While government spokespeople cite self-congratulatory statistics about target achievement over long waits for healthcare, we’ve all heard stories about the distorting effect that a preoccupation with targets can have on the way public services are delivered on the ground.
Such stories became legion in New Labour’s second term, when the government was going for broke on delivery. There were tales of ambulances parked outside A&E departments (so that patients weren’t admitted until they could be treated within the four hour waiting target), of GP surgeries not allowing patients to book appointments more than 48 hours ahead (to meet the access target of seeing most patients within 48 hours) and of wily school heads using vocational qualifications designed for adult learners to improve their schools’ position on GCSE achievement.
Now, in the third term, some dramatic and unintended effects of the focus on targets have come home to roost. We have financial deficits as a result of poorly designed healthcare target systems and, in the Home Office, an endless saga of problems caused in part by a focus on short-term goals. But, with at least some results looking good on paper, are critics merely displaying the malice of what Harold Wilson used to call the ‘whingers and knockers’ in their curmudgeonly efforts to take the shine off every government good-news story?
While the government has not commissioned serious research into gaming and cheating over targets and was slow to move towards more careful verification of the reported figures before the 2005 general election, studies both by academics and by independent scrutineers indicate that the gaming problem is far from trivial when managers are faced with ‘P45 targets’.
Of course, you would have to be a conspiracy theorist on the scale of the da Vinci code to believe that all the reported performance improvements were produced by gaming, particularly over long waits in health. But students of such systems have known since the days of the Soviet regime that targets tend to produce three classic types of unintended effects – threshold effects, ratchet effects and output distortions – and you don’t have to look too hard to find evidence of each one in New Labour’s public services.
Three unintended effects
Threshold effects denote the way that targets can unintentionally destroy incentives for achieving excellence above the target level – such as A&E waits of less than four hours or ambulances arriving in less than eight minutes.
Ratchet effects denote the way targets unintentionally encourage managers to hold back on their achievements, in case higher achievement leads to higher targets in the next time-period: the universal response to ‘efficiency-gain’ budgetary targets. Output distortions denote what happens when managers focus on incentivised activities at the expense of others – for example, the lack of attention to completion of drug rehabilitation treatments in the days of the early PSA targets based on treatment starts.
Given these well-documented side effects, it’s no surprise that the Conservatives are attracted to the idea of scrapping waiting time targets and focusing on health outcomes instead.
In fact, the present government has had similar concerns since the delivery frenzy of New Labour’s second term passed its peak. Attempts are being made to shore up the credibility of performance numbers: many health waiting times have officially been reclassified as ‘standards’; all the talk in Whitehall is about trying to improve on the crudities of the Soviet-style targets that were hastily adopted in 1998, and indeed several important health targets are concerned precisely with health outcomes.
