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Friday, 21 December, 2001, 21:09 GMT
NHS: Should government targets be scrapped?
NHS trusts "fiddled" waiting lists in an attempt to meet government targets, a report by the National Audit Office has revealed.
The investigation by the independent financial watchdog found that nine trusts in England manipulated their lists to show they were treating patients within the 18-month target set by ministers.
The report highlights a record of "deliberate manipulation" over a period of up to four years at some hospitals.
Staff failed to add patients to waiting lists, others were deleted and in some cases medical records were adjusted to suggest patients had been treated on time.
Are government waiting list targets an unrealistic measure of NHS performance? Should they be scrapped? What is the best way to ensure targets are met?
This debate is now closed. Read your comments below.
Targets are useful as a measure of performance and motivation for improvement, but the NHS is not a factory, or a sweatshop. We who have given our lives to the NHS are numb with shock that a Labour government is trying to squeeze more from us.
The manipulation of hospital waiting lists in order to meet government-set targets is inexcusable, but those quick to criticise the individuals involved may not be aware of the repressive nature of central NHS management. I speak as a Consultant Surgeon (with no interest in private practice). I am not prepared to divulge where for fear of reprisal against me or my Trust. Save to say that our Trust management is under intense pressure to meet various targets which it has been recognised we are under-resourced to do. Failure to comply with these targets is met with the threat of WITHDRAWAL of funding for the next financial year.
Just as in education, where funding depends on "performance" indicators, there is a great incentive to manipulate data merely to ensure that the level of service provided does not deteriorate further. Until the government is prepared to admit to the electorate that the Health Service is in terminal decline and to direct funds to support struggling units this will not be reversed.
Do not be re-assured that if your local hospital fails, you can be treated at a nearby "successful" unit. I know of no hospital with surplus capacity. There has been a protracted under-funding of the NHS for many years and investment in Medical, Nursing and Ancillary staff by successive governments has been inadequate. There are no staff to recruit at present and therefore any monies set aside for this purpose can rest safely in the Treasury without fear of being spent. Oh, and if you are hoping to have your elective operation funded by the NHS in the private sector, just ask yourself who will operate. By far the majority of surgeons and anaesthetists work well in excess of their contracted hours to the NHS already. Those who do have a private practice reduce the burden of patients on the NHS list already.
The increase in "medical errors" recently reported should come as no surprise. Contrary to popular belief, medical staff do not intend to commit harm. The increase is likely to be due, in part, to increased reporting but it is also more than likely that many errors occur because staff are over-stretched. Would you wish to be flown by a pilot who has already clocked up his permitted hours for the week - I suspect not. If I am up all night operating I am expected to work normally the next day. After all, if we don't meet our targets .....
There will always be dishonest people in any system who try to cheat the figures, this doesn't mean the targets themselves are wrong. This just means more oversight and auditing is needed. The many in the NHS who have called for scrapping the figures have proved themselves unsuitable to work there: if they cannot accept the need for measurable accountability then they are irresponsible and unfit to hold our health and lives in their hands!
Keep targets but scrap the connection to funding. If a hospital shows it is not meeting targets, it loses funding and therefore the pattern of bad treatment is reinforced. The public need as much information as possible on the service provided by the NHS but not when the measurement actually distorts the funding of treatment.
If clinicians are being asked to do the impossible and managers threatened with the sack if they don't is it any surprise that waiting lists are "fiddled". The key issue is to ensure that urgent clinical priorities are seen first and no one waits for lengthy periods in pain or discomfort.
All that the latest news proves is that, having trumpeted the success in reducing waiting list numbers and replaced them with waiting list times, the reduction in numbers was a mirage achieved by treating the easy options and making difficult cases wait.
I think I will investigate whether I can take out medical insurance in Germany and get it to pay for treatment in Germany when I am ill. Mind you, I do expect a reduction in the already very high NI contributions I pay. Oh, by the way, I am an IT contractor and as a one-man company pay both employee and employer NI contributions on everything I earn (as well as higher rate tax). The term "sick joke" comes to mind.
Waiting list details are just figures. As such they will always be bent and manipulated to bolster current policy. Unfortunately, what we seem, too often, to overlook is that the numbers stand for PEOPLE. Some more needy than others.
The only way to remedy this whole situation, in my opinion, is do away with the waiting list issue and get to the point. Provide enough surgery units to carry out the required operations as demand dictates.
I have heard politicians from all parties complain that it doesn't matter how much money you plough into the NHS, it will never improve matters. Batter sack them then... they're not doing their job very well. Provide the service according to demand. Full stop.
The manipulation of waiting lists is a disgrace. Those involved have breached the public's trust, should have been dismissed from their jobs for gross misconduct and possibly face criminal charges.
The targets that the government have set for the NHS are meaningless and measure nothing that is of use when planning or managing services. As an NHS manager, I would like to see much more autonomy for NHS services to run themselves - obviously with the necessary accountability for actions that comes with greater responsibility. Modernisation that the government wants will not happen if they continue to micro-manage the NHS from Whitehall.
The system should not be run by doctors - they should certainly be involved but I would rather see doctors treating patients than shuffling paper. There are people like me who are trained to do that sort of thing. And we shouldn't scrap the NHS and privatise healthcare - the American model that everyone seems to think is so great leaves 44 million people without healthcare, including approx. 10 million children. Do we really want 15% of people in our country to have no access to healthcare? I say that we should stick with what we have and allow managers to work with doctors, nurses and other professionals to make things better with as little government interference as possible in the fine detail of how things should be done.
Jeremy Knowles, UK
I have been a consultant for almost 15 years now, and the NHS is no different from any other "business". If you set a target and measure performance against it, the employees will do their utmost to perform to that particular target - to the detriment of other not so important measures. Waiting lists today, death rates from particular problems tomorrow, it matters not. Ask any accountant....
The Government has itself to blame for picking measurements which can be adjusted, for example: no one should wait for more than 9 months = everyone waits for 8.5 months. They should report more useful statistical measures such as average, standard deviation etc. Then the only way they have of improving the figures is to see everyone quicker.
Because I have a terminal illness I visit my hospital on a regular basis. I have never had to wait, I've never have had to wait for all the drugs I need including vitamins. All of this is free to me.
Just thought you would like to know that the NHS works for me!
It is my experience that all measures of performance are fiddled. From production cheats on the factory floor to company director's performance bonuses. The only reason management is reasonably effective is because the performance tests take some account of dishonest responses. Testing performance is an essential tool of effective business management. It identifies areas needing improvement and encourages good departments to maintain their standards.
The health service now is much better run than it was 20 or 30 years ago. The main reason that it appears to be struggling is that the load is increasing faster than resources and management improvements. Accident and Emergency, for example, is inundated by stupid, self-inflicted injuries arising from DIY and ill-considered leisure activities. More people are living longer, allowing illnesses with a a strong genetic component, such as cancers, time to become an important drain on healthcare resources.
Snide attacks on politicians may be very clever, but they are also misguided. Politicians do not run health services, nor do they give detailed advice on how to do so. The role of the politician is to provide the backing for a long-term management strategy, developed by people who do know about health services. It is my belief that the Blair governments have provided much more effective support for this objective than any of the preceding Tory administrations.
The NHS should be scrapped.
We should move to a combined public private system, similar to NL. Those earning over a given threshold should pay into a private or public insurance scheme. Those under the threshold would be treated out of public finance.
Everyone would have access to the same system.
Private insurance would be required to cover certain minima.
I used to work as a information manager (read statistics fiddler) for a couple of NHS trusts.
Everyone working there knows the figures are fiddled but what can they do? If you don't fiddle and everyone else does it makes your hospital look bad.
The statistics are so mangled as to be utterly meaningless. I'm surprised it has taken this long for the general public to catch on.
These hospitals have to have targets and Managers must ensure they are met. If people are ill, they must be treated in a timely way. To ensure this happens the NHS needs to manage its resources well. I have been to several casualty units and been amazed at how many staff were standing around chatting, and that is indicative of poor job satisfaction. The answer is to provide a backup of support services for Doctors and Nurses and ensure that all they have to do is examine and treat people. That will please the majority of these skilled people. Making nurses feed patients and make beds is a pretty poor use of their time, the same goes for Doctors filling in reams of paperwork.
Those that have advocated that Doctors shouldn't be allowed to be in the NHS and do private work in their free time should realise that they are entitled to do whatever they like in their free time, and if they were forced to choose, inevitably they would be moving to private practice. The NHS would then have to contract out to them at a much greater cost, again reducing the cost effectiveness of the NHS. It may make many Doctors emigrate because the pay is so much greater abroad.
They came to power on a platform that they would introduce targets for the NHS service, then twisted the arms of the NHS Trusts to meet them. Then surprise surprise some not so "enthusiastic" CEO hass fiddled the figures to look good and hey presto at the last election Alan Milburn was quoting these figures as a success story of Labour in Power. Now he wants to crucify them.
The NHS is a bottomless pit that sucks up this nations cash, and then the more they get the less they want to do, the poorer the service.
It is not just the NHS that needs an overhaul but the Secretary of State should address his short comings and resign. However this bunch of charlatans don't believe in that do they?
Waiting list targets are a worthy if ill-judged attempt by the government to improve the NHS. However the only way things will change is if the end users are empowered through paying for their treatment. Hospitals would try to do things better because they'd need the patients' money to survive. Look at food production and distribution. Imagine how bad things would be if the government tried to run a free National Food Service instead of letting the supermarkets get on with the job?
If we do have "targets" it should for things that relate directly to patient care, e.g. post-operative infection rates. Nor should Trust managers be blamed too much, it's generally well known that Trusts which submitted a true picture to the Regional Authorities were frequently told to "go back and make the figures come out right". I'm sure most politicians actually do want to improve things, but somewhere between them signing the cheque and the actual people on the front line the money disappears into ever more grandiose reorganisations.
The Government will certainly be judged on its performance relating to "waiting-lists" with the NHS. NHS Trust - would you trust the government on statistical manipulation of patient data, because that is what it basically amounts to? Removing information only to improve the waiting lists is an indictment parallel with fraud. Integrity and honest accountability is what the Government will be judged on at the next General Election. Budgetary management is required with the same rules and principles applying to all hospitals not with some allowed to exercise departure from disclosure. A like for like basis is consistent and easy for us all to understand, it has to be the way ahead.
Vijay K Vijayaratnam, UK
The biggest joke of all here is politicians conning us that they know how best to run a healthcare service. Doctors would do a much better job if they let us alone and funded the system at normal European levels.
I'd just like to know how many people are employed in fiddling the target statistics. It boils down to too much spin and not enough action. The government can publish all the statistics it likes, but we, the general public, know that waiting lists are getting longer and that people are dying because of the waiting lists. Scrap the lists, together with the incompetents that produce them, and hire more medical staff.
Scrap the lists. Simple idea: Let the doctors and nurses treat the patients. If they have to aim for targets, then people are always going to lose out. All this paper work needs scraping.
The only way to cure the ills of the NHS is to make it compulsory for MPs, government ministers and the PM to use only the NHS. They would soon make sure it works then.
S Clarke, England
As usual the hardened Tories will argue for the NHS being scrapped when something like this happens. I have lived in three Scandinavian countries, all of which offered excellent state-run health care. So why can't the NHS do the same? The answer lies with 18 years of Tory mismanagement which has left the NHS in such a bad state that it is possible for those who believe it is their money being spent on the undeserving poor to argue for its being scrapped.
It should be the government which is scrapped, not their targets!
They have consistently failed to deliver improved services despite years of pleading for more time for their funding to feed through.
If managers have not been encouraged to fiddle numbers by government targets and funding carrots, then they have effectively been forced into the situation by ministers and officials anxious to show improvements, even if they are pseudo-statistics.
Governments who live by targets and statistics will also die by them.
Hospitals have routinely 'doctored' waiting list figures ever since targets were first introduced. I can say this with certainty, being a former director of two NHS Trusts. The targets themselves are not necessarily conducive to good patient management and may work against the most efficient working of many hospitals. The trouble is that the government needs easy measures against which to assess performance; what they should do is look for genuinely meaningful measures, even if these are more difficult both to measure and understand. The amount of time spent on the regular returns of waiting list numbers is enormous and mostly a complete waste.
The NHS should also add the priority and lead-time for all types of issues. In particular, how much money is wasted on non-chronic and non-life threatening issues such as IVF and breast implants. I am of the opinion that money is wasted in treating things that the NHS principles were not originally intended.
Nicola Crossley, UK
As with all targets thrust upon those in the public sector, they are determined by bureaucrats who have absolutely NO understanding of working life within the public sector.
If these targets were removed, we could all stop constant 'trouble-shooting' and work towards long-term improvements.
The NHS should be scrapped period! It should be run as a company and we then take out a medical bills insurance. The NHS is too big; the hierarchy is not accountable enough and are a law unto themselves. Consultants spend half their time seeing private patients and on holiday. Somebody needs to take a step back and look at the big picture. We are a greedy nation and a consultant just tries to get as much as he can for the smallest effort like the rest of us.
They imposed 'targets' on the police service for things like response time, clear-up rates, time to answer the phone and many other fields. Two things happened: police officers spent even more time filling in forms, and the figures were fiddled to meet the targets. In no way did these theoretical targets do anything to improve results, all they did was get in the way, and provide a tool for the non-combatant politician and media to beat the police with. In the same way the targets for the NHS have proved pointless and easily twisted.
This and every other government needs to realise that 'tinkering' with either the NHS or the Criminal Justice System is just a waste of money. What is needed is an in-depth study by non-politicians aided by acknowledged non-aligned experts, and then a root and branch reorganisation of the whole system, be it law and order or the NHS.
Targets scrapped? What targets have not been scrapped? Perhaps the better question would be whether the NHS should be scrapped as such, and something that works put in its place.
Of course we should be retaining targets for these authorities to be aiming for. If we do not then how on earth are we going to measure effectiveness (or lack of it) within the NHS? We should be doing more about following up on such abuses by making an example of those who have been responsible for yet another cover-up. After all, it can't be that difficult to replace someone who can fail to meet targets by such a gross margin, can it?
Why is anyone surprised? Exactly the same thing happens everywhere targets are set - whether it's in industry, in sport, or in the NHS. People do whatever it takes to achieve their target number. People can be extremely creative in finding ways to make the number without actually doing whatever it is the number is supposed to measure.
Nine people sacked and nine people re-hired surely they have all just swapped hospitals or jobs!
Manipulation of waiting lists distorts medical need and undermines clinical performance.
The only way to see whether a company is performing well is to set measurable targets. This is common practice in industry, and is certainly applicable to the NHS.
Those of us who pay for the NHS want to know that our money isn't being wasted, and that service delivery is at a reasonable level.
Health workers need to realise that working for the NHS is not some kind of gift they are bestowing on us mere mortals. They are employees of a company that is funded by external investors (the tax paying public) and that they need to perform to a reasonable standard, or they will have to go.
This has already happened to the senior managers who attempted to lie to its investors - this should now filter down into the rest of the NHS.
So long as you have NHS consultants also doing private work they have no incentive to reduce their waiting lists - that affects their private work. Perversely, in attempting to reduce waiting times, hospitals often pay their own consultants to do NHS patients privately - eg. cardiac surgeons being paid £1000 per case on a Saturday morning to treat their own patients - why should they reduce their waiting list voluntarily when they receive rewards like this?
Waiting lists should be scrapped along with the whole idea of government provided health care. Brits may be proud of the NHS, but my experience with the NHS as a graduate student in London was that the standards of care and technology in the NHS were third world in quality. Why not simply provide people with health insurance and let the doctors compete?
Schools have periodic inspections (by Ofsted) which try to assess the overall quality of each school by detailed examination rather than some arbitrary figure that's open to manipulation. They have time to look at every aspect of operations and hopefully also investigate abuses of the system. I would normally trust the reports they produce. However, the result - a list of good and bad points - doesn't fit in with society's obsession with league tables, as the report can't be reduced to a single figure. What on earth does it matter if a school or hospital at the other end of the country has a higher score than my local one? All I am interested in is that the local one makes the best use of the resources it has, and is learning the lessons quickly when others are doing better.
19 Dec 01 | Health
Crackdown on waiting-list 'fiddles'
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