Head To Head

Have targets done more harm than good in the English NHS? No

BMJ 2009; 338 doi: (Published 16 January 2009) Cite this as: BMJ 2009;338:a3129
  1. Gwyn Bevan, professor of management science
  1. 1Department of Management, London School of Economics and Political Science, London WC2A 2AE
  1. G.Bevan{at}

    James Gubb (doi:10.1136/bmj.a3130) argues that the focus on targets has ignored underlying problems important to patient care but Gwyn Bevan believes it has resulted in real improvements in care

    John Major’s government introduced targets as standards for hospital waiting times and ambulance response times to emergency calls in 1991 as part of The Patient’s Charter.1 The regime of star ratings provided a test of the efficacy of taking targets seriously. The regime applied to NHS organisations in England from 2001 to 20052 and was unusual because it rewarded success and penalised failure in a process of naming and shaming. It replaced a system of perverse incentives that penalised success and rewarded failure—for example, by rewarding hospitals with long waiting lists with extra money to bail them out.3 In Wales and Scotland, however, a system of perverse incentives continued.4 5

    The charter standard for ambulance response times—that 75% of category A calls (those for conditions that may be life threatening) be met within 8 minutes—applied in England from 20016 and will apply for Scotland from April 20097; for Northern Ireland, the target was 70% by March 2008,8 and for Wales, 65% for 2008-9.9 The charter standards for maximum hospital waiting times (for 1995) were six months for general practitioner referral to a first outpatient appointment and 18 months for hospital admission for inpatient or day case treatment.10 For Northern Ireland, by March 2009, the targets are 9 weeks for a first outpatient appointment and 13 weeks for hospital admission.11 For the other countries, targets apply from general practitioner referral to hospital admission and are 18 weeks for England (by December 2008)12 and Scotland (by 2011)7 and 26 weeks for Wales (by 2009).13 The English NHS has had the most demanding targets and the best performance over the period when star ratings applied to ambulance response times (from 2002) and hospital waiting times (from 2001) (table); despite the English NHS having the lowest spend per capita.

    Performance for hospital waiting times, ambulance response times, and indexed spend per capita on health services for UK countries 1997 to 2005 (end March)11 w1-w10

    View this table:

    Improved performance

    Four detailed studies have consistently confirmed the comparative excellence of performance in England under the regime of star ratings. Scotland’s published statistics on hospital waiting times are not comparable with those of other UK countries. However, Propper and colleagues used rigorous econometric analysis of three different datasets to compare outcomes from England’s “stringently-monitored targets policy with associated sanctions for failure” with those from the Scottish system of “aspirational and historical targets with no associated sanctions and little bite.”14 They concluded that the “regime in England lowered the proportion of people waiting for elective treatment relative to Scotland.” Willcox and colleagues compared governments’ attempts to reduce waiting times in Australia, Canada, England, New Zealand, and Wales from 2000 to 2005 and concluded that “England has achieved the most sustained improvement, linked to major funding boosts, ambitious waiting-time targets, and a rigorous performance management system.”15

    The Auditor General for Wales identified the cause of longer waiting times in Wales than England as ineffective performance management and called for “more robust incentives and sanctions to drive continuous improvement in waiting time performance.”4 The auditor also described how the failure of the Welsh ambulance services to meet the 75% target had resulted in less demanding targets being set, which had also been missed, and identified systemic weaknesses in performance management.16

    Tackle gaming

    My analyses of the star ratings system have always pointed out improvements in reported performance and dysfunctional consequences. There is evidence of three types of gaming: neglect of what has not been targeted (such as, value for money), manipulation of data (for waiting times and ambulance response times), and “hitting the target and missing the point” (for example, by cancelling and delaying follow-up outpatient appointments, which were not targeted).2 17 18 19 Labour’s target regime is the worst system ever invented, except for all the others (as Winston Churchill famously described democracy). Gaming does not mean that we ought to reject targets but rather that they are being taken seriously; we should therefore make audit and random checks on gaming practices integral to an effective regime of targets.

    Conservative policies for the NHS are to scrap Labour’s top-down process targets and replace them with outcome measures, implying that there is a policy choice between the two.20 But better outcomes follow from treating ill people more quickly, particularly for diagnosis or treatment of cancers21 and ambulance response times to category A calls.22 Furthermore, most of the evidence contradicts the hypothesis that longer hospital waiting times in Wales have enabled it to achieve better outcomes than in England. Wales has higher mortality from causes considered amenable to health care, coronary heart disease, stroke, and diabetes23 and lower rates of admission to stroke units, which will result in poorer outcomes.24 Detailed analysis of four hospitals along the border found the Welsh hospital had the highest mortality and, unlike in the English hospitals, mortality was increasing.25

    Private enterprises recognise the “bottom line” as a constraint, but that success comes from pursuit of other objectives. The targets that the NHS in England are now required to achieve for hospital waiting times and ambulance response times are standards that we ought to expect from a modern well funded NHS, and are the equivalent of the “bottom line” for private enterprises. As the Darzi review recognises,26 the next logical step is to maintain these standards but focus on continuing to improve clinical outcomes to narrow the gap with international benchmarks.27


    Cite this as: BMJ 2009;338:a3129


    • I thank Sarah Jamison for supplying data on hospital waiting times for Northern Ireland.

    • Competing interests: GB was director of the office for information on healthcare performance at the Commission for Health Improvement from 2001 to 2003 and had lead responsibility for the commission’s contribution to, and development of, star ratings for NHS organisations in England.