Setting targets improves NHS performance in England but can cause
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
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: