Sophia Christie on the power of targets

Last week's joint letter from new health secretary Alan Johnson, junior minister Professor Sir Ara Darzi and NHS chief executive David Nicholson demonstrates a clear commitment to engage staff at all levels in the next stages of change.

Early commentators have picked up on the clinical leadership message and associated it with another populist cry - 'an end to targetry'. This coincides with an interesting shift in language in the Department of Health, from 'targets' to 'indicators'.

The evidence of the last five years has shown that we make the most progress at the least cost when we combine several factors - clinical knowledge, good use of resources, capable management and a concern with social issues such as public health and equality. Targets have been one of the key management tools for delivering this.

The NHS plan brought clarity and focus to the project of 'saving the NHS'. It made commitments and established expectations for improvement in specific areas. It did this in terms of health status and outcomes, as well as individual service experience.

In terms of cancer and coronary heart disease, there was significant national investment in clinical networks dedicated to specific service improvements. This approach combined clinical leadership with management support to deliver a huge improvement in outcomes and access. As a result, cancer services today are vastly better than those of a few years ago. This work was tied to clear, ambitious national targets.

This approach created particular challenges and opportunities in deprived areas. The burden of ill-health meant the baseline was further below targets than average. In the past the expectations of local people tended to be lower and this created less push for change. Local service infrastructure, particularly in primary care, tended to be fragile, with challenges in recruitment, retention and often basic capability.

This effect tended to create a tolerance of the link between poverty, poor health and poor services. Clinicians and managers shared low expectations for local health and the potential for improved outcomes, creating a vicious cycle in which poor standards in services contributed to maintaining poor health status.

But the imposition of national targets has had a huge impact in deprived areas. By establishing expectations of the same health outcomes and service standards for poor areas as for wealthy ones, the government established a benchmarking process. This revealed for the first time the true extent of variation in service delivery and outcomes and provided a basis for local performance management.

This would never have been attained by allowing us to establish local targets - our low aspirations and fear of failure would have limited ambition. The dominant clinical mantra was that by definition these populations could not share the same health status as those above the national average. This is true statistically, but by establishing a different set of expectations and a performance regime that was at times frankly punitive, the mean performance has shifted significantly towards what was previously the province of the best.

The introduction of a clear management process to set out an expected outcome, monitor it, celebrate achievements and tackle poor performance has had huge impact. We are now tracking an 18-week total wait rather than the hidden year between referral, diagnosis and treatment. The concern is shifting from absolute targets to the rather more difficult to track agenda of respect and values.

The risk is that the success of this approach is lost in over-compensating for its weaknesses. The national regime was by definition insensitive. It did not recognise the different starting points of different areas and therefore the 'value-added' of local services. This was disheartening for staff delivering significant improvements but still 'failing'.

Many targets were poorly conceived - reducing unplanned admissions became numbers of high users in structured management, and worse, numbers of 'community matrons'. Many had unintended consequences - notoriously the accident and emergency four-hour wait, which drove clinicians to admit people rather than wait for diagnostic results.

The ability to set local variations allowed some organisations to set targets that merely reflected local population trends and then easily exceed them. Others setting ambitious targets for change may have attained the same outcome but 'failed' if they fell below the local aspiration.

Managing two primary care trusts, I saw the complacent one achieve a rating of excellent as a result of setting a very low target on breastfeeding, whereas the more ambitious deprived area, despite achieving the same rate of initiation, earned only a rating of fair.

Most difficult to sell to clinicians have been targets perceived as bureaucratic or political. The recent attempt to standardise reporting of ambulance response times seems to have increased ambulance investment by around 10 per cent to provide a 30-second improvement in telephone answering.

There is no doubt the system needs improvement, particularly if we are to re-engage frontline staff in genuine improvement.

If we are now to have 'indicators', let them be limited in number but of real strategic significance. They should drive investment into the areas of greatest impact and need - in which context tariff needs urgent review for acute services and development for the community.

Most importantly, though, the government can be assured we shall do our utmost to distort work locally to meet local circumstances. It should maintain its own focus on national performance and benchmarking to keep us from slipping back into one set of expectations for the middle classes and another for the disadvantaged.

Sophia Christie is chief executive of Birmingham East and North primary care trust.