Health targets in the NHS: lessons learned from experience with breast feeding targets in scotland
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* Harry Campbell
* Anne Gibson

## Introduction

Goal and target setting is a basic precondition to effective management and the basis for accountability for both the use of health services and for achieving health care outcomes1

Target setting has long been seen within business as an essential part of formulating any strategy. Targets should be related to actions known to be effective, be achievable but challenging, and be able to be monitored through indicators (see box).2 Targets can highlight key aspects of policy and act as a stimulus to increase commitment to policy implementation. Careless target setting, however, based on inadequate data or unrealistic short term objectives, can be counterproductive in that the resulting targets may discourage action and place unnecessary stress on those expected to achieve them.3 4 5

#### Health targets: desirable features

*   Should provide an overall goal and sense of purpose

*   Should be related to actions known to be effective

*   Should be achievable over a specified time

*   Should be realistic but challenging

*   Should be measurable and be able to be monitored

*   Should be agreed by those who have a part to play in their achievement

*   Should be expressed in terms of health improvements or reductions in risk factors in the population

The publication of the consultative documents *The Health of the Nation* in 1991 and *Scotland's Health: A Challenge To Us All* in 1992 heralded a new government approach to health planning, central to which was a need to identify clear objectives and specific targets for improving health.6 7 These targets were to be identified in each of the key areas of greatest health concern and where the greatest opportunity for real improvements in health could be realised. Their main aim is to stimulate and direct coordinated action.6

Although it was envisaged that the results of target setting would be assessed, no published reports have looked at the results of target setting for health in the UK. A number of key questions posed in the *BMJ* five years ago are still unanswered:

Do targets inspire, motivate and encourage coordination and common purpose among health workers and organisations?

Can they engage other sectors at local and national level?

#### Summary points

*   Given the centrality of targets to government health strategy, the process of target setting has received very little attention

*   Our review of experience with breast feeding targets in Scotland found little evidence of targets stimulating coordinated intersectoral action

*   Inadequate attention was given to the process of target setting

*   Targets were generally established with little or no public consultation

*   Experience with target setting should be reviewed to identify problems and to highlight and share good practice

*   Health commissioning staff need opportunities to share their experiences and training to develop their skills in formulating targets

Will they mobilise support from ordinary people and communities?8

In this article we take the opportunity provided by the recent adoption of breast feeding targets by all Scottish health boards to look at one example of target setting in the NHS in Scotland.

## Breast feeding targets

In 1993 the national review of food and nutrition in Scotland recommended the adoption of targets for breast feeding,9 and in November 1994 the Secretary of State for Scotland announced a national target: more than 50% of women to be still breast feeding their babies at six weeks of life by the year 2005 (an annual increase of 1.3% in the percentage of mothers breast feeding every year from 1990). The Management Executive of the NHS in Scotland reinforced this by asking all health board general managers to advise them of proposals for local breast feeding targets and milestones in line with local circumstances by January 1995.10

The case for setting breast feeding targets in Scotland is well founded: breast feeding rates are the second lowest in Europe and among the lowest in the world.11 There is good evidence that raising these rates would improve health in children by preventing diarrhoeal episodes12 13 14 and reducing the numbers of cases of lower respiratory infection,14 15 necrotising enterocolitis,16 and other serious neonatal infections.17 In addition, there have been more recent reports of biologically plausible links between breast feeding and improved intellectual development in young children.18 19

Breast feeding rates are measurable, and national systems either exist or could be readily put in place to monitor them. Effective action to support women who choose to breast feed has been identified. Several studies have shown that support for breast feeding mothers in UK maternity hospitals is inadequate,20 21 22 23 and trials have shown that improving hospital practices can increase the rate of breast feeding.24 25 26 27 28 29 Recent experience from several countries, including Norway, Denmark, Australia, and Canada, has shown that coordinated interagency action can substantially increase in breast feeding rates over one or two decades.30 31 32

## Experience in setting breast feeding targets in Scotland

To review experience with setting breast feeding targets in Scotland, we sent, on behalf of the Scottish joint breast feeding initiative, a short questionnaire to the directors of public health of 14 Scottish health boards in July-October 1995. Details of breast feeding targets were requested together with information on how these were set, how they were to be monitored, what consultation underpinned the target formulation, and how the targets related to activities designed to achieve them.

### Results

A completed questionnaire was received from directors of public health or their representatives in all 14 health boards. Table 1) shows the sources of advice used by the health boards in formulating their targets and the groups involved in consultation about the targets, and table 2) shows the breast feeding data they used.

View this table:
[Table 1](http://www.bmj.com/content/314/7086/1030/T1)

Table 1 
Sources of advice and bodies consulted by health boards in formulating targets and specific activities undertaken to achieve targets

View this table:
[Table 2](http://www.bmj.com/content/314/7086/1030/T2)

Table 2 
Sources of data on breast feeding and their use by health boards in the setting and monitoring of targets

All health boards established breast feeding targets within six months of receiving the Management Executive letter on breast feeding targets. Before then only five health boards had had breast feeding targets. Nine health boards adopted the national target proposed by the Management Executive, with four of these adopting supplementary additional targets. Of the remaining five health boards, three adjusted the national target either up or down to make it more realistic and achievable for their area, and two expressed the target as annual milestones–that is, percentage increases each year from a baseline level.

Seven health boards reported that the process of target formulation was not linked to any new strategies or activities to promote breast feeding (table 1). Even among the boards that did take action, such as those adopting baby friendly hospital projects,34 none reported more broadly based breast feeding promotion strategies or strategies involving partners outside the NHS. Despite this, 11 health boards considered that the establishment of breast feeding targets would be effective in raising rates of breast feeding in their area and that the target set was achievable.

Health boards' plans for monitoring breast feeding rates are shown in table 2).35 36 Four health boards had adopted strategies which would not provide the data necessary to monitor their stated local target.

### No link between targets and action

These results show that experience with breast feeding targets in Scotland is not encouraging. The establishment of targets did not lead to the development of new activities designed to achieve these targets in seven health boards. In the seven health boards which did record new activities, these were all restricted to NHS action. In an area where healthy alliances with other agencies and organisations is essential, the dominant focus on NHS activities is disappointing. Although consultation with health professionals was achieved through local multidisciplinary “joint breast feeding initiatives,” only one health board reported that it had consulted the public and none reported consulting its local health council. Equally, it is disappointing that the national call to health boards to formulate breast feeding targets was not accompanied by new government action in support of breast feeding.

## Central input to target setting

![Figure1](http://www.bmj.com/https://www.bmj.com/content/bmj/314/7086/1030/F1.medium.gif)

[Figure1](http://www.bmj.com/content/314/7086/1030/F1)

Various groups produce material to promote breast feeding. This one comes from the National Childbirth Trust (drawn by Christine Roche) NATIONAL CHILDBIRTH TRUST 1996/

CHRISTINE ROCHE

The uncritical adoption of the national target reported by the NHS in Scotland in the Management Executive letter to all health boards10 resulted, in three cases, in local targets that were not appropriate. In one case the adopted target was too low as it was below the baseline rate, and in the other two cases it appeared to be too high since the health boards concerned acknowledged in the questionnaire that the target would “probably or definitely not be achieved.” Such targets are likely to be counterproductive and not to result in an increased commitment to promoting breast feeding.

The rate of annual increase in breast feeding rates required for health boards to reach their targets ranges from 0% to 2.3% with a median of 1.5%. Four boards preferred a system in which they would make a proportional contribution to the national target whatever their starting point. This approach, however, would result in considerable variations between areas in the absolute change each was required to achieve and would perpetuate existing variations.5 Ten health boards favoured a system of local autonomy in target setting with decisions made on the basis of planned actions and agreed in corporate contracts with the NHS in Scotland.

Clear national direction is important, as is assuring that national information systems exist to underpin monitoring of target indicators. Five of the health boards did not report viable monitoring systems and another six mentioned the requirement for local surveys that consumed both time and resources.

Furthermore, targets were expressed variously as rates at birth, hospital discharge, six weeks, and four months after birth. This unnecessary variation will not facilitate national monitoring. Targets need to be expressed in a standard manner, and efficient national systems should be in place for both monitoring and reporting progress. Such systems would avoid unnecessary local time and resources being spent in establishing local data collection systems. This is one example of the need to define and distinguish national and local actions and responsibilities in target setting.

## Local input to target setting

Relevant local factors which should be considered in target setting include baseline rates and trends in breast feeding; local interventions being carried out and their likely effectiveness; and an assessment of the extent to which the target depends on factors not amenable to control within the NHS. Clearly health boards should attempt to broaden the base of consultation. In particular, target setting should be seen as an opportunity to involve other statutory agencies in “healthy alliances,” offering them partnerships in expressing local targets and encouraging ownership of and commitment to these targets. Examples of this could include collaboration with local education departments in presenting education about breast feeding and infant nutrition in schools as part of “preparation for parenthood” or “preconceptual health” programmes; collaboration with social work departments and local employers in improving the adequacy of facilities for breast feeding in businesses, shops, and public facilities; and collaboration with local authorities to fund and support voluntary groups to support women who choose to breast feed.

Methods of including the public in consultation exercises also need to be further developed. Increased partnership with local health councils and voluntary organisations may be one way to achieve this. Supportive community action to promote breast feeding would probably contribute significantly to achieving breast feeding targets.

Further discussion is required on how targets set by health commissioners within health boards should be transmitted to provider trusts. Opinions on this varied widely: one respondent noted that specifying milestones would be less antagonistic than targets, while another recommended that targets must have financial penalties to be effective. The results of this survey suggest that it may be worth while to provide an opportunity to share experience in how local targets are communicated to provider trusts so that they lead to motivation and joint action rather than confrontation and conflict.

## Need to review experience with local target setting

Many of the problems identified with breast feeding targets in this survey are due to inadequate attention being given to the process of target setting. Several possible reasons exist for this. Targets may have been set in response to the national call for a target but without adequate local priority being given to breast feeding promotion. Alternatively, the short period for response to the Management Executive letter and the existence of many competing demands on health boards may have resulted in inadequate staff resources being available for the target setting exercise. Finally, health board commissioning staff may not have had the opportunity to develop skills in target formulation.8

Given the centrality of targets to government health strategy, it is remarkable that more attention has not been given to this issue. The Audit Commission has recently highlighted areas in which progress towards targets has been poor and emphasised the importance of having targets which are achievable yet challenging to encourage and direct action.33 If we are to understand the role of target setting in improving NHS performance then reviewing experience in setting targets is important.

Two main aims of targets were to direct and coordinate NHS action and to promote intersectoral collaboration. If we are to achieve these aims we need to document current practice, identify both good and bad practices, and train staff. We need to identify more precisely what actions are most appropriately carried out at a national or local level and assess what contribution targets can make in mobilising support for health action from other statutory agencies and non-NHS partners and from local communities.

## Acknowledgments

Funding: None.

Conflict of interest: None.

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