Setting targets improves NHS performance in England but can cause problems

24 February 2006

The star rating system for English NHS trusts seems to have improved performance, but systems need to be put in place to minimise gaming and ensure targets are not causing problems elsewhere, according to an article in the British Medical Journal (BMJ).

Annual performance ratings have been published for NHS trusts in England since 2001. This process of naming and shaming gave each trust a rating from zero to three stars. Although the government has now abandoned star ratings, targets are likely to remain.

But have targets improved performance and what ought to happen in the future, ask the authors of the article, professors Gwyn Bevan and Christopher Hood?

The key target for accident and emergency departments was the percentage of patients to be seen within four hours. In 2002, before any target was set, 23% of patients spent over four hours in accident and emergency, but by 2004 only 5.3% stayed that long.

Similarly, reported performance improved greatly after ambulance trusts were star rated on their response times, and hospitals were rated on the number of patients waiting for elective surgery.

Interestingly, after 2003, reported performance improved in other UK countries, dramatically in Wales and Northern Ireland. This suggests that the naming and shaming policy in England put pressure on the NHS in the other countries, say the authors.

But the use of targets results in gaming, they add. For example, extra staff being drafted into accident and emergency departments, operations being cancelled, and patients having to wait in ambulances until staff were confident of meeting the target. This means that when reported performance meets the targets, nobody knows how genuine the improvements are.

Nobody would want to return to the NHS performance before the introduction of targets, so how can we maximise the social benefits and minimise the costs of a regime of targets with sanctions?

They suggest introducing more uncertainty in the way that performance is assessed and better auditing of performance data. They also call for an independent body to investigate the genuineness of reported improvements and the costs to other services.

Although these changes would not wholly eliminate the gaming problems associated with any regime of targets and terror, they could reduce them, they say. The current combination of performance measures that are highly predictable to managers and an audit system that is poorly equipped to detect gaming, risks losing credibility, they conclude.

The full article: Have targets improved performance in the English NHS? BMJ Volume 332 pp 419-22, can be downloaded at: http://press.psprings.co.uk/bmj/february/ac419.pdf

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