Hitting the target and missing the point?

Targets divide opinion. At their best, they focus resource and leadership time on delivering priorities; protect access and quality standards for patients and service users; and provide transparent measures against which the public can hold providers, policy makers, and even politicians to account. A recent example is the access standards which have raised the profile of mental health services and its funding. At their worst, different targets pull in different directions and create perverse incentives, act as a blunt regulatory tool or divert boards’ attention from local priorities.

In a system as politicised as the NHS, national performance targets will continue to play a vital role. However the arrival of a new parliament means it is timely to review the value of national requirements within the system. I am including within that bucket traditional ‘targets’, indicators, or expectations associated with national guidance such as staffing levels. Recent announcements show a willingness on the part of national policy makers to review existing measures, however there is a need to ensure the messages sent to the system by different targets are aligned. The simplification of referral to treatment targets has been widely welcomed for instance. However at the same time, the accompanying sanctions are being reviewed and the financial context means providers face stricter controls and a greater reporting burden.

So, how then might we shape targets which are most helpful to patients and those delivering services? 

Working with the Health Foundation, NHS providers and primary care colleagues from the NHS Alliance came together in June to review the principles which should underpin national targets. The pros and cons of individual measures continued to generate debate. However there was consensus that constructing targets with the following aims in mind will help us all to hit both the target and the point:                                                                      

• Reset the balance between national and local measures. The success of the five year forward view rests on the capacity of local health and care systems to galvanise change and introduce more preventative and integrated care models. The national regulatory and reporting frameworks need to support this vision with an appropriate balance of constitutional and national commitments and local flexibilities. Our members also note that targets necessarily capture past performance. Alongside traditional performance indicators, provider boards are keen to develop measures of assurance which help them look ahead to manage risk.

• Consider a balance between organisational and local health economy measures. While there will always be some deliverables for which organizational boards retain the line of accountability, there is real enthusiasm to see how some shared targets at local health economy levels might influence collective behaviours. On a related point, most of the existing national targets mean that activity gets organised around a process rather than the optimal outcome. While introducing outcome based measures would be complex, involving provider boards, clinicians, staff and patients in the development and testing of targets may support a longer term move towards greater use of collective, outcome focussed measures.

• Focus on improvement. Research by Monitor confirms that financial incentives and sanctions are not the most effective driver of behavioural change. In a high risk industry like health care, proportionate, risk based regulation is a difficult balance to strike, and some enforcement activity and contractual sanctions will be justified. However much greater focus on improvement, rather than sanctions which often penalise those providers most in difficulty, would be warmly welcomed by provider boards, keen to free up headspace to learn from each other and drive up quality within an affordable envelope.

• Review regularly. With so many advancements in technology and clinical practice, targets need to be relevant, time bound and fit for purpose. There should be a robust, clinically evidenced bar for introducing new targets and repealing existing ones. Part of that upfront assessment should evaluate how a proposed target will interact with existing measures and support the five year forward view. 

Targets serve an important function and there is no doubt they are here to stay. With that in mind, everyone in the system has a role to play in making sure they are fit for purpose and ‘hit’ our shared aim of driving sustainable improvements in care.

Miriam is Head of Policy at NHS Providers twitter.com/miriamdeakin