comment: Managers and clinicians swamped by tide of national NHS targets

Published: 19/09/2002, Volume II2, No. 5823 Page 17

Earlier this week, an HSJ journalist was talking to a senior health service moderniser.

'Remind me', the moderniser asked. 'Is it 15 or 12 months We are aiming for now on inpatient waits?'

With the plethora of targets littered across every aspect of the service, it is no surprise that even those whose job it is to help national delivery of government goals get confused. What hope then for the typical manager - whose in-tray fills up on a daily basis with new things to worry about, or reminders of old ones?

Those at the centre often express frustration that managers and clinicians see targets everywhere. Privately, they insist that relatively few really matter - and these are not increasing in number.

This is a classic case of not seeing it from the other person's point of view. As far as our 'typical manager' or clinician is concerned, every piece of guidance and direction that arrives from the centre sets them another new target. And these still rain down as, for example, national service frameworks develop or the National Institute for Clinical Excellence works through its programme. The NHS plan let a thousand flowers bloom in the form of new national initiatives. Two years later, the resulting bouquet threatens to bring on a debilitating attack of hay fever across the service.

A few on the receiving end might choose not to meet some of these national targets, but they will spend plenty of time making sure they are protected from the, possibly severe, consequences of their actions. Some look for guidance from the centre, but the best answer they tend to get is: 'Do this first, but make sure you do the rest of it as well.'

The result is, to take just one example, the kind of mess we have around echocardiography, in which GPs express frustration at having to refer so many patients and hospital clinicians complain about unnecessary referrals.

Having set a target - directly or indirectly through a framework for example - it is very hard for the Department of Health to unset it. 'Are they suddenly saying that something that was important, is not any more - why did they not realise this sooner, preferably before setting the target?'

This is the kind of question governments hate.

So HSJ has a proposal for the DoH and those bodies that represent the target-bound managers and clinicians of the NHS.

Let them declare a target amnesty.

The government and service can get together behind closed doors and thrash through every target - of every sort - set by the centre. They will go into the meeting with their own target - getting rid of, say, 75 per cent of these national goals.

Freed from this target tyranny, managers and clinicians across the land could begin to get to grips with local priorities.

In return, the medical and management organisations will praise the government for their foresight and throw their weight behind the only four targets that really matter to government: A&E, inpatient and outpatients waits, plus attracting and retaining enough staff to meet future demand.

The government wants a focus on these four because it believes it will have the greatest impact on public opinion about the NHS, and therefore on this administration's success in transforming it. It knows that public satisfaction with their GPs is relatively high. The problems are with secondary care.

Our news focus (page 11-13) shows how meeting current targets in all three areas is fraught with difficulty. Overseas clinical teams will have an impact on some particularly hard pressed areas, but not on the great bulk of hospitals.

The DoH is apparently looking at creating a dedicated programme designed to increase hospital productivity. If it goes ahead it may take a whole-systems approach to the problem in an attempt to identify bottlenecks, and give significant freedom to clinicians in meeting local issues, but be driven by a robustly enforced protocol. It is likely, given the current flow of policy, to have significant private sector input.

Sounds like a good idea. Let's clear the ground first, by focusing on far fewer targets.