Malcolm Lowe-Lauri's carefully worded article emphasised the processes that may be provoked by a target culture. It is surely right that these are the clue to any improvement in performance associated with targeting, other than thrashing the horses. However, the article colludes with the general statement of 'Targets Work', without really considering the less attractive side, the inappropriate pressure, demoralisation and waste of resource that may also accompany poorly considered target declarations.
He treats the process element largely as a black box of design/redesign, as if one could not know any principles that might be offered to those put under the target cosh. The Modernisation Agency, now superseded, had that in mind, of course. If targets are promulgated with serious attention to the system under consideration then fewer problems may be anticipated. Indeed, a concern for such detail appears to be a criterion of a responsible or irresponsible target exercise (a qualification that might be applied routinely with benefit to all targeting initiatives).
As it happens there are some general principles in Medicine for clinical intervention that fall out of experience and are applicable in other situations. Since the planned achievement of targets is typically inadequate there must be over-performance in any system design, systems should be proactive rather than reactive, subject to informed regular review and depend not on a model of aiming at an outcome but on action thresholds of intervention. The black box of process can have definable characteristics.
In the event we can declare any target at random, whether it be Ministers of State or the clinic audit nurse, but the costs of achievement are typically unknown (the cost of Concorde as the consequence of developing a supersonic aeroplane is given as the usual example).
A well-known US pizza company became notorious for having asserting that they could deliver a pizza within 30 minutes but their speeding delivery van hit someone on a road crossing and their pockets and reputation suffered considerably. They now say that they will deliver as fast as any competitor. Achievement is not affected by circumstances at random.
The factors that impair performance typically outweigh those that enhance it; journeys can only be so fast, and good average results then depend on speeding! The need to invest real effort in successful systems is a form of entropy, when considered in the frame of thermodynamics.
David Milliband seemed recently to realise the long buried truth of this when under pressure from David Cameron on the Environment. He declared that targets are of little value without the resources to achieve them. He might have added 'the intellectual and financial resources', since the semantic and practical expression of targeting behaviour remains a source of continuing confusion (see references). Analysis reveals a confusion between the use of target as 'aiming-point' or 'goal' and has generated real benefit in experimental clinical methodology through more careful consideration of the targeting paradigm.
A general support for targets arguably perpetuates much anxiety and waste unless we are more concrete about the processes involved and try to understand them better, so that the article could have gone further. This is actually an expert debate masquerading as a matter of general culture, in which some antagonists, like John Seddon, would do away with targets altogether on the evidence of their negative effects and under performance.
Eric Will MA BM FRCP, Consultant Renal Physician, Department of Renal Medicine, St James's University Hospital
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