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)
Patients with suspected cancer forced to wait so NHS targets can be hit (The Telegraph, 7th June 2009)
Planning measures ‘perverse incentives’ (LGC, 3rd July 2009)
Patients moved from A & E units before they were properly assessed to hit a Government target to treat them within four hours (The Telegraph, 14th July 2009)
‘A&E targets put patients at risk’ (Telegraph & Argus, 14th July 2009)
Hospital chairman quits over dangerous targets (The Telegraph, 25th July 2009)
‘Prisoner chess’ is a result of government targets (The Independent, 21st October 2009)
NHS staff ‘fiddle waiting time figures’ survey claims (The Telegraph, 21st November 2009)
Call for 999 ambulance response targets rethink (BBC, 17th December 2009)
Police still burdened by Government targets, says former chief constable Tim Brain (The Telegraph, 7th January 2010)
‘Two-tier’ ambulance trust accused of prioritising town dwellers over rural patients to meet targets (The Telegraph, 10th February 2010)
Hospital ‘bent the rules’ on four-hour A&E target: report (The Telegraph, 4th March 2010)
The Ambulance service is being paid bonuses for not taking patients to hospital in a bid to help the NHS hit controversial targets (The Telegraph, 27th March 2010)
Manipulation of the examinations system is being fuelled by a target-driven culture (The Telegraph, 9th December 2011)
Forces were routinely manipulating crime statistics to meet targets (BBC, 29th November 2013)
NHS hospitals appear to be “gaming” the system to meet performance targets (The Independent, 22nd April 2015)
Two police workers who made fake 999 calls to meet performance targets have been sacked (BBC, 17th August 2016)
Desperate 999 call handlers attempted suicide amid an “endemic culture of bullying” at a scandal-hit ambulance service intent on hitting targets (The Telegraph, 13th February 2013)
Doctors ‘being pressurised into manipulating patient records to meet A&E targets’ (The Independent, 27th January 2018)
Amber Rudd admits deportation targets are used by Home Office after denying it (The Independent 26th April 2018)
Natural-birth targets ‘put lives of mothers at risk (The Times, 28th September 2018)
Police had ‘perverse’ target to limit number of drink-drive busts (The Age, January 15th 2019)
Secret CPS target may have led to rape cases being dropped (The Guardian, 13th November 2019)
NSW Police set quota for 241,000 personal searches and strip searches in 12 months documents reveal (ABC news, 13th February 2020)