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Last Updated: Sunday, 15 May, 2005, 00:19 GMT 01:19 UK
Targeting the NHS targets
By Nick Triggle
BBC News health reporter

GP - generic
GPs have had to make sure patients can book an appointment within 48 hours
This government will be forever associated with targets when it comes to the health service.

The t-word really came to the fore in the 2000 NHS Plan, which set more than 200 targets from increasing staff numbers to cutting waiting times.

Since then hundreds more have followed with the introduction of national service frameworks for a range of conditions and public service agreements.

Some of them, such as the 2010 target to increase cancer survival rates, have been broadly welcomed.

GP access - Family doctors have to give patients appointments within 48 hours, but some have stopped taking advanced bookings
A&E wait - Casualty departments must see people within four hours, critics say it has led to them being discharged too early or moved inappropriately
Waiting lists - Ministers promised to reduce the numbers waiting for operations, but it apparently led to less urgent cases being seen ahead of urgent ones to achieve the target

But for years doctors - and now patients as it became apparent during a TV election debate when the prime minister was harangued over GP access targets - have been criticising the obsession.

The targets that have attracted most ire have been the 62 which NHS providers, such as hospitals, doctors and ambulance services, are assessed against.

These included the 48-hour target for seeing a GP, which critics say has lead to family doctors stopping taking advanced bookings.

Another target which has attracted much resentment has been the four-hour A&E wait target.


A British Medical Association survey revealed the target has distorted clinical priorities by forcing doctors to move patients around wards inappropriately, or discharge them early to meet the target.

Joe Farrington-Douglas, a researcher at the Institute for Public Policy Research, said: "A lot of the problem with targets has been that health ministers see a problem and they try to attack it with targets.

The NHS is a sluggish organisation. How else do you incentivise a not-for-profit organisation?
Tony Harrison, of the King's Fund

"If you put a target in place it can have unintended consequences.

"I think the most effective targets have been the ones that focus on outcome - such as reducing heart disease death rates - as these allow clinicians the scope to use their knowledge and skills."

Tony Harrison, a senior researcher at the King's Fund, agrees targets have been wrongly used.

He cites the attempts to tackle patient waits for hospitals.

Labour came to power in 1997 promising to reduce the waiting list, this was achieved, but it soon became apparent less serious patients were been treated more quickly just to keep the numbers down.

In the NHS Plan five years ago this was then changed to include waiting times - by the end of this year no-one should have to wait longer than six months for an operation.

But as improvements were made with times, waits from GP referral to diagnosis have increased as the only wait that counts is post-diagnosis.

'Unintelligent targets'

Last year the then health secretary John Reid introduced a new target, pledging from 2008 patients should only have to wait 18 weeks from GP referral to treatment.

Mr Harrison said this was an example of unintelligent targets.

"It is not rocket science, the government should have been more aware of what the knock-on effect would have been.

"The problem is that the targets that have been introduced have been too absoulutist, which have meant that managers have been a bit naughty and patients have not always been treated on the basis of clinical need.

"However, unlike the Liberal Democrats and Tories, I am not for scrapping targets. The NHS is a sluggish organisation. How else do you incentivise a not-for-profit organisation?"

A&E sign
The majority of people are seen at A&E within four hours

Under pressure from professionals, and the Tories and Liberal Democrats, which would both scrap centrally-set targets, the government has acknowledged they are blunt instruments and has begun to change tact.

The Department of Health said there are no plans for new targets and many of the ones set in recent years - such as the GP access and A&E wait - have now been reached and are becoming standards instead.

From this April NHS providers will only be assessed on 20 targets - a drop of 42 - including MRSA levels, the 18-week wait and tackling long-term conditions.

But despite the change in direction, the Department of Health still maintained targets were necessary.

A spokeswoman said: "It is true, we are moving away from targets to standards.

"But that is not to say targets did not and do not have a place. There is a very good reason for their existence, they drive up standards."


Mr Harrison doubts whether the new focus on standards will make much difference in reality, arguing if they are too specific they will be targets in everything but name.

And the NHS is facing even more as primary care trusts have been given the power to set local targets, raising the prospect of a plethora of new targets to sit alongside the 20 national ones.

But Gary Fereday, a policy manager at the NHS Confederation, which represents health services managers, said the new system was still an improvement.

"Targets were a blunt and crude instrument, but they did achieve quite a lot. I think what we will see now is a more relaxed atmosphere where we do not get these perverse incentives."

And Dr Michael Dixon, chair of the NHS Alliance, believes the system is now more sophisticated.

"You will get local bodies deciding what is best for the area and that is only right. They know what works best, and it will ensure everyone is fully engaged."

Dr Dixon believes targets have a shelf-life and that has now expired. "In the future, the national targets will act as a safety net. They will not be driving improvement like they did in the past."

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