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Gaming and Targets in the English NHS

Process-driven performance targets were used in the English NHS in the late 1990s and early 2000's to drive improvement. There have been clear successes, and well-documented instances of perverse incentives leading to negative behaviours, such as data manipulation and resource diversion. Recently, policy in England has moved away from targets, focusing more on locally-negotiated metrics. The literature was searched for relevant materials, from a broad social science perspective. Probative work from all disciplines was brought together to give an overview of targets, perverse incentives and the routes to minimising such unintended consequences, and to enable conclusions to be drawn. The consequences of targets are well-documented, but less well understood. Routes are available to mitigate the potential for perverse incentives, within the design and interpretation phases and also in terms of sanctions for gamers. These have largely not been followed, rather the political fashion has moved away from targets altogether. It is hypothesised that this will lead to an increase in waiting times, although this has yet to fully manifest. While targets may swing in and out of fashion, the psychological drivers remain: wherever a measure is imposed that carries with it a consequence, there will be a perverse incentive. Process-driven targets in healthcare have supporters and critics. Their heyday in the English National Health Service was primarily during the New Labour Government of the late 1990s and early 2000s, with the combination of process-heavy targets and high levels of incentive leading to not only high levels of compliance and improvement, but also well-documented instances of gaming behaviour. Proponents of the use of targets point to notable successes in the reduction of waiting times where key targets were introduced (such as ambulance Category A (life-threatening cases) response times). Opponents raise a number of issues around the negative behaviours that targets give rise to, for example the diversion of resource to the measured area and the distortion of clinical priorities. Recently, it would appear that health policy has moved away from targets as a measurement system; in this paper we argue that if it is hoped that this will prevent perverse incentives and gaming arising, then this is unlikely to succeed: wherever performance or quality are measured, then there will be an incentive to manipulate the data or circumstances to give the appearance of compliance. We conclude with a consideration of the strategies available to reduce or mitigate gaming through how measures are designed, interpreted and how gaming is perceived.