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Off the hook on targets?

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24 June, 2010

It has been clear to hospital trusts in recent years that if they can’t meet the two major access/waiting targets most of the time, they will be managed quickly and toughly, up to and including chief executive sackings.

So will the downgrading then scrapping of the A&E and elective targets mean trusts struggling with them are now off the hook? Targets are being replaced, it is hoped, by continuous improvement against a range of openly published quality and safety measures.

Are the trusts failing on targets the same ones that perform poorly on safety and quality measures? The language of cultures of failure, organisational failure and the importance of boards suggests bad organisations are likely to be rotten right through.

In a graph I have plotted trusts’ Dr Foster patient safety rating (based on a bunch of safety measures including the HSMR, though also some process indicators) and highlighted those who have recently been pulled up by the DH for targets performance, or by Monitor for governance.

I have also plotted on a measure from the 2009 inpatient survey - patient experience being an indicator favoured by the new government. The figure is for the percentage of patients at the trust rating their overall care as excellent, very good or good.

See the results

There is no apparent association between any of them, suggesting trusts  failing on waiting times would get away with it if the NHS focused only on patient satisfaction and a single high-level patient safety measure.

Of the seven non-FTs listed with performance problems on standards and targets only four also had problems elsewhere, and none of those were on the performance framework’s quality measure. Just four of the FTs red-rated for governance by Monitor in Q3 were also in financial trouble (risk rated one or two).

Digging deeper, Picker Institute research into which inpatient survey questions are most strongly linked to the overall experience (which will glare most strongly to observers or choosing patients) did not identify A&E waits.

However, it is the questions about waiting that have seen the most sustained and significant improvement in recent years, as waits have fallen.

Patients who said they waited less than four hours has increased from 54 per cent in 2002 to 65 per cent in 2009. The proportion who felt they had to wait too long to get to a ward fell from 33 per cent to 30 per cent in the same period. On elective, those saying they thought they were admitted as soon as necessary increased from 68 per cent to 76 per cent.

It suggests if a trust’s waits rose sharply the associated experience measures could fall quickly - and make it difficult to maintain and improve the overall experience scores. The outcry that led to the imposition of targets is also clearly testament to their importance to the public, and then necessarily to politicians and policymakers.

Part of the trick of replacing targets with a large range of measures, with much lighter performance management, might be to tune the high profile indicators closely to what the public want, as well as those with clinical backing.

A 2008 Health Foundation review said there was little evidence out there about the effects of public reporting systems, or how best to design them.

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