What can history teach us about performance regimes?

1. What can history teach us about performance regimes? Steve Harrison University of Manchester stephen.harrison@manchester.ac.uk

2. Preliminary stuff • Data drawn from ESRC-funded (RES-166-25-0051) study of development of health system performance regimes in England & Netherlands from 1982-2007 • Data: Documentary records, published work & interviews with 49 English & 24 Dutch participants (mainly regulators, academics, policy entrepreneurs, specialist media correspondents) • An explicit element of the study was to explore explanatory power of ‘path-dependence’ concepts • Publication details: Pollitt C, Harrison S et al (2010) ‘Performance regimes in health care: Institutions, critical junctures and the logic of escalation in England and The Netherlands’ Evaluation 16(1)

3. The ‘performance regime’ • PIs do not exist in a vacuum, but • may be used in various ways for various purposes by various actors; and • are embedded in a social political & economic context. • We utilised the concept of performance regime to signify the relevant organisations, policies and groups of interested actors, along with the rules, cultural norms and behavioural assumptions which order the relationships between the various groups and organisations at particular points in time. • Such contexts & the manner of usage of PIs taken to be at least as interesting as PIs themselves

4. Endogenous reproductive mechanisms in performance regimes: a logic of escalation? • Tendency for a few, simple measures to become more comprehensive & complex, eg • Policy makers all want ‘their’ areas to have indicators • Politically high-profile topics can’t be omitted • Increased number of indicators brings increased complexity of interpretation • Initial formative approach - PIs as the means of facilitating local enquiry into organisational performance & thereby facilitating local approaches to differences/ problems identified – tends to become summative - PIs define key aspects of organisational performance, thereby providing absolute targets (or relative ‘league tables’) to be pursued, & by which locals account to the hierarchy

5. Logic of escalation 2 • Tendency for summative approach to feature • incentives (eg QOF) & sanctions (Stevens’ ‘constructive discomfort’, Bevan & Hamblin’s ‘targets & terror’); & • associated pressures to cheat or ‘game’ • ‘Gaming’ seen as marker of regime effectiveness(!!!), but also gives further twist to regulation & sanctions regime • Tendency for incentives/ sanctions regime to raise issues about validity & meaning of PIs, which • provokes technical responses (eg standardisation of measures) & supposed simplification (eg creation of composite indices), with the result that • indicators become more complex & more difficult for non-experts to understand

6. Logic of escalation – 3 • ‘Ownership’ of the regime becomes more diffuse, eg • Gradual establishment of a performance ‘industry’ of multiple regulators, academic units & others, with associated discourse of ‘progress’ • Groups not involved in original arrangements use regime to pursue own ends (consultants, analysts etc) • Tendency for external trust in data/ interpretations to decline – UK is bottom of European league table (!!) of public trust in official statistics. Tsoukas’s ‘tyranny of light’, as a result of • Competitive interpretations/ analyses of data • Opacity to non-experts • Statistically illiterate news media

7. What about the Netherlands? • Same general level of economic & technical development, health care demand etc as UK • Parallel history of health policy issues & developments – cost-reduction, rationing debates, quality management, regulated competition • But Netherlands has coalition governments in ‘consociational’ democracy, unlike UK ‘majoritarian’ democracy (Lijphart 1999) • Hospital PIs first introduced 2003 after c10 years of discussion about health system performance • Somesigns from our research are that Netherlands is subject to similar ‘logic of escalation’ described above, though somewhat inhibited by more consensual democratic style – exogenous factors seem to make a difference too.

8. So what? • History doesn’t simply ‘teach’ us anything – we may learn from it, but even when we try, we may all arrive at different interpretations, eg • Does ‘gaming’ indicate failure or success? • Does occurrence of problems mean that policy should give up or try harder? • ‘Wouldn’t start from here’ - tempting but facile • Path-dependence perspective suggests that it will probably take a big exogenous shock to break the cycle of escalation • Two personal concerns • Level of abstraction of performance concepts • Has ‘performance’ become the product?