The star rating system for English NHS trusts seems to have improved performance, but systems need to be put in place to minimise gaming and ensure targets are not causing problems elsewhere, warn LSE academics in this week's British Medical Journal.
Annual performance ratings have been published for NHS trusts in England since 2001. This process of naming and shaming gave each trust a rating from zero to three stars. Although the government has now abandoned star ratings, targets are likely to remain.
But have targets improved performance and what ought to happen in the future, ask professors Gwyn Bevan and Christopher Hood of the London School of Economics and Political Science (LSE)?
The key target for accident and emergency departments was the percentage of patients to be seen within four hours. In 2002, before any target was set, 23 per cent of patients spent over four hours in accident and emergency, but by 2004 only 5.3 per cent stayed that long.
Similarly, reported performance improved greatly after ambulance trusts were star rated on their response times, and hospitals were rated on the number of patients waiting for elective surgery.
Interestingly, after 2003, reported performance improved in other UK countries, dramatically in Wales and Northern Ireland. This suggests that the naming and shaming policy in England put pressure on the NHS in the other countries, say the authors.
But the use of targets results in gaming, they add. For example, extra staff being drafted into accident and emergency departments, operations being cancelled, and patients having to wait in ambulances until staff were confident of meeting the target.
This means that when reported performance meets the targets, nobody knows how genuine the improvements are.
Nobody would want to return to the NHS performance before the introduction of targets, so how can we maximise the social benefits and minimise the costs of a regime of targets with sanctions?
They suggest introducing more uncertainty in the way that performance is assessed and better auditing of performance data. They also call for an independent body to investigate the genuineness of reported improvements and the costs to other services.
Although these changes would not wholly eliminate the gaming problems associated with any regime of targets and terror, they could reduce them, they say. The current combination of performance measures that are highly predictable to managers and an audit system that is poorly equipped to detect gaming, risks losing credibility, they conclude.
Click here to download Have targest improved performance in the English NHS? (PDF)
Gwyn Bevan, professor of management science, Department of Operational Research, tel: 020 7955 6269; mobile: 07786 788 967, Email: firstname.lastname@example.org
Jessica Winterstein, LSE Press Office, on 020 7955 7060, email email@example.com
Gwyn Bevan is professor of management science in Department of Operational Research and LSE Health and Social Care at LSE. See: Professor Gwyn Bevan
Professor Christopher Hood is LSE visiting centennial professor and a research associate at the Centre for Analysis of Risk and Regulation Programme Director, Regulation of Government and Governance. See his page in Research and expertise for more details.
Improved target system needed in the NHS (27 Feb)
English NHS trust star ratings have improved performance since 2001, write the experts in the British Medical Journal, but no one is sure of the cost. 'We still don't know how genuine the improvements are or the costs to other services,' state Professor Gwyn Bevan of LSE, and Professor Christopher Hood of Oxford University, UK.
Western Daily Press
Sights set on targets (18 Feb 06)
Gwyn Bevan and Christopher Hood from LSE say that target-based assessment, such as the star ratings for NHS trusts in England, seem to have improved performance.
Target fever tempts NHS fiddle figures (17 Feb 06)
Gwyn Bevan and Christopher Hood from LSE say that target-based assessment, such as the star ratings for the NHS trusts, seem to have improved performance.
BBC News Online
NHS 'target effect' fears raised (18 Feb 06)
Extra controls are needed to make sure hospital bosses are not manipulating services to meet targets, a study says. LSE researchers said targets had helped to improve NHS performance in England. Also mentioned in Epolitix.com.
Experts highlight NHS target risks (17 Feb 06)
Research by experts at LSE, published in the latest edition of the British Medical Journal, found that the star rating system for English NHS trusts seems to have improved performance. 'Regulation by targets assumes that priorities can be targeted, the part that is measured can stand for the whole, and what is omitted does not matter,' warned professors Gwyn Bevan and Christopher Hood.
Warning on health target 'gaming' (17 Feb 06)
Extra controls are needed to make sure health bosses are not manipulating services just to meet Government targets, researchers have said. Target-based assessment, such as the star ratings for NHS trusts in England, seem to have improved performance, according to Gwyn Bevan and Christopher Hood from LSE. Also mentioned in UK regional dailies, Virgin.net, This is London.
Health chiefs using resources to hit targets-report (17 Feb 06)
17 February 2006