Targets: more effective than we think

By Michael Blastland
Analysis, BBC Radio 4

Where have all the headlines gone about MRSA, the hospital superbug?

Hygiene measures implemented as a result of target-setting have worked.

Maybe the answer lies in the fact that the risk has plummeted.

It never was that high, but still high enough to be politically unacceptable and quite high enough to cause public fear.

But it has been falling fast.

Why? The answer is unfashionable: targets, probably.

Targets have done foul things across the public services.

They have led to complaints that a number plucked from the air comes before the needs of individual patients.

There have been accusations of cheating and 'gaming' to try to make results look good when overall performance is poor, and allegations of a power-grab by Government, of massive box-ticking bureaucracy, of damage to morale.

All are supported by evidence.

The effects of targets have been both comic and tragic.

Unsung success

Examples run from the police chasing trivia to bump up clear-up rates, like the infamous reported case of a man accused of insulting a police horse, to the suspicion that people went blind or even died because hospital behaviour was distorted.

One prominent critic, John Seddon, says targets "always" fail. Not sometimes but always, because they make an arbitrary number the focus of people's efforts and impose it from top to bottom of the hierarchy, instead of shaping a service to do right by the patient or user.

The political weather is surely now against them. The Conservatives have spoken of making a bonfire of targets. The media cannot get enough of their absurdities. Labour too talks of moving on.

But should the figures in these charts make us think?

Last week, it could have been reported that we had had the largest percentage fall in quarterly figures for MRSA since it came to public attention years ago: down about 27 per cent in one quarter (and nearly 40 per cent in a year).

Of course, the large fall in the latest quarter might not be sustained (it was preceded by a small rise). About 500 people still suffered. There will be variation across hospitals. But the improvement is unmistakeable.

MRSA and C.Diff were both ruthlessly targeted by the Government with a good deal of rough justice. It looks as if this has worked.

Some would say it was top-down control that caused the rise in hospital infections in the first place, by forcing every bed to be occupied.

Waiting times

And it could be that these numbers lie, but I doubt it. That would require an awfully big conspiracy. And when the change is so large, are they likely to be so wretchedly unreliable as to tell us the wrong story?

The same is true of waiting times. For decades, long waits were ranked by the public as the very worst aspect of the health service. But, whatever the government of the day said, whatever wheeze it tried, the problem worsened. It was a scandal that nothing improved.

Until targets.

It is true that there are abuses and exaggerated claims about waiting times.

MRSA cases have fallen dramatically as a result of target-setting.

The Government tends to say 'waiting times have fallen' as if this means for everyone. It does not. For years, the median wait - the wait for the person in the middle of all waits - was above the figure in 1997 and has only recently begun to fall.

But the target was long waits - and long waits have all but disappeared.

The quality of a performance regime is measured not only by what goes wrong, but whether what goes wrong outweighs what goes right.

If the clamour is for politicians to do something about long waits, and resources are diverted to that end, it may well be that other aspects of the service suffer - though that claim could be exaggerated.

But if long waits were the priority and long waits fell dramatically, failure is a strange word.

Does that redeem all target setting? Obviously not. At times it has been indefensible.

Even supporters agree without hesitation that it can be overdone. In fact, most say that targets as a general tool of performance management have had their day.

It would be surprising though if they disappeared altogether, even if the language changed - to benchmarks, or rights ('targets with lawyers', as they have been called).

One view is that 'monitoring and assessment' will be tomorrow's buzz-phrase, where measurements are used to raise questions, not to supply cut-and-dried answers: 'tin-openers not dials' in the words of one shrewd observer.

A question for the Government is how, if the system can on occasion produce good results, it seems to have fallen into disrepute.

If the abuses had been admitted and more readily dealt with, if the gaming had been tackled head on, if targets had been set more sparingly and carefully, could the regime have done more good with less damage?

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Michael Blastland presents the first in a new series of Analysis on Monday 21 of September on BBC Radio 4 at 8.30pm. Or you can download the podcast here.