NHS Targets 'have had their day' as review set to introduce new revised targets

Lord Prior, chairman of NHS England is reported to have signalled that [NHS] ‘targets have had their day’ (The Telegraph, 14th February 2019). Targets and the choice agenda has led to a fragmented health care system and have ‘failed almost totally’. Prior is quoted on how targets work in Accident and Emergency departments:

“Of course the gaming that has developed around these targets and the bad behaviour…go to any A&E department and everyone measures the time…you get to 3 hours 55 minutes and all hell hits. Everyone runs around like headless chickens to get them out or get them through or discharge them before the four hours.”

This description of how targets can distort services (see Sam Spencer on Targets at Rethinking Service) driving them out-of-control and potentially defeating the purpose of the service will be familiar to leaders and managers who study services as systems from an effectiveness perspective. The evidence of the unintended consequences that often arise are widely reported in the press (see below).

Targets aren’t actually going

Those who hope that the target regime is being dismantled will be disappointed. The rest of the article highlights that this is not the radical change the headline suggests. NHS England Chief Executive Simon Stevens indicates that this is actually part of a review of ‘clinical targets’ and new and revised targets will be deployed in different parts (such as for strokes, heart attacks and sepsis).

Even if you believe targets work, there is still a responsibility

If you are a leader, manager, business analyst, technology designer, services improvement consultant it is important to understand why and where things go wrong. A basic grounding in the theory and the thinking surrounding targets (e.g. theories of control, incentives, human motivation, variation, variety attenuation, unintended consequences) and the different perspectives is key. And we should at least know how to study the services that we help bring into being to understand what the actual impacts of the designs are. If they are found to be harmful then they should be removed or improved. And if as leaders we can’t influence or remove, we have a duty to protect the service, staff and service users from any predictable adverse effects.

I believe that most people are good people who do things with the best of intentions. A belief in the efficacy of targets however, does not absolve responsibility. The impact of most are never seen or understood, and yet they are still there if you know how to study.

There are some good books available to explore the subject. I recommend reading ‘I want you to Cheat‘ and ‘The Whitehall Effect‘. It is also worthwhile reading some counterpoint arguments, for example this article on Michael Barber’s defence of targets (The whole point of setting a target is to distort activity in The Independent 16th February 2016).

Targets in the news

I am interested in the assumptions and motivations around the introduction of targets. Over the years I have been collecting instances where the unintended consequences of targets hit the press. The articles begin before the age of austerity and different political administrations. I don’t expect that these will change people’s views, evidence doesn’t work like that to change thinking. It may however provoke curiosity. As designers, leaders and managers of services ‘do no harm’ must be an absolute minimum professional criteria, and curiosity a core tenet for doing what we do.

Here are a selection and please feel free to email me with your examples and links.

NHS Targets are Crazy nurses warn (Independent, 24th January 2003)

Targets can seriously damage your health (British Medical Journal, 18th September 2003)

Election deportation targets put lives at risk (IRR news, 11th April 2005)

Indicators, targets and the decline of education? (Teaching Expertise, February 2008)

‘Creative’ solutions to knife crime thwarted by government targets (Children & Young people now, 28th May 2008)

Targets aimed at speeding up English planning decisions have led councils to reject more developments (BBC, 17th December 2008)

Hospital turns away ambulances…to meet Government targets (Sutton and Croyden Guardian, 17th December 2008)

NHS targets ‘harm hip patients’ (BBC, 24th December 2008)

Hospitals ‘dump’ patients in wards to hit target (The Telegraph, 23rd December 2009)

Culture of targets prevents nurses from tending to patients (21st March 2009)

Hospital uploads paper referrals to hit Choose and Book targets (Pulse, 25th March 2009)