WHAT’S MEASURED IS WHAT MATTERS: TARGETS AND GAMING IN THE ENGLISH PUBLIC HEALTH CARE SYSTEM
| Date | 01 August 2006 |
| Published date | 01 August 2006 |
| Author | CHRISTOPHER HOOD,GWYN BEVAN |
| DOI | http://doi.org/10.1111/j.1467-9299.2006.00600.x |
Public Administration Vol. 84, No. 3, 2006 (517–538)
© Blackwell Publishing Ltd. 2006, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.
ARTICLES
WHAT ’ S MEASURED IS WHAT MATTERS:
TARGETS AND GAMING IN THE ENGLISH
PUBLIC HEALTH CARE SYSTEM
GWYN BEVAN AND CHRISTOPHER HOOD
In the 2000s, governments in the UK, particularly in England, developed a system of
governance of public services that combined targets with an element of terror. This
has obvious parallels with the Soviet regime, which was initially successful but then
collapsed. Assumptions underlying governance by targets represent synecdoche
(taking a part to stand for a whole); and that problems of measurement and gaming
do not matter. We examine the robustness of the regime of targets and terror to these
assumptions using evidence from the English public health service on reported suc-
cesses, problems of measurement, and gaming. Given this account, we consider the
adequacy of current audit arrangements and ways of developing governance by
targets in order to counter the problems we have identifi ed.
MANAGING PUBLIC SERVICES BY TARGETS: AND TERROR?
In the mid-eighteenth century, Voltaire (in Candide ) famously satirized the
British style of naval administration with his quip ‘ ici on tue de temps en
temps un amiral pour encourager les autres ’ . In the early twentieth century,
the USSR ’ s communist czars combined that hanging-the-admirals approach
with a system of production targets for all state enterprises. The basic system
survived for some 60 years, albeit with various detailed changes over time,
before the Soviet system fi nally collapsed in 1991 ( Ericson 1991 ) – a decline
that has been attributed by some to not hanging enough admirals to counter
gaming produced by the target system.
Gwyn Bevan is Professor of Management Science in the Department of Operational Research and
LSE Health and Social Care, London School of Economics & Political Science. Christopher Hood is
Gladstone Professor of Government and Fellow of All Souls College, University of Oxford.
518 GWYN BEVAN AND CHRISTOPHER HOOD
© Blackwell Publishing Ltd. 2006 Public Administration Vol. 84, No. 3, 2006 (517–538)
In the 2000s, Tony Blair ’ s New Labour government in Britain adopted a
watered down version of that system for performance management of public
services, especially those in England. Having tagged a new set of government-
wide performance targets onto the spending control system in 1998, in
2001 it added a key central monitoring unit working directly to the Prime
Minister. From 2001, in England, the Department of Health introduced an
annual system of publishing ‘ star ratings ’ for public health care organizations.
This gave each unit a single summary score from about 50 kinds of targets:
a small set of ‘ key targets ’ and a wider set of indicators in a ‘ balanced
scorecard ’ ( Secretary of State for Health 2001a, 2002a; Commission for Health
Improvement 2003a, b ; Healthcare Commission 2004). While the Blair govern-
ment did not hang the admirals in a literal sense, English health care manag-
ers (whose life was perceived to be ‘ nasty, brutish and short ’ even before the
advent of targets: Cole 2001 ) were exposed to increased risk of being sacked
as a result of poor performance on measured indices ( Shifrin 2001 ) and,
through publication of star ratings, also to ‘ naming and shaming ’ ( Anonymous
2001 ) (something that had been applied to schools and local government in
the previous decade). Although there have been developments in perfor-
mance assessment of public health care organizations in other UK countries
following devolution, the policy context differed from England ( Greer 2004 ):
there was no emphasis on a few key targets, nor publication for ‘ naming and
shaming ’ ; nor was performance assessment linked with direct sanctions or
rewards ( Scottish Executive Health Department 2003; Farrar et al. 2004;
Auditor General for Wales 2005 ). Hence these countries offer a natural ex-
periment in assessing the impacts of the system of star ratings.
This paper seeks to explore some of the assumptions underlying the sys-
tem of governance by targets and to expose those assumptions to a limited
test based on such evidence as is available about responses to targets in the
English public health care system up to 2004. How far did the system achieve
the dramatic results associated with the Soviet target system in the 1930s and
1940s? Did it, for instance, produce a real breakthrough in cutting long wait-
ing times – a chronic feature of the pre-targets system for 40 years – and how
far did it produce the sort of chronic managerial gaming and problems with
production quality that were later said to be endemic in the Soviet system?
And to the extent that target systems of this type invite gaming by managers
and other actors, are there ways of making targets and performance mea-
sures less vulnerable to gaming without scrapping them altogether?
THE THEORY OF GOVERNANCE BY TARGETS AND
PERFORMANCE INDICATORS
Governance by targets and measured performance indicators is a form of
indirect control necessary for the governance of any complex system ( Beer
1966 ). The form of control that target systems represent is a version of
homeostatic control in which: (1) desired results are specifi ed in advance in
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