Targets and performance management

Part of Time to Think Differently

Targets and performance management were used under the Blair and Brown governments to tackle some of the negative impacts of the long-term underfunding of the NHS, which had resulted in very long waiting times and patient outcomes that compared poorly with other countries.

They were also designed to reduce variations in standards of care and concerns about the so-called ‘postcode lottery’ in which patients’ access to care depended as much on where they lived as on their needs. Other concerns included a health care system that was often unresponsive to the needs of patients and that was slow to innovate.

The Blair government set about tackling these problems by making a commitment to raise spending on health care in England to the European Union average, and linking this spending to the delivery of national standards and targets. This included:

establishing the National Institute for Clinical Excellence (NICE) to ensure greater consistency in the funding and provision of drugs and other technologies
publishing a series of national service frameworks setting out standards for the provision of care for people with cancer, heart disease and other conditions
promulgating targets for improving performance, most visibly in relation to cutting waiting times for treatment.

Progress towards meeting standards and targets was reviewed on a regular basis, both within government through a focus on the delivery of public service reform, and within the NHS through active and often detailed performance management of NHS organisations.

Did it work?

There is clear evidence that the targets and performance management approach contributed to improvements in NHS performance. Some of the most tangible achievements included major reductions in waiting times, reductions in health care-acquired infections and - through the national service frameworks - improvements in areas of clinical priority like cancer and cardiac care.

Although this approach had positive impacts, there were also some negative consequences. These included evidence of gaming and, in some cases, misreporting of data to avoid penalties and sanctions under the performance management regime. Concerns have also been raised that areas of care not covered by targets may not receive sufficient attention, and that performance management creates a culture of compliance and risk aversion within NHS organisations that inhibits innovation. At its worst, performance management has the effect of disempowering those working in the NHS and creating an over-reliance on central guidance.