I recently acquired some ‘cutting-edge wearable technology’ that improves my personal performance through ‘haptic feedback’. In other words, a pedometer that tracks how far I walk and vibrates when I hit the recommended 10,000 steps a day. Simply having the number of steps I take counted and presented back at me as graphs on my smartphone – I do love a good graph – means I achieve the 10,000 target more often than not.
Just a small example of how performance measurement and targets can change behaviour. But one that neatly encapsulates many of the points we make in our new publication On targets: How targets can be most effective in the English NHS.
Targets have a long history in the NHS, going back at least 25 years. We found plenty of evidence on the impact of targets – for better and for worse – but surprisingly little material on how to make most effective use of targets. That seems an important omission: a new target on cancer diagnosis was set just last month and targets don’t appear to be going away anytime soon.
Not that we suggest getting rid of them. My local supermarket may regularly ask me to prove my age, but I’m still old enough to remember the dark days of people dying on waiting lists and stories of MRSA rates being out of control were all over the front page of most newspapers. Both are examples of problems where targets were an important part of the solution.
Besides, I spent thirteen years in the civil service working on delivering government policy, much of which involved pulling different policy levers and hoping for visible results. The evidence is about as clear as it gets that, in the right circumstances, targets have contributed to some pretty spectacular improvements – as well as almost inevitably some unintended consequences. But how can policymakers ensure they’ll be most effective?
For starters, targets aren’t a panacea and the context matters. We identified five tests that need to be met for a target to be appropriate:
- Is there a pressing problem that requires national action?
- Does the NHS have control and influence over the issue?
- Does the NHS have the capability and capacity to take action?
- Is the NHS equipped to measure change?
- Would a new target align well with wider system activity?
Not passing these tests raises serious questions about whether a target is the right approach.
But passing all five also doesn’t guarantee success. Creating an effective target – one that achieves everything it was intended to do with minimal adverse consequences – is in no way an exact science, and a fair degree of pragmatism is needed. For some of the targets set over the last 15-20 years, the urgency of taking action meant policy had to boldly go where the evidence had yet to tread.
A good example is the target set in response to public concern about crowding in emergency departments at the turn of the century. We’ve now spoken to over 40 people with experience of targets, and I can’t recall a single one who didn’t recognise the case for doing something in A&E at that time. The evidence was clear about the problem – crowding in emergency departments is associated with higher mortality, among other things – but didn’t offer a clear solution for tackling crowding.
Not ideal, but doing nothing simply wasn’t an option. In those circumstances, the target initially produced probably won’t be right first time, so there needs to be a process of testing, modifying and iterating. The NHS is a complex adaptive system, so hardwire feedback mechanisms and be ready to act on the insights they generate. Our report highlights several other ways policymakers can best navigate that complexity.
The biggest downside of targets in the NHS is that they have sometimes been too powerful. Apply enough pressure, offer big rewards for success and threaten serious consequences for failure and performance will almost certainly improve, if only on paper. So much better to ensure providers can access practical, proactive support to help improve performance, rather than whipping them harder.
I could hit my personal 10,000 steps target by taking smaller steps or finding more time for walking by stopping other beneficial physical activities that don’t involve steps. I could strap my high-tech pedometer to one of my children, who will gladly run around so I don’t have to. Or I could just deny the target’s legitimacy – 10,000 isn’t a scientifically-proven, optimal number. Equally, I could beat myself up about the days I only walk 9,999 steps and demand a recovery plan. That would be just as daft.
So I could hit my target, but completely miss the point of it. No target is perfect, but targets have been a big part of the progress made by the NHS since 2000. If we’re going to use targets, let’s make sure we have a realistic view of what makes them work as well as their limitations.