Missing the Target

The NHS has been the focus of much recent pre-election debate. A huge amount of the debate has centred on the service’s (in)ability to hit one particular target; that 95% of patients attending A&E will be seen within 4 hours.

It is remarkable that one single statistic has become a shorthand with which to capture the status of a £100bn plus organisation employing more than 1.2m people in England alone. Of course, getting treated promptly in an emergency is important but if the result came in consistently at 95.1% would that mean that everything in the world of the NHS was rosy? Of course not, any more than a result of 94.9% would mean that everything was wrong.

Targets can be useful but taken in isolation they can also drive highly destructive individual behaviour and lead to unwanted results elsewhere. Given the lure of massive personal bonuses linked to uni-dimensional financial targets, the private sector has seen countless instances of CEOs who have made blinkered decisions to the detriment of longer-term or wider organisational performance. Likewise, the history of educational and social programming is littered with examples of well-meaning professionals chasing targets which fail to capture adequately – or even usefully – the complexity and inter-connectedness of human behaviours.

The now infamous NHS 95% target is a perfectly well intentioned attempt to translate an understandable ambition to ensure that, “People who are really sick or at risk receive appropriate medical treatment quickly” into something concrete and measurable. But as politicians are now finding out, if you set a demand-responsive target without reference either to the levels of demand or the resources available you are likely to come a cropper.

Indeed, shifting demand is often the explicit or implicit way in which target-driven but revenue-constrained organisations and individuals seek to achieve their targets. And the fundamental problem for the NHS is that as a universal service it effectively has nobody else to pass the demand on to. So, if social services cuts back on care spend, the demand shows up in the NHS. If GPs cut back on out-of-hrs services, the demand shows up in the NHS. Even if Local Authorities cut back on gritting icy pavements, resulting in more slips, falls and broken legs, the demand again shows up in the NHS.

The technical challenge in designing meaningful targets which these examples highlight is the need to take a genuinely ‘whole system’ approach. Put simply, setting targets in one sector or area of activity mustn’t be allowed to distort behaviour in another sector or area to which it is linked. As with Local Authorities and the NHS, this is a particular challenge for governments which like to allocate financial budgets and accountability within tightly defined boundaries. Real world behaviour is a poor respecter of conventions drawn up for the benefit of management accountants.

More prosaically, experience suggests that single targets rarely drive the behaviour or measure the progress that organisations and programme designers actually want. There is a balance to be struck. Set too many targets and there is no direction at all. But in our experience, getting close to target across half a dozen or so complementary indicators is almost always a signal of better outcomes than crossing the finishing line on one alone.