Indicators come before targets
30. A target defines a goal which a system is supposed to reach. Not reaching it is often seen as a failure of the system which can attract criticism. Efforts by the organisation to avoid failure might involve defensive action which could be unhelpful to citizens dealing with the organisation.
31. However, experience suggests that with complex systems, what can be measured is often not sufficiently detailed to allow for meaningful performance monitoring. The result is often oversimplification of the system to a set of numbers which do not provide adequate information to allow improvement of the outcomes of the complex system. As a result, opportunities for performance improvement across the whole system are often missed.
32. Intermediate outputs only tell you if the system is malfunctioning. If a target has not been met, it is a clear indicator that the system did not perform, but nothing can be said about what part of the system failed or why. Nor can such data help you identify where action to correct or improve the system is needed to establish or restore performance. One example might be the 4 hour waiting time target for patients attending A&E. Hospitals are criticised for failing to make this target. However, rather than being a measure of inefficiency within A&E, the 4 hour target may reflect problems elsewhere in the flow of unscheduled care patients. Current evidence suggests that failure to meet the 4 hour target is most frequently due to high levels of bed occupancy within hospitals. Patients who have to be admitted are increasingly having to wait for an empty bed. In recognition of this fact, New Zealand - which has a six hour target for A&E waiting - has made the target one for the whole hospital, not just the A&E department. Better bed management within the whole hospital may be the solution to unacceptable waiting times in Emergency Departments. Targets tend to focus attention of only one element of a system and may divert attention away from other areas requiring attention which, as well as being other aspects of the hospital setting, includes available care and support within the community. Evidence is very clear, patients who wait more than 4 hours have poorer outcomes and this target needs to be kept but it should be seen in the context of other determinants of patient flow.
33. A similar problem exists in attempts to understand the complex social, cultural and economic determinants which influence health and wellbeing. If we are to make progress in narrowing health inequalities, we need to understand the complex links in the system that allow social or economic inequity to lead to health inequality. Such understanding is clearly essential to allow agencies to take preventative action.
34. Indicators identify a direction of travel for the system. The task of the organisation is to ensure that what is being measured is moving in the right direction as identified by the indicator. That direction may have a target associated with it but the principal task is to ensure steady progress towards the target, not necessarily achieve it right away. For example, the proportion of adults meeting the latest physical activity recommendations in 2015 was 63%. The task for health and social care institutions might be to design a number of services which would support more adults to be physically active over the coming years. It might be reasonable to set a target of, say 70% of people being active by 2020. However, we need to be confident that we can accurately measure physical activity and that we have a credible method for achieving change, if we are to set such a target. In the meantime, the indicator sets a direction for physical activity in Scotland.
35. What is clear is that the usefulness of indicators and targets depends on how they are set, what is measured and how the data is used. If they are to be useful, they need to be based on timely, accurate information which allows the workforce to design and test progressive improvements to support delivery of targets and indicators they have had a say in shaping.
36. Not all the targets and indicators currently in use across health and social care in Scotland fulfil these conditions. However, many are suitably aspirational and with appropriate staff and public involvement would allow continuous improvements to be made. Too often, however, when targets are set beyond the capacity of the system to cope, organisational attention becomes fixed on meeting deadlines and opportunities to improve processes and outcomes across the whole system are missed.