical Commissioning Group (CCG) confirmed the trust recorded 800 cases from March 2011 to April 2012.

    The figure is four times higher than a trust similar in size would expect, according to Bolton CCG.

    Bolton NHS Trust said acting chief executive Dr Jackie Bene had stepped aside after initial findings revealed “potential discrepancies” in data.



    • stevie says:

      I have been banging on about the effort put into managing people and not systems for years. We employ managers and dont tell them what to manage. Employees will manage themselves but should not have to manage process that is the managers job. A good manager will engage the employee to improve the process but it is his role to manage the process. An employee will perform better if there is a manager making his job easier.


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