Once upon a time the word target used to have many in healthcare reaching for their crucifixes, or whatever else was needed to ward off evil spirits.

Once upon a time the word target used to have many in healthcare reaching for their crucifixes, or whatever else was needed to ward off evil spirits.

Sometimes we used to see the word 'political' in front of target, as if only politicians thought it a good idea for patients not to spend all day and sometimes all night in accident and emergency.

As managers we would inwardly, and sometimes outwardly, groan at the thought of more targets coming round the corner.

But the evidence from around the world, as assembled by Sheila Leatherman from the Judge Institute and North Carolina University, is that targets work. They achieve desirable change. Ten or so years ago the term 'trolley waiter' emerged to describe the consequences of unacceptable delays in A&E.

But public concerns move on. A current one is infection, so there are now targets for that. It's a moving staircase, and some of us are now nervous when there isn't a target. I remember someone standing up at a chief executive conference two years ago to complain that the absence of targets for mental health meant a lack of attention.

I think targets work in hospitals, because to achieve them we have to review processes. What many of us discovered is that there weren't actually any processes at all. There were procedures and there were tacit understandings of what to do in a given situation. But there were also understandings which failed, procedures which needed regular work, confusion, delay and ultimately risk, as patient safety literature shows.

So when the Modernisation Agency and others talked about process redesign, they were getting ahead of themselves. We were actually engaged in process design, and still are.

And it's not just us. Michael Hammer, the architect of 'business process re-engineering', says it is the same for US hospitals he works with.

What did the designs look like? From my own mixed experience and observations of others, they would range from terrific new models (such as direct-access cataract services) to the use of people or kit to apply a sort of operational sticking plaster over a gap or snag in the patient journey.

The latter was sometimes referred to as delivering 'through perspiration rather than inspiration'. The trouble is that this uses a lot of people, ties up a lot of cost and does not prepare us for when targets move into more searching territory. Especially if some areas such as diagnostics were barely covered.

All of which brings me to the 18-week referral-to-treatment target for 2008. This is going to need both inspiration and perspiration. It is hard to find anyone in King's, clinical or managerial, who thinks compressing the patient experience to a maximum 18 weeks is a bad thing.

We are all on the same page so far. The question is can we stay there when it comes to reorganisation and interdependence in other hospitals and primary care?

And this will extend to the independent sector via independent treatment centres, but also spot purchasing by commissioners (and providers) to cover gaps in time and capacity.

This target is asking how we organise ourselves, programme our work, and lessen the extent to which we juggle patients around in complex and poorly connected ways.

We have had a taster with the 31- and 62-day cancer targets. As a tertiary centre, patients sometimes come to us after 62 days have elapsed. Worse, we have on occasion sent patients whose journey has been almost as long to neighbouring centres.

When we look closely we see the difference between patient contact time and elapsed time has been unacceptably great. We pick up on the waits for key diagnostics and treatments, but we have to do more about when the journey looks rather vague and as yet undefined by a pathway.

For all that, I am continually impressed by care groups in King's who have come up with their own one-stop outpatient clinics or decide to see all referrals within two weeks, not just the potential cancers.

They also develop ways to do radical surgery on a day-case basis because the results and experience combined are better for their patients.

Our job is to pull this together into an overall framework, meeting, among other things, the 18-week target.

To help this kind of inspiration, we must manage the consequences of previous perspiration - replace the sticking plaster with something more substantial.

For that we have to go back to the designs we have, map them again and work out new ways of cutting through what often resembles a Heath Robinson picture. The deal with our professionals is key to this. We will have to trust our information systems, trust each other and trust patients.

The first of these is the hardest. Information for performance is no easy objective unless there has been the resources and strategic foresight to invest in it.

If you do not believe me take a look at the challenges involved in administering the referral-to-treatment process and a look at the faces of those running the projects in individual trusts. Trusting each other is a matter of our leadership and should be more familiar territory.

Trusting patients? Surprisingly, they seem perfectly capable of connecting themselves to dialysis machines, are happy to volunteer for day-case treatment when it is available, are usually very good at keeping to appointments which they consider a reasonable demand on their time, and have a good grasp of the telephone as a bit of breakthrough technology.

All in all, there are needs and opportunities for process redesign here.

Malcolm Lowe-Lauri is chief executive of King's College Hospital trust, a finalist in the acute healthcare organisation of the year category in this year's HSJ Awards.