A ‘retail policy’ in search of a customer? What the public really think about NHS targets

If I asked you which policies in the NHS are ‘retail policies’ – those which politicians might use to gain favour with the electorate - what would you say? Announcements to reduce waiting times? To recruit more nurses? To build shiny new hospitals? They all have a simple message and they all tap into very visible aspects of care which most people can identify with.

In our recent work looking at NHS performance targets we heard many people working in the health system suggest that targets (those about access in particular) are examples of ‘retail policies'. Many of these professionals we spoke to suggested that this could be one reason why targets have been so tempting to politicians over recent decades and also why they are so difficult to change or remove.

So, if targets really are retail policies, we would expect the public to know about them and like them: people would want to ‘buy’ what they are being sold wouldn’t they?

Well we decided to ask people what they really thought.

We worked with insight agency BritainThinks to do some research into public attitudes on NHS targets. We held two focus groups followed by two full-day deliberative events, one in London, one in Manchester, involving around 70 members of the public from a cross-section of backgrounds.

The results challenged some of our working assumptions about the attachment that members of the public actually have with NHS targets.

• First, awareness of the core NHS targets was very low. People didn’t know what their ‘rights’ were (some of the access targets are indeed rights under the NHS Constitution). Some were able to point to improvements in waiting times for A&E and hospital services, based on their recollections of negative media coverage of this topic 15-20 years ago, but few of these realised that targets had been involved in reducing the waits.  
• Second, people’s starting point on the issue of targets was largely negative. At best, targets made them think of bureaucracy and at worst, of a ‘private sector ideology’ suited to selling cars but not health care.
• Third, people’s minds changed quite a lot once they had a chance to understand and engage with some of the arguments, both for and against targets. People actually started to think that targets might just be a ‘necessary evil’ policy approach in some cases. They saw it as an approach to be used sparingly and with a huge amount of potential to be done much more effectively, but an approach which could have a time and a place nonetheless.

So what did people think could be done better? Well they recognised that targets are synonymous with ‘priorities’ in the NHS so they wanted to be part of this conversation (or to know that other people who represent similar views to them were). They viewed this conversation in two distinct parts.

• Participants saw communicating ‘the what’ of targets policy as a job for politicians. They wanted to know about any new or amended targets as changes happened and for this information to come straight from the Secretary of State for Health or Prime Minister, because from a voters’ perspective, this is where the buck stops.
• They wanted to be involved in ‘the how’ of policy, where they thought much more independence and breadth of advice was needed i.e. that politicians shouldn’t go it alone. They foresaw benefits from members of the public taking a more active role in shaping priorities, along with health care professionals and experts in the area, so that these priorities could be informed by what people actually need and what the clinical evidence says should happen to make this a reality.

This desire for greater collaboration in setting targets policy, and priorities for the NHS more broadly, was strongly corroborated by the work we did with professionals, policymakers and academics too. This is why effective collaboration features as a key take away message for policymakers in our new report On targets: How targets can be most effective in the English NHS.

Does a ‘retail policy’ equal a bad policy? Well not necessarily if the true objective is improved patient outcomes and it is implemented well. Some of these ‘retail’ policies on targets have been associated with important successes as well as drawbacks, and responding to what people want and need is important in any policy. However, a basic rule of both ‘retail’ and ‘policy’ is to make sure supply is able to meet demand. So, combining intelligence from both the people using services and those delivering them, is critical to give the policy a half decent chance of meeting its real objectives (improvements in quality) and of having any kind of shelf life.

Natalie is a Policy Fellow at the Health Foundation - you can follow Natalie on Twitter @NatalieBerryTHF