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An ethnographic study of goal planning in the rehabilitation of acute stroke patients conducted by Levack et al. (2011) illuminated how certain issues were ‘privileged’ by HCPs, considered as more important which consequently constructed and dominated goals set. These privileged goals tended to have ‘an orientation towards

physical functioning […] short timeframes for their achievement, and […] conservative estimates of progress’ (Levack et al. 2011, p. 210). However, considering the

elements of SMART goal setting as discussed earlier, the goals that are privileged could be, not those that are deemed most important as Levack et al (2011) suggests, but those which are more easily measurable and can therefore assist with meeting professional and organisational needs - proving and demonstrating effectiveness. This argument is supported by Levack et al’s (2011) observation of a lack of goal setting in relation to social and psychological functioning (areas which are more difficult to objectively measure), despite these areas being frequently raised as issues and concerns by HCPs and discussed at length by the MDT. The aims of privileged

110 goals highlighted above were considered by Levack et al. (2011, p. 210) to reflect one main objective, ‘to return the patient to the community as quickly and as safely as

possible.’ Although Levack et al. (2011, p. 210) consider this objective to be reflective

of ‘clinicians’ over-riding sense of responsibility’ they omit to highlight that this aim is perfectly in line with broader health care organisations ’ (especially acute services) consistent and recurring aim: to ensure regular and continual patient throughput. Continual and rising pressure on services with hospitals repeatedly having ‘bed crisis’ where there is no room for new admissions is a contemporary (and also longstanding) reality for health care services and bed managers. Goal setting can again be seen as a technology which is mobilised to assist with the disposal of patients (Latimer 1995). In this case, to discharge from an NHS rehabilitation service into the community. This organisational aim was imbued within the talk of Levack et al’s (2011, p.210) health care professional informants as demonstrated by a Physician who said:

In order for the process [of goal setting] to work it’s necessary to bring things down from a long-term – what people are going to get out of their life kind of level – which is how I like to see it, down to the nuts and bolts of what is required to get somebody out of hospital. And clearly it’s possible to use the term goal planning right down to that level but for me that’s really more of the issue of task allocation and completion.

The influence of organisational aims and objectives on goal setting has been identified and discussed elsewhere. Simpson et al. (2005) analysed goal setting statements in two brain injury community rehabilitation services. They speculated that organisational objectives explained the differences between the goals being set. They found that the content of goals differed significantly between s ervices and that in one service they changed over time. They concluded that organisational change and its extent was influential in generating these discrepancies. They also highlighted how the differences between organisational agendas, structure and service provision were visible through the goals being set, thus stating that:

‘while goal statements may be reflective of client expressed need and the

client/service provider relationship, the data indicate that goal setting may also be understood as an organizational activity embedded within unique

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service frameworks and socio-political contexts.’(Simpson et al. 2005, p. 907- 8).

Simpson et al. (2005) therefore suggest that goal setting can be, and is , utilised differently by differing organisations. Goal setting can be manipulated, moulded to fit with a given set of organisational aims. The flexibility of goal setting therefore may explain the longevity of its use. Simpson et al. (2005) do recognise however that other factors could have accounted for the differences they saw, including the severity of individual patient impairments, professional background and experience of individual clinicians and their relationships with patients.

Simpson et al. (2005, p.902), citing Kuipers et al. (2003), theorise that goal setting is

‘representative of the interface between the organization/service provider and the person with ABI.’ Similarly, Alve et al. (2013, p. 156) highlight that planning

processes, more specifically patient participation in treatment plans (including goal setting) can provide a focus for interactions between patients and service providers , becoming a tool to facilitate ‘collaboration between the client, public services, and

different service providers.’ Simpson et al. (2005, p. 902) also suggest that the

governance, accountability requirements, the expectations of funding bodies and the pressures they place on organisations heavily influence goal setting practices. They discuss an array of potential uses of analysing and tracking patient goals for organisational purposes, suggesting that goals provide ‘a means for benchmarking,

moving beyond audits of ‘activities’ or ‘occasions of service’ to examine the content of issues addressed in rehabilitation service delivery.’ They also consider how looking

at goals set over time can be set against the goals of the organisation, their ethos and aims.

Stilwell et al. (1998) raise how benchmarking through goal setting allows services to evaluate themselves and compare themselves against other services and organisations. Whether this is for quality control, service development, market driven reasons or any others, is not stated. Wressle et al. (1999, p. 80) citing Swedish Health and Welfare regulations however do make a direct link between goal setting

112 and measuring service quality stating that ‘[q]uality can be defined as the degree of

goal fulfilment.’ However, governance and accountability requirements ‘creates tensions for the goal setting process’ (Simpson et al. 2005, p. 902) in particular

because they move away from the moral aims and discourse surrounding this technology – that of patient centred practice.