Public health policy and target setting

The way in which societies respond to population health problems is generally by agreeing what needs to be done to tackle serious concerns and improve the health of the public. The policies they adopt vary enormously in their sophistication and effect. As the policies adopted, particularly at a national level, have grown both in their span and implications it has been found necessary to back them up with the practical strategies need to support their implementation and, hopefully, success.

The substantial growth in the development of public health policies, whether at a global or national level, has seen increasing attention being paid to the use of targets as a tool in assisting with the implementation of strategies for their achievement. In the United Kingdom (UK) the production of a secession of public health policies, which have expanded into the wider area of cross-sectoral working, has been accompanied by a commensurate growth in the use of targets.

Targets have been a feature of health policy in the UK for a substantial proportion of the history the NHS. In the last ten years, they have been increasingly used as a tool in performance management, not just in health but across the entire public sector. Targets are seen as an integral part of public health planning and programme design. However, setting targets is a complex, imperfect process and there is no inevitably that their use will lead to improvements in outcomes or performance.

What are targets?

There are many definitions of what exactly targets are but the World Health Organisation’s (WHO) 1998 definition provides a good basis for exploring their nature.

‘Health targets define the concrete steps which may be taken towards the achievement of health goals. Setting targets also provides one approach to the assessment of progress in relation to a defined health policy or programme by defining a benchmark against which progress can be measured.’

Targets specify time bound desired levels of improvement and can be informed, or indeed driven by:

• political policies;
  
• public priorities or concerns;
  
• previous performance;
  
• internal comparison with other units within the organisation;
  
• external comparison identifying good practice (either in other public organisations or with private sector organisations).

In the health sector high-level targets are considered by many as necessary in order to achieve the goals and objectives set out in health policies and are primarily set for either one or both of the following reasons:

At a global level, important examples are the Millennium Development Goals (see Chapter 22). Targets are also a tool used in managing the performance of individuals, organisations and systems where the targets represent a level of performance/standards that should be achieved. At their best they are used to:

An example of targets used in performance management at a national level in the United Kingdom were Public Service Agreements between the Treasury and other government departments. Each agreement described how targets will be achieved and how performance against these targets would be measured over a three-year period.

Targets can be set in relation to a wide range of elements of policies and programmes. They can relate to inputs, demand, activity, infrastructure, outcomes, outputs and processes. As well as the element to which they are applied, the nature of the target can vary and a major division is into qualitative or quantitative targets.

Indicators are developed to measure movement towards, or away from, a pre-defined target and are a mechanism for keeping track of progress towards an overall goal. There are some measures that can be used as both an indicator and a target. For example, Target 5 of the Millennium Development Goals is to reduce the under-five mortality rate by two thirds between, 1995 and 2015. The under-five mortality rate is also used as an indicator to monitor progress towards this overall target.

History of targets

Targets have been a feature of subnational, national and international health policy for over half a century and in that time have been through numerous iterations, however as the WHO states ‘when it comes to implementation the track record of health targets is less clear and less perfect’ (Kirch, 2008).

Targets for health policy have existed since the second half of the twentieth century and at that time were focused on ensuring the necessary supply of services to meet the newly realised demand for health care. The targets set were often phrased in terms of hospital beds or health professionals per head of population, their geographical spread and the number of individuals who did or did not have access to health services. In the late 1970s, the focus of health policies shifted from service expansion to reducing health care expenditure through improving the efficiency of health services delivery. Targets were now focused on reducing expenditure by controlling supply, for example through capped budgets for hospitals, through capitation fees for GPs, or by limiting the number of doctors in training and the number of hospital beds.

In the 1980s, WHO and some national governments were at the forefront of a campaign to place population health at the centre of health policy action. This change in focus was influenced by the growing availability of information on the risk factors for diseases and the evidence of effectiveness of treatments. Both of these could link policy action to the potential health benefits for the population. Both national and supranational policies started to translate policy priorities into health targets. For example, in 1982 the European region developed regional health targets to aid achievement of the WHO Health for All strategy. Many countries subsequently adapted these targets to their local situation.

The Health of the Nation strategy (HOTN) launched in England in 1992 signalled a shift in national health policy from health care to health. The strategy included 27 targets that were seen as a source of inspiration rather than a management tool. The targets quantitatively indicated what level of health in the populations should be attained and by when. They included infant mortality rates, prevalence of hypertension, deaths due to motor-vehicle accidents, and mortality rates due to coronary heart disease or lung cancer. Health targets were widely supported at this time as a helpful way of prioritising actions and focusing efforts, however, they were criticised for following a mainly disease based model. Targets were often based on arbitrary numbers and people argued that this resulted in some targets being set too low such as those for CHD and stroke.

In 1999 following a change of Government in the UK, and a review of HOTN, a new strategy, Saving Lives: Our Healthier Nation (OHN) was published. The new health policy had two key aims; to improve life expectancy and to narrow the gap in health between the worst off and best off in society. The strategy was also disease focused but in contrast to HOTN, OHN targets were focused on both improving health outcomes as well as ensuring that key policy objectives were being met.

Targets were also now increasingly used as a management tool integral to the governance of health services both to monitor progress in improving health and to manage the performance of services. To ensure that the policy objectives were achieved the government developed a performance management framework with performance indicators. Organisations were rewarded or sanctioned according to their performance against these targets and indicators. The rewards and sanctions included; budgetary allocation that was based on the measured performance (more money allocated to the better performing organisations); bonuses and renewed tenure for managers; reputational effects (shame or glory on the basis of league tables of performance).

OHN saw a shift in the emphasis of health targets from inputs and structures to processes, outputs and outcomes and there were considerable improvements in the reported public health performance of the NHS in England subsequent to its publication. However, there was widespread concern about the large number of indicators and the top down bias and centrally driven nature of these targets. There were numerous examples of organisations and services that engaged in undesirable practices in order to achieve their targets and opponents of this system strongly criticise targets for creating poor quality services (Fulop, 2000; Seddon, 2008).

In 2010 the newly elected coalition government published Liberating the NHS, its white paper for health and Healthy Lives, Healthy People, its public health white paper. Both white papers signalled an intention to replace top down process targets with evidence based and relevant outcome measures. An outcomes framework was constructed covering the three key areas of public health, the NHS and adult social care.

The value of targets

Targets help drive improvement in a number of ways:

• Identify priorities and help define an agreed direction: targets indicate which areas are high priorities for action and can be used to focus attention, efforts and resources on achieving the desired health outcome.
  
• Provide accountability: targets explicitly states what outcomes an organisation is working towards and demonstrate to the rest of the organisation, the public and other stakeholders what is regarded as important and that there is a commitment to deliver.
  
• Motivate staff: people are motivated in different ways and targets can be used as a tool to motivate people to find ways to improve outcomes. Targets can provide individuals with a clear understanding of why some things need to happen and their role in making them happen. Targets can provide staff with an overall goal and a sense of purpose especially if they reflect policy priorities. Targets can motivate staff if they are challenging but realistic and there is a sense of ownership. Rewards or sanctions associated with targets may also motivate staff.
  
• Share learning and good practice: targets provide an opportunity to focus on what has been achieved, to identify lessons learnt and share examples of good practice where possible. In this way targets that are not met can still lead to improvements and so should not be seen as a sign of failure.

Problems with targets

Target setting is an imperfect process, many targets are not set well and do not result in improvement. An understanding of the deficiencies and failures of targets can be highly instructive and aid the process of improvement. Common problems identified with setting targets include:

• Perverse incentives: A perverse incentive is an incentive that has an unintended and undesirable effect, which is against the interest of the policy makers. This occurs when the indicator does not accurately measure the health outcome and results in action that is focused on improving performance in respect of the indicator rather than action that achieves the intended health outcome. For example, a hospital that was having difficulty meeting a national target of giving access within 48 hours to patients wanting to attend a genito-urinary medicine clinic decided to stop providing that service rather than fail a target.
  Indicators should be reviewed to make them more reflective of the intended health outcome; this can be achieved with the use of a balanced suite of indicators and focusing on outcomes as far as possible.
  
• Gaming: The use of targets results in a distortion of practice, where people use targets to cheat the system rather than as a tool for improvement. This reduces the ability of policy makers to be confident that there have been genuine improvements when the reported performance meets the targets. For example a target that no one should wait more than four hours in accident and emergency departments was introduced. Acute trusts were penalised financially for not achieving this target and, in some instances, resorted to drafting extra staff into accident and emergency departments, operations being cancelled, and patients having to wait in ambulances until staff were confident of meeting the target (Bevan, 2006).
  The introduction of uncertainty in the way that performance is assessed, for example varying the targets from time to time, can reduce the potential for gaming. Other suggestions for reducing gaming include focusing on outcomes as far as possible, better auditing of performance data or the introduction of an independent review of the reported improvements and the costs to other services.
  
• Lack of attribution: Targets are allocated to individuals/organisation that have little or no control over them and cannot be achieved by those who are made primarily responsible; this is particularly an issue with targets that are set in partnership with other organisations or people or require such partnership working to be achieved.
  For example, it could be argued that it is contradictory to set local targets to reduce alcohol related harm whilst promoting other national policies that oppose changes in alcohol pricing and encourage alcohol consumption (Hadfield, 2009).
  
• Conflicting targets: Achievement of one target results in doing worse in another. This may occur because the performance indicators do not accurately reflect the whole picture and may require indicators that are more representative or the use of multiple indicators. In other instances this may arise because of real differences across policy areas. For example the installation of brighter street lights to reduce crime may conflict with the goal of reducing use of energy or promoting dark skies.
  
• Wrong type of indicators: The indicators do not provide an appropriate assessment of the outcome for which they have been set. For example four week quit rates for smoking cessation are used as an indicator of success; however, this is based on self reports and is not a reliable indicator of successful long term quitting (Ash, 2009).
  Outcome indicators are often preferred as they reflect what one is trying to achieve, however, input, process and output indicators may be required to provide a better understanding of what is going on and what action can be taken.
  
• Unreliable data: Data used to monitor performance are unavailable, inconsistent, incomplete or not timely. Targets should only be set if there is a robust mechanism for monitoring progress and indicators should be reviewed to ensure that they are consistent with what they are asked define.
  For example the 2008 Health Survey for England used two new methods to measure physical activity; all participants were questioned about their activity as done in previous years and a sub sample was also asked to wear pedometers for a week. The survey results highlighted enormous discrepancies between the two methods, emphasising the importance of using reliable methods to track trends over time (Cavill et al., 2009).
  
• Lack of ownership of targets: Targets that are not agreed by partners risk a lack of ownership and are unlikely to attract sufficient support to achieve the intended improvements. For example clinicians may disengage with processes to improve performance and health outcomes if targets are externally set or set top down.
  Those responsible for the target need to be clearly identified and made aware of how they will be held accountable for the target.
  
• Ambiguous indicators: In some instances an indicator can be interpreted in different ways and it is generally considered inappropriate to set targets against these indicators. Indicators should be objective, and operationally precise. For example the percentage of individuals that eat healthily is ambiguous, instead the percentage of adults (18 or older) that eat five or more portions of fruit and vegetables in a day is operationally precise and less open to interpretation.
  
• Distorted activity: Targets set for areas of health care are often limited to diseases or health problems that are easily measured and controlled and where quantitative and timely data is readily available. More complicated diseases that are more difficult to measure and not amenable to targets, such as many psychiatric conditions, are frequently ignored. It is clearly desirable that targets should measure aspects of public health and service delivery that are truly important rather than those that are easily measured.
  It is therefore necessary in some areas of practice to consider making use of a wider, and potentially unorthodox range of targets and indicators, or other methods such as qualitative or narrative reports.
  
• Too many indicators: A large number of targets and indicators may overwhelm those responsible for them and also become meaningless if they include everything. Therefore indicators should only be used if they provide useful information that can lead to action against the objectives and priorities identified. The application of an appropriate level of parsimony in the selection and imposition of targets is something that is rarely seen and often neglected entirely. Indeed, the desire to limit the number and range of indicators can generate opposition from vested interests who wish to see their own narrow subject area covered.

Characteristics of good targets

Targets should be set using the SMART criteria to ensure that they are properly constructed and successfully achieve their aim:

Specific – clearly indicate who or what is the focus of target and what is the intended outcome. The target should be clear, unambiguous and easy to understand by those who are required to use them.

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