• Performance measures
• Quality measurement
• Organizational theory

Targets have assumed a central role in the management of healthcare and public services more generally in the UK over the last 25 years. They emerged from ideas of ‘new public management’ in the 1980s and of a strong performance management approach under prime minister Tony Blair from 1997.1 While targets can be effective2 and are an important part of public accountability, Quinn3 provides more evidence in this issue of the journal that they can also produce unintended or unanticipated consequences, some of which are unhelpful. They investigated the impact that an English NHS target has had on referral practices. The target in question was the ‘18-week referral to treatment standard’ introduced in 2012. The standard states that at least 92% of patients should have been waiting for less than 18 weeks for treatment after their referral. Quinn found strong evidence for a threshold effect over the period 2015–2020, when some patients seem to have been prioritised based on the target rather than clinical need. Specifically, they found evidence of a spike in the number of hospital trusts at the target threshold.

This study joins a long litany of examples of the unintended impact of targets, a number of which are explored in a previous editorial in this journal.4

The theory of the target setters seems to be that hospitals need a clear focus on government-set goals and that, without this, they will direct their attention elsewhere or possibly fail to put in the required effort.5 There are several risks with this approach.

Focusing on one element of a complex system means that important interactions tend to be ignored or oversimplified, which can produce effects that undermine the intent of the target. For example, a rigid focus on hitting the 18-week waiting target for 92% …