Targets will be remembered as one of the defining features of Labour’s approach to health policy since 1997. However, Labour did not invent targets: the previous Conservative government had set targets in the 1990s – for example, guaranteeing a maximum two-year wait for non-emergency surgery and reducing rates of death from specific diseases.
But what was different about Labour's approach to targets in the NHS (and across the public sector more generally) was the volume of targets and the vigour with which they were performance-managed from the centre.
There has been particular criticism of the targets for waiting times and the strong performance management that accompanied them – dubbed 'targets and terror' by some (Bevan and Hood 2006). However, the strength of the target regime in England is also credited with having driven faster reductions in waiting times than other UK countries between 1996 and 2006 (Connolly et al 2009).
Have the targets that were set for health been met?
The government's targets were set out in policy documents – such as the NHS Plan of 2000 – and through Public Service Agreements (PSAs), which set out priorities for the expenditure allocated by Treasury spending reviews. The Department of Health publishes a report every autumn that tracks achievement against PSA targets. Many of the targets have been met or seen considerable progress, with the exception of targets to reduce inequalities in health status. The main targets, with an indication of whether they have been met, are below.
So what's wrong with targets?
Targets have been blamed for distorting clinical priorities. The Conservative party has claimed that the four-hour target for waiting times in accident and emergency (A&E) has led to distortions such as holding emergency patients in trolley waiting areas. And media reports based on internal ambulance service documents suggest that some patients have been held in ambulances outside emergency departments to avoid 'starting the clock' (Guardian 2008, Telegraph 2009).
Analysis published by the Information Centre in 2009 found that the number of patients leaving A&E reaches a peak as the four-hour deadline approaches: 66 per cent of patients are admitted to inpatient wards from A&E in the last ten minutes before the four-hour deadline, while the figure for all patients who pass through A&E is 21 per cent.
In relation to the inpatient waiting time target a survey of consultants in eight NHS trusts (The King's Fund, 2005) found that a 'significant minority' of clinicians felt that 'attempts to meet maximum waiting times targets can clash with their own clinical judgments concerning when to admit patients from waiting lists'. However, the same research concluded that 'no evidence was found of substitution of lesser for more serious cases' and that 'serious and extensive clinical distortions are likely to have been fairly limited'. More recently, Dr Colin-Thomé's report on failures in emergency services at Mid Staffordshire NHS Foundation Trust concluded that an over-reliance on process measures and targets had come at the expense of focusing on the quality of services provided to patients (Colin-Thomé 2009). But it is very difficult to establish how widespread such problems may be.
Another concern is that targets concentrate resources on one area at the expense of others. Infection control targets, for example, have been successfully met, but apply to a limited range of infections and at-risk populations (Millar M 2009). MRSA, for example, has been the focus of media attention and was the first healthcare-acquired infection for which a target was set, but it accounts for only 2 per cent of healthcare-acquired infections in the NHS (Millar M 2009).
In summary, enforced targets do appear to have been successful in improving aspects of NHS performance, particularly in relation to waiting times, but there is some evidence of unintended consequences – for example, distortion of priorities or neglect of other non-targeted activities. However, it is important to recognise that such unintended consequences may not be the inevitable result of targets in themselves, but rather of the particular way in which those targets were designed and enforced.
Public Service Agreement targets
Life expectancy
Target: By 2010, to increase the average life expectancy at birth in England to 78.6 years for men and to 82.5 years for women.
Current status: Progress According to 2006-8 figures, life expectancy at birth in England continues to increase for both men – 77.7 years – and women – 81.9 years.
Health inequalities
Target: By 2010,to reduce health inequalities by 10 per cent as measured by life expectancy at birth.
Current status: Deterioration The relative gap in life expectancy was 7 per cent wider in 2006-8 than the baseline for men (compared with 4 per cent wider in 2005-7) and was 14 per cent wider than the baseline for women (compared with 11 per cent wider in 2005-7).
Smoking
Target: By 2010,to reduce adult smoking rates to 21 per cent or less overall and to 26 per cent or less among routine and manual groups.
Current status:Met In 2007 the percentage of the overall population aged 16 or over who smoked was 21 per cent and in the routine and manual occupations it was 26 per cent.
Mortality rates from heart disease
Target: By 2010,to reduce rates of death from heart disease and stroke and related diseases by at least 40 per cent in people under 75.
Current status: Met For the period 2006-8, rate of deaths from circulatory disease in England was 74.8 per 100,000 population, a decrease of 47.1 per cent.
Inequalities gap in rates of death from heart disease
Target: By 2010,to reduce the inequalities gap in rates of death from heart disease between the fifth of areas with worst health and deprivation indicators (the spearhead group) and the population as a whole by 40 per cent.
Current status: Progress The baseline figures for 1995-7 showed the absolute gap (ie, difference) in deaths from heart disease between the spearhead group and the population of England as a whole was 36.7 deaths per 100,000 population.
For the period 2006-8 the gap was 22.6 deaths per 100,000 population (a decrease of 38.4 per cent).
Mortality rates from cancer
Target: By 2010, to reduce rates of death from cancer in people under 75 by at least 20 per cent.
Current status: Progress For the period 2006-8, the rate in England was 114.0 deaths per 100,000 population, a decrease of 19.3 per cent.
Inequalities gap in rates of death from cancer
Target: By 2010, to reduce the inequalities gap in rates of death from cancer between the fifth of areas with worst health and deprivation indicators (the spearhead group) and the population as a whole by 6 per cent.
Current status: Met The baseline figures for 1995-7 showed that the absolute gap (ie, difference) between the spearhead group and the population of England as a whole was 20.7 deaths per 100,000 population.
In 2005-7 the inequalities gap was 18.6 deaths per 100,000 population (an increase from 18.0 deaths per 100,000 in 2005-7, but a decrease of 10.5 per cent since the baseline).
Suicide
Target: By 2010, to reduce rates of death from suicide and injury of undetermined intent by at least 20 per cent.
Current status: Progress The baseline figure is a three-year average rate for the period 1995-7, which showed 9.2 deaths per 100,000 population.
In the period 2006-8, this reduced to 7.8 per 100,000 population (a reduction of 15.2 per cent).
Four-hour wait in A&E
Target: By 2004,to reduce to four hours the maximum wait from arrival in A&E to admission, transfer or discharge. In 2003 this target was adjusted so that 98 per cent of patients in A&E be seen within four hours.
Current status: Met In the first quarter of 2005, 97 per cent of patients were seen within four hours; currently this figure is 97.8 per cent.
Access to GP services
Target: From 2004, patients should be able to see a primary care professional within 24 hours and a GP within 48 hours.
Current status: Progress In the GP patient survey of 2007/8 87 per cent of patients reported that they had seen their GP within 48 hours. (Information Centre 2009)
Under-18 conception rate
Target: By 2010,to reduce the rate of conception in under 18s by 50 per cent.
Current status: Limited progress In 1998, there were 46.6 conceptions per 1,000 females aged 15-17.
Between 1998 and 2007 England's rate of conception for females aged 15-17 fell overall by 10.7 per cent.
18 weeks from referral to treatment
Target: By 2008,no one should wait more than 18 weeks from GP referral to hospital treatment: 90 per cent of patients admitted to hospital for treatment and 95 per cent of those not admitted should receive consultant-led care within 18 weeks unless it is clinically appropriate not to do so, or they choose to wait.
Current status: Met Latest data (2009) shows that 93 per cent of admitted patients and 98 per cent of non-admitted patients began treatment within 18 weeks. The median length of wait was 8 weeks for admitted patients and 5 weeks for non-admitted patients.
Patient experience
Target: To secure sustained national improvements in patient experience as measured by independently validated surveys.
Current status: Limited progress Measurement of this target is through the National Patient Survey, which asks patients about their experience of care. For the 2009 Department of Health annual report, improvement was measured on two surveys:
- the adult inpatient survey showed an increase on the baseline with a score of 76.0 against a baseline of 75.3 (2007/8)
- the emergency department user survey score was 75.7, a slight decrease on the baseline score of 75.8 (2004/5)
Mental health services
Target: To improve life outcomes of adults and children with mental health problems through year-on-year improvements in access to crisis and child and adolescent mental health services (CAMHS).
Current status: Met The percentage of primary care trusts reporting that they provide: a full range of CAMHS; access for 16 to 17 year-olds; 24-hour cover and a full range of universal services by local authority/PCT rose from 13 per cent to 27 per cent from 2008/9 to 2009/10.
MRSA rates
Target: The total number of cases of MRSA in each of the years 2008/9, 2009/10 and 2010/11 should be below 3,850 (half the 2003/4 baseline) for each year.
Current status: Met In 2003/4 7,700 cases of MRSA were reported. The total number of cases reported in 2008/9 was 2,935, which is 24 per cent below the 50 per cent baseline year reduction target.
Clostridium difficile rates
Target: In 2010/11 the number of cases of C. difficile should be 30 per cent less than the figure for 2007/8.
Current status: Met In 2007/8 55,498 cases of C. difficile were reported. The total number of cases reported in 2008/9 was 36,095 which is 7 per cent below the 30 per cent 2010/11 baseline year reduction target.
Sources: Department of Health Autumn Report 2008 & 2009, PSAs 2002, 2004, 2007