Reading report presentation Bevan, G., & Hood, C (2006). Have targets improved performance in the English NHS?.

British Medical Journal, 332. Gwyn Bevan: Professor of Management Science Christopher Hood: Gladstone Professor of Government and Fellow of All Souls College Oxford. Audience: Addressed to the patients, public and NHS organisations so that they are aware of how well the National Health Services (NHS) are performing. Objective: To find out whether the star rating system has improved performance against three key targets.

How did they go about answering the objective? The datas were collected from the National Audit Office - compared data in England across different trusts, before and after the star rating system was applied. - they used this data and compared it to other UK countries that did not adopt the system. Star rating system is a scheme that rewards success and penalise failures. It uses a process of naming and shaming, which means, the performance of the trusts will be publicly exposed, so that they can feel ashamed, hence be pressured to improve their trusts. The trusts are rated according to their performances against meeting the three key targets. If they achieve more than two of the key

targets, then they are awarded three stars. And the benefit of this is that they are able to receive funds from earned autonomy. But if they achieve lower than the two key targets, they receive an immediate zero star. This means, the chief executive of the trust is at the risk of losing his job. The three key targets are: - Accident and emergency departments - Ambulance category A calls - First elective hospital admission The key target for accident and emergency department - Based on the percentage of patients to be seen within four hours. i) The target was 90% in 2003, and then it increased to 98% in 2005. In 2002 23% spent more than four hours and it decreased to 5.3% in 2004. The key target for Ambulance category A calls - Based on the number of calls made to the ambulance services that can be met within 8 minutes ii) The target was 75% of calls be met within 8 minutes There are 30 trusts, and only 17 trusts were used in this literature. Before the rating system was applied: 1 Response rate of 75% and 2 trusts lower than 45% After applied: 14 trusts exceeded 75% and lowest performer achieved 71%.

The key target for first elective hospital admission - The target is maximum time waiting for elective admission. o 18 month by end of 2001 o 15 months by 2002 o 12 months by 2003 o 9 months by 2004 Before: 12 and 9 months were reported to be 67,000 and 185,000 in 1998. After: end of 2005, only 24 patients reported to be waiting more than 12 months and 41 more than 9 months. Overall, from the data, they were able to determine the shift in performances across the key targets from that before and after the star rating system were applied. In summary: The literature concluded by standing on their claim, the star rating system for English NHS trusts has improved reported performances on key targets. - It increased patient satisfaction - And reduced waiting time for elective admission and ambulance services Other UK countries such as Scotland, that did not adopt star rating system were criticised by the auditor general for taking no incentives to improve the waiting time performances. - They experienced poor waiting time performances and lowered patient satisfaction.

Although the system has been of beneficial to the services in England, Wales and Northern Irelands, however, it resulted in gaming problems. There are other types of gaming problems, but in this literature it is based on the following three factors. First one: Neglect of what not been targeted For example, some ambulances trusts change locations from rural to urban, and they might have done worse services in the rural areas compared to urban dwellings, hence achieving the target. So they might have change locations after the system was applied. Secondarily: Hitting the right target but missing the point For example, according to the rules of classification, patients with urgent needs (serious cases) are given top priority than those less serious cases. Hence, lower waiting time in the accident and emergency room Lastly: Manipulation of data Targets that have not been met might have been concealed by ambiguity in the way data are reported. For example, 9 NHS trusts had inappropriately adjusted their waiting lists, 3 others had deliberately misreported waiting lists. Should targets be implemented or not Targets should be implemented Target is a process of naming and shaming.this is one way of pressuring the trusts to reach the target, hence increase performance.. Very effective system in short term objectives

Questions and Comments Which improvements in targeted performance in the English NHS were undermined by other types of gaming and whether similar problems were experienced in other UK countries? A more extensive system should be put in place to address other health services other than the key targets listed in the literature. A system needs to be established to minimise gaming and ensure targets are not causing unwanted effects elsewhere.