Design and implementation of indicators and targets
23. The theme that the effectiveness of targets depends on how they are designed and implemented was discussed in a paper published by the Health Foundation in 2015  . Berry and colleagues suggested that the design of any new target needs to be pragmatic, collaborative and iterative.
24. Ideally, targets should focus on achieving agreed outcomes. However, where processes are essential to the delivery of desired outcomes, pragmatism is necessary. The earlier a patient with cancer is diagnosed and treated, for example, the greater the likelihood of good outcome. Waiting time for treatment, therefore, is a pragmatic indicator of the probability of better treatment outcome.
25. Collaboration/coproductionin design is essential to ensurethat targets are relevant to and supported by those who have to deliver them and those who are affected by them. Bodenheimer and Sinsky (2014)  argued that constructive engagement with staff should be seen as a way of preventing burnout. They proposed that the Triple Aim of improving population health, improving care and services delivered to the public and improving efficiency of services should become a Quadruple Aim. The fourth limb of this aim would be to improve the work life of health and social care workers by allowing them to be involved in how the indicators were implemented.
26. Public sector staff are motivated to deliver best care to those they serve. They are more likely to feel valued and empowered if they have been involved in shaping indicators and targets and are given responsibility and recognition for developing new approaches and using them to improve care.
27. Iteration, continuous examination of the effectiveness of indicators and targets is crucial. No target is likely to be perfect, and frontline staff should be involved in regular reviews to ensure that they remain appropriate, that lessons are being learned and spread to other areas of the service and that problems are dealt with and benefits maximised.
28. This point about iteration is of great importance for this present review. Targets have political significance. Berry and colleagues suggested that, for NHS England: "the existing suite of targets needs to change, but this will require strong political leadership and should be gradual not wholesale.Removing targets without a credible alternative in place is not without risk, but there is a strong case for clarifying how the existing targets fit within the vision for wider transformations in care. Permission to change the amount of managerial and political capital invested in targets is needed in order to rebalance the current, disproportionate focus on delivering against targets over other priorities. The totemic status of targets means strong political leadership from the centre of government will be necessary to make such changes stick."