© 2000 by European Journal of Public Health
The experience of setting health targets in England
Naomi Fulop1 and David J. Hunter2
1 Health Services Research Unit, London School of Hygiene and Tropical Medicine London, UK
2 University of Durham Business School Durham, UK
Correspondence: Dr N. Fulop, Senior Lecturer, Health Services Research Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK, e-mail: naomi.fulop{at}lshtm.ac.uk
Background: This paper presents an analysis of the English experience of setting and monitoring targets during the 1990s. It draws on two studies of the former national public health strategy, ‘Health of the Nation’ (HOTN). Methods: the two evaluations conducted 16 case studies between them, two in each health region in England. Over 250 individual and group interviews were conducted and over 400 documents were analysed. In eight health authorities, an analysis of expenditure was also carried out to determine what impact, if any, HOTN had on resource allocation. Results: Full results are published elsewhere. Lessons for the new strategy are as follows: i) the role of central government is key in ensuring that there is a consistent message across government in support of the health strategy and in fostering the development and dissemination of an evidence-base for public health, ii) The new strategy needs to address the underlying social and structural determinants of health and health inequalities directly, iii) Both studies found widespread support for targets as a helpful way to prioritise and focus efforts. However, national targets must be credible i.e. based on sound and convincing evidence. The development of local targets needs to be encouraged, and process targets should supplement outcomes locally and nationally, iv) The new strategy needs to be communicated widely – to broaden ownership outside the National Health Service, and include the public, v) To sustain momentum and ensure effective implementation, the strategy must be embedded in the performance management framework for health and local authorities, vi) Partnerships between key local agencies to work together for health need to be encouraged, either via a statutory framework or with other incentives. Discussion: The new English strategy, ‘Saving Lives’, is outlined in relation to the development of targets. The wider issues of a target-based approach to health policy include: i) Importance of distinguishing between the objective to ensure that policy is directed towards the achievement of health outcomes, and monitoring progress to ensure that health policy objectives are being achieved, ii) The role of targets as an inspiration as well as or instead of a management tool, iii) A target-based health policy should: set targets which are realistic, achievable and challenging; involve stakeholders; link targets to implementation; consider technical issues e.g. small numbers, availability of data; be based on evidence; express targets in terms of health improvement, iv) Target-based health policies should avoid: perverse incentives; distortion of data; too many targets; target setting without resources, v) The experience from England provides lessons for other European countries introducing a target-based approach to health policy.
Keywords: health policy, health targets, performance management