Published: 07/11/2002, Volume II2, No. 5830 Page 17

Why is the health service so obsessed with targets?

Achieving ever-higher levels of activity within evertighter cost constraints has become the keystone of any acute trust chief executive's job, and is rapidly doing the same for those who thought they could escape by joining a primary care trust.

At first glance, it seems as if demand for healthcare is rising inexorably, and it is the task of those delivering the service to 'crank the wheel' of care ever more quickly to satisfy that demand. The entire system seems intent on oiling the crank so that it can turn ever more quickly, without anyone seeming to ask why demand is increasing, and whether anything can be done to contain the relentless rise.

So is there a real rise in demand? Can it be contained, or is the NHS doomed to try forever to restrict the clamour of needs?

The short and depressing answer to the first question is that real demand is rising, but the more encouraging qualification is that the causes are various, so we might be able to do something about them.

First, let's dispose of the most important and least amenable reason: our population is getting older, and older people get sicker, and have a growing need for healthcare.As we adopt healthier life styles, the rate of growth in demand may get less, but it will not level off until the demographic picture itself becomes more stable.

So the healthcare system will also need to grow in order to deal with illness that is more complex, more chronic - and just more.

The good news is that the other reasons for rising demand are less absolute. If we could take our eyes off the grindstone of service delivery long enough to review the horizons of health gain and demand management, we might understand these reasons better.

There is no doubt that want is rising at least as quickly as need.

In every aspect of today's society, our tolerance of frustration is falling and in the health field we are adroitly turning 'dis-ease' into 'disease', medicalising life's problems in futile attempts to forestall our frustration by 'doing something'. Partly this is because we now have so much appealing technology, but mainly this phenomenon reflects the modern fantasy that we can rule every aspect of our lives; we fear the loss of this illusory control more than almost anything else.

Combine this desire for medical intervention with an NHS that is 'free at the point of delivery', and one can see how demand is likely to continue rising indefinitely.

The political masters of the NHS currently promote the message that there is such a thing as a free lunch, but do much less about advertising the limits of the service, whether in terms of its capability or its capacity.

It is as if we were at a great 'all you can eat' buffet. Not only do we eat far too much, but we get angry if there is even a short wait between each groaning platter.

This wouldn't happen at an expensive restaurant, where we'd realise that our meal was actually costing quite a lot.

Ifthere was a way of getting the public to understand the real cost of each NHS procedure, perhaps their enhanced sense of responsibility might help to contain rising demand and costs.

After all, as a recent prime minister notoriously remarked, most of us manage our own budgets fairly well.

It is not so different where clinicians (especially doctors) are concerned: referring doctors feel none of the consequences of their actions so there are few incentives for them to modify their behaviour.One of the main lessons of fundholding was that spending 'their'money gave GPs a greater sense of responsibility for the way resources were used.

The challenge is to find a way of doing this that doesn't use a market approach.

Demand is also driven by the move towards specialisation: we used to celebrate generalists for being 'jacks of all trades', but now we criticise them as 'masters of none'.

In health, as in other parts of society, we all want experts - super specialists with complete solutions to all our problems.

Developing specialists creates referrals: not only new ones from GPs, but also from the specialists making referrals to each other, none straying beyond their own ever-narrower areas of expertise.

Thus demand is driven by societal pressures.Until we begin to address the underlying issues, we will be stuck on the same treadmill.

It is time to consider the whole picture - for a change.

Jonathan Shapiro is a senior fellow at Birmingham University's health services management centre.