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 …