Beyond Targets: Measuring Better and Rebuilding Trust; Comment on “Gaming New Zealand’s Emergency Department Target: How and Why Did It Vary Over Time and Between Organisations?”

Document Type : Commentary


Health Quality Intelligence, Health Quality and Safety Commission, Wellington, New Zealand


Tenbensel and colleagues identify that a target for emergency department (ED) stays in New Zealand met with gaming in response from local hospitals. The result is in line with studies in other jurisdictions. The enthusiasm for targets and tight performance measurement in some health systems reflects a lack of trust in professionals to do the right thing for altruistic reasons. However such measurement systems have failed to address this loss of trust and may, ironically, have worsened the situation. A more promising approach for both improving performance and restoring trust may depend upon collaboration and partnership between consumers, local providers, and central agencies in agreeing and tracking appropriate local responses to high level national goals rather than imposing tight, and potentially misleading measures from the centre.


  1. Tenbensel T, Jones P, Chalmers LM, Ameratunga S, Carswell P. Gaming New Zealand’s emergency department target: how and why did it vary over time and between organisations? Int J Health Policy Manag. 2020;9(4):152-162. doi:10.15171/ijhpm.2019.98
  2. Kirk S. How's your DHB doing? Govt does away with National Health Targets. Stuff; 2018.  Accessed January 6, 2020.
  3. Kontopantelis E, Doran T, Gravelle H, Goudie R, Siciliani L, Sutton M. Family doctor responses to changes in incentives for influenza immunization under the U.K. Quality and Outcomes Framework pay-for-performance scheme. Health Serv Res. 2012;47(3 Pt 1):1117-1136. doi:10.1111/j.1475-6773.2011.01362.x
  4. BEVAN G, HOOD C. What’s measured is what matters: targets and gaming in the English public health care system. Public Adm. 2006;84(3):517-538. doi:10.1111/j.1467-9299.2006.00600.x
  5. Levitt SD, Dubner SJ. Freakonomics: A Rogue Economist Explores the Hidden Side of Everything. William Morrow; 2005.
  6. Ardagh M. The 'six hour target' in New Zealand is associated with reduced mortality and greater efficiency. N Z Med J. 2017;130(1455):12-14.
  7. Ardagh M. How to achieve New Zealand's shorter stays in emergency departments health target. N Z Med J. 2010;123(1316):95-103.
  8. Jones P, Wells S, Harper A, et al. Impact of a national time target for ED length of stay on patient outcomes. N Z Med J. 2017;130(1455):15-34.
  9. Strathern M. ‘Improving ratings’: audit in the British University system. Eur Rev. 1997;5(3):305-321. doi:10.1002/(SICI)1234-981X(199707)5:33.0.CO;2-4
  10. Locker TE, Mason SM. Analysis of the distribution of time that patients spend in emergency departments. BMJ. 2005;330(7501):1188-1189. doi:10.1136/bmj.38440.588449.AE
  11. Bevan G, Hamblin R. Hitting and missing targets by ambulance services for emergency calls: effects of different systems of performance measurement within the UK. J R Stat Soc Ser A Stat Soc. 2009;172(1):161-190. doi:10.1111/j.1467-985X.2008.00557.x
  12. Mears A, Webley P. Gaming of performance measurement in health care: parallels with tax compliance. J Health Serv Res Policy. 2010;15(4):236-242. doi:10.1258/jhsrp.2010.009074
  13. Lipsky M. Toward a theory of street-level bureaucracy. Institute for Research on Poverty Discussion Papers. University of Wisconsin–Madison; 1969:48-69.
  14. Lipsky M. Street-Level Bureaucracy: Dilemmas of the Individual in Public Services. Cambridge: MIT Press; 1980.
  15. Le Grand J. Knights, knaves or pawns? human behaviour and social policy. J Soc Policy. 1997;26(2):149-169. doi:10.1017/S0047279497004984
  16. Marshall MN, Shekelle PG, Leatherman S, Brook RH. Public disclosure of performance data: learning from the US experience. Qual Health Care. 2000;9(1):53-57. doi:10.1136/qhc.9.1.53
  17. Dunleavy P, Margetts H, Bastow S, Tinkler J. New public management is dead--long live digital-era governance. J Public Adm Res Theory. 2005;16(3):467-494. doi:10.1093/jopart/mui057
  18. Health Quality & Safety Commission. A Window on the Quality of New Zealand’s Health Care 2018. Published June 14, 2018.
  19. Sullivan H, Gillanders G. Stretched to the limit? the impact of local public service agreements on service improvement and central–local relations. Local Government Studies. 2005;31(5):555-574. doi:10.1080/03003930500293450
  20. Young K. Local public service agreements and performance incentives for local government. Local Government Studies. 2005;31(1):3-20. doi:10.1080/0300393042000332828
  21. Boyne GA, Law J. Setting public service outcome targets: lessons from local public service agreements. Public Money Manag. 2005;25(4):253-260. doi:10.1080/09540962.2005.10600128
  22. Bourne M, Franco-Santos M, Micheli P, Pavlov A. Performance measurement and management: a system of systems perspective. Int J Prod Res. 2018;56(8):2788-2799. doi:10.1080/00207543.2017.1404159
  23. Melnyk SA, Bititci U, Platts K, Tobias J, Andersen B. Is performance measurement and management fit for the future? Management Accounting Research. 2014;25(2):173-186. doi:10.1016/j.mar.2013.07.007
  24. Ministry of Health. System Level Measures Framework. Last updated February 8, 2018.
Volume 10, Issue 4
April 2021
Pages 221-224
  • Receive Date: 01 February 2020
  • Revise Date: 02 March 2020
  • Accept Date: 03 March 2020
  • First Publish Date: 01 April 2021