This blog is the third in a new series called ‘Fact or fiction?’, where experts from the Nuffield Trust give their take on the data and evidence behind some of the current perceptions of what is happening with the NHS.
Views on targets are highly polarised. Special interest groups are keen to get a target for their priority area while detractors question their clinical validity and assert that care has become 'all about meeting targets'; a sense of achievement abstracted from meaning. Yet in the past targets have been associated with dramatic improvements in care, such as massive reductions in healthcare associated infection and waiting times for treatment. Recently some of those gains have been reversed, such as the four hour target in A&E dipping below 90 per cent and the suspension of the 18 week referral-to-treatment target for planned care. This has prompted much anguish and headlines that the NHS is “dying” and “third world”.
So, are targets good or bad for the NHS?
What do we know?
How do targets work?
If there’s an issue you want to improve - for example, crowding in A&E – then one way to achieve that is to set a target. This needs two elements: first, pick a measure that is related to what you want to improve (such as the percentage of patients spending less than four hours in A&E). Second, decide what level of performance you expect providers to achieve on your measure (95 per cent). These decisions – often from politicians – crystallise value judgements about what is acceptable performance. But they can be quite technical and might not necessarily connect to what patients or clinicians think is most important.
While setting a target makes explicit a (relatively) objective goal for the system, a lot depends on the ability of politicians to define what they want in terms that are measurable. It has long been said that bad laws make money for good lawyers, and the same is true of indelicately implemented targets. Huge volumes of guidance have to be published to restrict opportunities for 'gaming' and distorting services. While the intent of the target might be evidence-based (for example, patients spending longer in A&E have worse outcomes) critics will question the details (why four hours rather than three or five?).
One of the fundamental challenges to targets is that they measure what can be counted rather than what matters. This is particularly true when a target (one tiny slice of activity) is used to infer quality (which is the result of a complex array of care processes and interactions).
Then why not instead set a broad goal for the system – such as 'do good stuff'? This has substantial pitfalls too. It’s highly subjective and providers, policy-makers and the public may not agree on what 'good stuff' is. Also, while we can trust the professionalism of 97 per cent of providers that they will genuinely try to achieve 'good stuff', how can the other 3 per cent be held to account if goals are not clearly defined?
Have they worked in the past?
While not the first performance targets in the NHS, most of the targets we have today stem from the New Labour government in the 2000s. They introduced targets covering areas such as waiting times, cleanliness, smoking quit rates and reductions to the length of time patients spent in hospital.
These targets were generally achieved and the principle of accountability and performance management through targets was continued by the Coalition Government in the form of the NHS mandate and the NHS Outcomes Framework.
However, there were two important factors associated with success of targets in the 2000s: both the support and the pressure issued from the centre. The support made the targets part of a collective effort, augmenting many areas with improvement programmes which led to new solutions and spread expertise between organisations.
Significant funding increases for the NHS made rapid improvement easier to achieve. The pressure made it clear that achieving the targets was the priority and sometimes had the beneficial effect of reframing expectations of what was achievable.
But methods such as increasing the risk of managers being sacked and public “naming and shaming” led to dysfunctional behaviour such as 'gaming' data, short-termism, bullying and obsessive checking and assurance activities.
Do targets lead to quality?
Dysfunction was also evident in services being re-configured to maximise performance on things that were measured (at the expense of things which were not). In this way, targets are achieved through tactical and transactional methods rather than by transformation – which matters because systems built this way lack resilience.
The real story of targets is the way in which they have been performance managed. It is no coincidence that the targets to which most attention is paid tend to be based on process (such as access to care) rather than outcomes (such as mortality). This is because responsibility for an outcome is often ambiguous, but it is much easier to hold individuals to account and effect change in process indicators. The importance of focus perhaps also explains why performance regimes that span a wide range of measures tend to have less impact.
But there are limits to what political focus can achieve. If a service cannot realistically achieve a target then just shouting at them louder (without offering extra support) will not help, and may even be disruptive.
So why does it happen? Part of the problem is a tendency to treat performance measurement as pass/fail. A unit achieving 95.1 per cent is no different to one achieving 94.9 per cent, so it makes much more sense to think about scales of performance. Another is a lack of perspective. In most cases performance is shaped by the system over months and years, with meaningful change happening over similar timescales. Constantly asking whether we’re 'nearly there yet' won’t help.
Fact or Fiction?
In summary, targets can be effective if used sparingly and for a few carefully chosen areas. Adding increasing numbers diminishes their effectiveness and confuses organisations about what the priorities really are. There are also problems with the way in which people respond to targets, both at the frontline, those managing the system and the media. You want a target to focus people's minds on improving care, not absorb them to the exclusion of all else. While any decline in performance needs to be taken seriously it is important to take a broader and more nuanced view when considering quality. A target is a useful tool for improving services when combined with additional support, but targets should never be the sole arbiter of quality in the NHS.
Blunt I (2015) ‘Fact or Fiction? Targets improve quality in the NHS?’. Nuffield Trust comment, 13 February 2015. https://www.nuffieldtrust.org.uk/news-item/fact-or-fiction-targets-improve-quality-in-the-nhs