NB: THIS TRANSCRIPT WAS TYPED FROM A TRANSCRIPTION UNIT RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT: BECAUSE OF THE POSSIBILITY OF MIS- HEARING AND THE DIFFICULTY, IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS ACCURACY. ........................................................................ PANORAMA Fiddling the Figures RECORDED FROM TRANSMISSION: BBC-1 DATE: 29:06:03 ........................................................................ SARAH BARCLAY: We were told patients would be at the heart of the government's ten year plan to modernise the NHS. They didn't tell us targets could sometimes harm the very people they were meant to help. KEITH WILLETT: Some patients are being compromised because of the blunt targets that are set. JOHN WASS: Not meeting the targets is really not an option. BARCLAY: Who told you that? WASS: Various managers. IAN PERKIN: Come hell or high water, it doesn't matter whether achieved legitimately you just have to achieve them. BARCLAY: Tonight we reveal how patients are being deceived. STUART STANTON: It's common knowledge to me and most of the consultants I work with that many trusts are fiddling the figures. BRIAN DOLAN: Let's just say people are trying to think of ever more creative ways of not counting the figures, those are the ones that have lost sight of what's important, that's the patient. BARCLAY: When we began to investigate the impact targets were having in the NHS, we discovered a public service where many people were secretive and scared. They told us talking openly would be career limiting. Others agreed to speak anonymously to tell us how targets were really being met. IAN PERKIN Finance Director, 1990-2002 St. George's Hospital I don’t believe the NHS is populated with inherently dishonest people, it's just that there's this huge climate of fear and intimidation. There are lots of people who.. you know.. who are frightened to speak out. BARCLAY: First we went to Oxford to investigate what happened when pressure to meet targets in Accident and Emergency led to patients being left in limbo in a corridor when the hospital refused to admit them. An ambulance paramedic told us what happened at the John Radcliffe Hospital during last year. He said he'd lose his job if we identified him, so his words are spoken by an actor. PARAMEDIC: The hospital have their targets and we had ours, and we were pulling against each other. BARCLAY: Waiting times in Accident and Emergency start when a patient is officially handed over to hospital staff. As long as they're being looked after by ambulance crews, the clock isn't ticking. PARAMEDIC: We have to wait in what they called the 'ambulance waiting area' which was a corridor. They said they didn't have any space, didn't have nurses. The patient wouldn't be booked into the hospital and so officially hadn't started waiting. As far as the hospital was concerned, the patient wasn't on the premises. BARCLAY: Department of Health guidelines say patients should wait no more than 15 minutes before being transferred into the care of hospital staff. But at the John Radcliffe, ambulance crews and patients could wait for hours. PARAMEDIC: The longest I actually waited was 5 hours, sometimes half the crews waiting so the other half of the crews were running from one end of the county to the other taking longer and longer to get to the calls. When it was really bad, there could be as many as 7 ambulances just waiting. BARCLAY: In a statement to Panorama the hospital said some staff felt overcrowding meant that A&E was bordering on becoming clinically unsafe. The hospital admits the situation was not idea for patients. PARAMEDIC: I had a patient who was in heart failure, she was asthmatic so I felt I had to monitor her oxygen levels, and I didn't think there was adequate equipment to do it in the corridor. So I decided to take her back out to the ambulance, connect her up to our monitoring equipment because as she wasn't officially booked in, I was responsible for her. BARCLAY: The longer ambulance crews spent at the hospital, the longer they took to answer 999 calls within their target time of 8 minutes. With the hospital and the ambulance service under pressure to meet their own targets, the situation eventually reached crisis point. On December the 2nd, the Chief executive of the Oxford Ambulance Service issued an ultimatum to the John Radcliffe Hospital. It wasn't the responsibility of ambulance crews to look after patients at the hospital, it was theirs. PHILIP BOLLEY Unison Convener What it actually took was basically for our Board.. Trust Board and our Chief Executive to say.. you know.. we've got to sort this out and we're going to… if you don’t do so, we're going to be leaving patients within the Department. BARCLAY: Ambulance crews were told that from now on, they should leave patients in the most humane way possible and go. BOLLEY: It meant that we would arrive hopefully put them on a trolley if there was one, or, if not, it would have been on the floor. BARCLAY: You've been asked to leave the patients on the floor and leave? BOLLEY: Yes, and then leave the department. BARCLAY: And go on to the next job. BOLLEY: And then go on to the next job. BARCLAY: The ultimatum worked. To ease the backlog in A&E, extra beds for emergency patients were opened in the hospital's Medical Assessment Unit, a place where there are no waiting time targets. In many hospitals these units are better for some patients than A&E. But here they were crammed into 52 beds less than 18 inches apart, on average for almost 2 days. A recent report by the local Community Health Council said: "Such conditions should not prevail in a modern NHS hospital" and concluded "in order to meet targets, safety and care had been compromised." Brian Dolan is a former A&E nurse, now he's an A&E trouble-shooter. BRIAN DOLAN Emergency Nurse Consultant I get invited into hospitals and usually they're ones which are the euphemism is challenged, in reality they're in real trouble, and you find that they've got patients lying on corridors, they're waiting hour after hour to be seen and treated, and sometimes there's the senior management and the clinicians just feel they've run out of options, they just don’t know where to go next. BARCLAY: Brian Dolan is a part time adviser to the Department of Health. He also travels the country helping hospitals use targets to improve the way they work. He's seen many ways targets are fiddled. DOLAN: There's an awful lot of scams and an awful lot of juggling of the targets. For example, 5 cubicles and you count only 3 of them when you're counting the trolley waits. You put a patient on a bed and they say you stop counting the hours they're there because you say oh they're now effectively admitted, they're on a bed. Putting a door up and saying well that's an observation unit, it's no longer a cubicle, so therefore we wont count those trolleys. Putting a bit of a wall up and putting five or six patients in there and saying oh, that's the observation area, so we wont count those ones either. Sending them up to CT scan and stopping the clock. If they're being discharged and they're just simply waiting for transport, discharging them off the computer so it doesn't look like they've been there for quite as long. BARCLAY: There were 62 different targets affecting patients and managers in the NHS. Targets are the tools designed to measure how fast and how effectively the Health Service is delivering the government's plans to modernise the NHS. The 9 targets which matter most to NHS managers are the ones which determine how many stars a hospital gets. We spoke to one recent chief executive who described what happened if they failed to meet them. Their words are spoken by an actor. Former Chief Executive Words spoken by an actor It was always my understanding, and that of my colleagues, that certain of the targets were what are euphemistically described as P45 targets. What I mean by that is if a particular target wasn't delivered, it was absolutely a sackable offence. BARCLAY: A sackable offence? CHIEF EXEC: Yes, you would not remain in post. TONY BLAIR: Our task is to put in the money and the change over time that will make the realty once again match the vision behind it. BARCLAY: It was Tony Blair's commitment to spend unprecedented amounts of public money on NHS, and the Chancellor's insistence that the money came with strings attached that produced the target driven culture of Labour's NHS, targets set in Whitehall and applied throughout the Health Service by managers who could be called to account if they failed to deliver. Every NHS chief executive knows the buck stops with them. The Homerton Hospital in London has been chosen to become one of the first foundation hospitals. The government likes the Homerton and the Homerton likes targets. Because it's met all of the nine key targets, the government has given it three stars, its highest ranking for a hospital. NANCY HALLETT Chief Executive Homerton University Hospital I am clear that this is a better hospital as a function of the targets. They have given us a focus about where we need to go. BARCLAY: Nancy Hallett used to be a nurse. Now she's in charge of a budget of £100,000,000 a year. HALLETT: I can recall a time, I don’t know, 5-6 years ago, when we were shutting the Casualty because we couldn't get more people in there because it was all blocked up, there wasn't anywhere.. room to see anybody. That doesn't happen today. BARCLAY: Cutting waiting times in Accident and Emergency is one of the NHS's toughest challenges, and the one with the toughest targets. The government promised that by March this year, 90% of A&E patients would be seen and treated within 4 hours. RACHEL WILLINGHAM Senior Nurse, A&E In and out of the department within 4 hours I don’t think is an unreasonable request. You know.. I wouldn't want to go to an A&E department with a cut finger and expect to wait 8 hours. BARCLAY: The government was so determined not to fail its own target that it told hospitals their performance would be judged over just one week, the last week in March, and gave them three months to prepare. JOHN COAKLEY: The pressure started to build from that Christmas I think, if I remember. BARCLAY: The pressure from whom? JOHN COAKLEY Medical Director Homerton University Hospital The pressures came from the Department of Health, the Strategic Health Authority, they wanted to see our action plan for how we were going to meet the target for the week in question. You know.. what additional resources, if any, we were going to put in, what different ways of working we were going go encourage. BARCLAY: In the last week of March, patients arriving at the Homerton's A&E were processed through the system like clockwork. What did you have that week, was it mainly extra doctors and nurses? WILLINGHAM: We had extra doctors and nurses and more senior doctors on the shop floor all the time, and we did actually have an extra nurse as well. BARCLAY: What was it like in the A&E week when they were monitoring everything? CLEO LETT Receptionist It was a bit hectic.. very hectic. Very, very, very hectic. I'm not going to lie. BARCLAY: In the first week of March the Homerton saw just under 80% of A&E patients within 4 hours. Three weeks later, and the week the government was monitoring, they saw just under 97%. The planning paid off. But in some other hospitals the target was only met by cancelling many non-urgent operations so there were no long waits for A&E patients needing a bed. We spoke to a senior nurse manager who told us what happened. Nurse Manager Words spoken by an actor I know some Trusts that have met 100% and you know that's just a joke. For that week, what happened is, people knew that they were being investigated or looked upon, so for that week, all the resources were made available to make sure that all the beds were available, patients got to the ward on time, doctors… extra doctors came on board. BARCLAY: The reason they were all so worried, stars for hospitals were at stake to be won or lost. BRIAN DOLAN Emergency Nurse Consultant They were worried because it would impact on their star rating, on their performance, potentially could impact on their careers, so in their shoes I think anyone reasonable would have felt the same thing, thinking my job could be on the line with this. Nurse Manager Words spoken by an actor At the end of the week, everybody breathed a sigh of relief because it was all over. It was just like.. oh my God, I don't want to be here. I don’t want to be here. Because it was just like everybody was running about like bees buzzing and at the end of the day you just felt drained, and at any point in the day you could just burst out into tears because it was so tense. BARCLAY: Two months later we were allowed to spend a day at the Homerton. The 4 hour target was still in place, but with the pressure off, were they still managing to deal with 97% of patients in 4 hours? Have you kept it up since? NANCY HALLETT Chief Executive Homerton University Hospital No. (laughing) No, we had… and like everybody, we had a post-week dip where I think we all took our eye off the ball and it sank away. I think we underestimated though the sustainability factor. I think we thought more would just stay there and happen than dip. BARCLAY: In his latest annual report the NHS Chief Executive says 93% of patients were spending less than 4 hours in A&E by the end of March. But this figure is based on the week hospitals knew they'd be monitored. It doesn't reflect the everyday reality. WILLINGHAM: (on telephone) We need a couple of beds. 78 medics came in at 12.35. BARCLAY: By the end of next year the government has promised no one will wait more than 4 hours in A&E anywhere. WILLINGHAM: (on telephone) Are there actually physical beds available there or are they still waiting? Well yeah, you're full then, aren't you. No more. Okay. Alright. Cheers. So you'll get back to me about the gynae lady. BARCLAY: If there are no beds for patients who need to be admitted from A&E, they have to stay in A&E with the clock ticking. RACHEL WILLINGHAM Senior Nurse, A&E The net result is that we get congested down here. Can't physically see anymore patients because we're virtually full, so longer A&E waits. BARCLAY: 75,000 patients are expected to come through the Homerton's A&E this year, 8,000 more than last. And every single one of them is now a target to be met or missed, like Gerard who arrives just after midday. ANDREW PARROTT: (to patient) I'll need to ring the duty surgeon and then I'll come down and have a look at that because he may well need a general anaesthetic to have that fixed, but it needs cutting open and cleaning out. PARROTT: (on telephone) It's Andy. I've just seen a 24 year old chap who's presented with a rather large fluctuant abscess only… BARCLAY: But all the surgeons are busy. ANDREW PARROTT Emergency Nurse Practitioner Problems with surgical staffing at the moment, and sometimes patients wait longer than the 4 hour target time. We've seen them within 20 minutes and then there's a delay because there's one person trying to do five jobs. It's like a blockage on the M6. It starts at Birmingham and eventually the South East gets gridlocked. BARCLAY: Are you allowed to fail your targets? COAKLEY: We're allowed to fail our targets, we're not encouraged to. I think they're quite happy not to meet targets and explain why that wasn't done. BARCLAY: Who would you have to explain to? JOHN COAKLEY Medical Director Homerton University Hospital You'd have to explain it to our Trust Board, you'd have to explain it to our staff, we'd have to explain it to the Strategic Health Authority, Primary Care Trust, the Department of Health, and ultimately the Secretary of State for Health. One of the big problems is the constant badgering of how one is going to meet the target, and the further your performance slips away from a target, the more intense the badgering gets. BARCLAY: For hospitals that fail to meet their targets the cost is high. Fewer stars, less money, and, in the Department of Health's own words: "Excessive Whitehall control". Our senior nurse manager told us that's why she sometimes has to choose which to put first, the target or the patient. Nurse Manager Words spoken by an actor I think if the system was organised differently, the pressure to decide between patient and management would be less, wouldn't be as devastating. BARCLAY: What do you mean by devastating? NURSE MANAGER: That feeling of am I doing the right thing or am I not doing the right thing for the patient. Am I letting the management team down in terms of meeting the targets or in terms of not playing along then. BARCLAY: Is that what you're having to wrestle with? NURSE MANAGER: Yes. BARCLAY: We've spoken to many nurses, doctors, health service managers and former senior officials from the Department of Health who told us privately that while they accepted the need for targets in the NHS the pressure to deliver change under such intense political scrutiny was threatening to undermine much of what is good about the government's NHS plan. It's the 9 key targets, in particular the waiting time targets, that put NHS managers under the most intense pressure to deliver, and to be seen to deliver by their political masters. You were threatened with…? MANAGER: Well.. you were not going to have a job. BARCLAY: This is actress is speaking the words of an NHS manager who left the Health Service last year. She told us about some of the tricks she and her colleagues played in order to meet waiting time targets. Tricks which meant patients were deceived. Former NHS Manager Words spoken by an actor If we knew that you're going to breach next week but your consultant is on holiday next week so you're not going to get the operation, we'll bring you in to hospital anyway and then we'll discharge you. So we'll send you leave, say we'll keep a bed for you but your not going to get you're operation. BARCLAY: There are many disturbing stories behind the government's official statistics on NHS waiting time targets. Nurse Manager Words spoken by an actor I remember that what we've done on a few occasions is discharge a patient, let them wait in the waiting area and treat them supposedly as an outpatient because their 4 hour wait would have been up. And you're just going to give them the results as an outpatient which is crap for want of a better word. BARCLAY: If there hadn't been a target, would you have done that? NURSE MANAGER: No, you wouldn't, you wouldn't. BARCLAY: So when people say that targets interfere with clinical priorities, what you're saying is, that's true. NURSE MANAGER: Definitely. Definitely. BARCLAY: In the last 18 months many independent experts have expressed concern about the extent of fiddling in the National Health Service - The National Audit Office, the Public Accounts Committee, the NHS Confederation, the King's Fund and the Audit Commission – ask its chairman about fiddling, even he knows the tricks. JAMES STRACHAN Chairman, Audit commission You're about to breach the target, you then tell the Department to phone up 50% of the people on that waiting list and offer them, surprisingly, admission within the following two weeks, to which of course large numbers say "Two weeks? I can't do that." At which point they're told: "I'm terribly sorry, you have to go back to the beginning of the waiting list" and hence the target is met. BARCLAY: No one likes the world 'fiddling'. The NHS has it's own word – 'gaming'. By the way, patients are being deceived. STRACHAN: The real cause for concern is about a pressure to meet these targets is causing some NHS managers to game the system. It may not actually be fiddling but it's actually pushing the system to the limit. BARCLAY: When the government's published it's NHS plan 3 years ago, it produced a frenzy of target setting. According to a former senior manager who was working for the Department of Health at the time, there was a firm conviction that what could be measured could also be managed. STUART EMSLIE Senior Manager, 1998-2002 Department of Health We ended up with a myriad of targets. When you're a very busy manager in the NHS and you're faced with all these targets and all the other objectives that you need to meet, and bearing in mind that most individuals can only deal with perhaps five or six key objectives at any one time, and you've maybe got 50-100. It makes it very, very difficult to see the wood from the trees. BARCLAY: The NHS plan was Alan Milburn's persona blueprint for the future of the NHS. All the key professional organisations signed up to it and nothing was going to prevent him delivering it. 27th September 2000 ALAN MILBURN: It falls to this generation, to this Party, to renew the NHS for this new century. We have the chance to change the Health Service for good. That is our challenge, now is our opportunity. EMSLIE: There was something within the system that prevented or hindered bad news being fed back to ministers. There was a genuine perception that ministers only really wanted to hear about good news and not bad news. BARCLAY: Ian Perkin is one of the most senior NHS managers to talk publicly about the impact he claims targets are having on the Health Service. Until last December he was Finance Director of St George's NHS Trust, one of the largest in the country. IAN PERKIN Finance Director, 1990-2002 St. George's Hospital There's a culture that's grown up where the emphasis of management within the NHS has been about achieving targets, you know.. come hell or high water. It doesn't matter whether achieved legitimately, you just have to achieve them. BARCLAY: Ian Perkin's story provides another glimpse into the NHS's target setting culture. He's waiting for an employment tribunal to decide whether he was unfairly sacked from St George's. He told the tribunal he was dismissed for accusing a fellow board member of altering the figures for cancelled operations. In an NHS, where statistics and definitions are all important, Ian Perkin described in his evidence what happened when St George's Head of Information came to see him in October 2001. PERKIN: She'd had a complaint from one of her information analysts, that when they had put the figures in for cancelled operations for the first week in October, that there'd been 28 cancelled operations and the Deputy Chief Executive had told her to put in zero. BARCLAY: In a statement to the employment tribunal, the information analyst describes a phone call she says she received from the Trust's Deputy Chief Executive, John Parks. "I told him that the figure I had obtained was 28 patients and he said this was incorrect as all routine operations were being cancelled in advance. I mentioned that we usually have five cancelled operations, and it would seem quite odd to suddenly have no cancellations. John Parks replied that the cancelled operations figures were something that we were being closely monitored on at the moment, and that I should enter zero." BARCLAY: John Parks' lawyers told Panorama the suggestion that he'd been involved in the manipulation of official statistics was untrue. Ian Perkin claims that after raising this issue it was only a matter of time before he was asked to go. The hospital says his management style was causing problems. Either way, last July he was called to the Chief Executive's office. PERKIN: He said.. you know.. we want you to resign your post as Director of Finance with the Trust, and they said if you do that we'll second you to the Regional Health Authority for six months, you wont actually have to come into the office. We'll say you're doing special project work, and in that time we want you to find another job. BARCLAY: The number of cancelled operations is one of the 9 key targets that determine a hospital's star rating. Last year St George's failed to meet this target. Now further concerns have been raised about the way the hospital deals with patients whose operations are cancelled at short notice. Are you in favour of targets in general to try and improve the efficiency of the NHS? STUART STANTON Professor of Surgery St. George's Hospital I am, yes, but I think they've got to be targets which are set in conjunction with the medical staff. BARCLAY: Professor Stuart Stanton agreed to speak publicly because he's about to retire from the NHS. STANTON: I think management is besotted by targets. This is pressure put upon them from up above, then translated from senior managers to ordinary managers and translated across to the doctors and nursing staff. BARCLAY: Professor Stanton says that during the last six months up to 50 of his patients have had their operations cancelled several days in advance to get round government targets. STANTON: Well this is a device whereby the patient is informed 3 or 4 days before her scheduled date of admission that a bed is no longer available. I think this is an artifice whereby the patient then doesn't appear cancelled on the day list. BARCLAY: Only patients whose operations are cancelled on the day are guaranteed treatment within four weeks. But the Audit Commission says almost half the last minute cancellations in England take place the day before. STANTON: The pre-cancellation figures are not regarded as important, or even disregarded by the Department of Health, whereas the cancelled on the day figures are very important. They’re important to the hospital because the more patients cancelled on the day, the more black points chalked up against the trust, and the less likely they are to acquire the three stars or even the two stars which they aim for. BARCLAY: A letter to Professor Stanton from the Trust's Medical Director said pre-cancellations were "Unsatisfactory for all patients and I hope that we'll be able to stop doing this as soon as possible." He admitted "The process of reducing waiting lists does mean some patients are disadvantaged." We asked St George's to take part in this programme to answer Professor Stanton's claims and those of Ian Perkin. They declined. But the allegations of gaming in order to meet targets go further. The Audit Commission says the majority of NHS trusts which balanced their books last year, only did so by using money set aside for long- term commitments. At St George's it was almost £4 million. IAN PERKIN Finance Director, 1990-2002 St. George's Hospital We were being asked to take money which was intended to replace assets at the hospital to actually bale out the day to day expenditure and that's just not a sensible commercial thing to do at the end of the day because if you don’t replace the piece of equipment when it comes to the end of its recommended life, and of course what happens is you start to have breakdowns more frequently, you have to call people out to mend it, all those sorts of costs start to impact you and it's really the opposite of what you were doing in a good business sense. BARCLAY: It can also put patients at risk. An email sent to Ian Perkin by St George's Chief Engineer last June warned that continuing to cut costs on buildings and equipment posed a very high risk. The email contained a long list of the dangers already being posed by equipment which needed to be replaced. The Audit Commission also warns that more than half the trusts in England have been diverting money set aside for specific improvements to keep services running in the short term. JAMES STRACHAN Chairman, Audit Commission The system is being distorted to meet those targets in the sense that money that was intended for longer term purposes, like buying medical equipment, buying computers simply maintaining the buildings, that's being diverted in order to be able to meet waiting time targets. BARCLAY: One of the most difficult dilemmas posed by the government's targets is to what extent they're delivering widespread improvements to patients' health as opposed to creating a different kind of rationing by focusing on what they say the public wants most – shorter waiting times. Of the 9 key targets 5 deal with waiting times, and it's here the government can claim the most success. But none of them deal with the more complex issue of the quality of care a patient should be entitled to expect. STRACHAN: People, when they stand and look back, after they've been through the NHS, had an operation, bee to the doctor, and you asked them: "What really matter for you?" they all talk about the quality of care, not waiting times. BARCLAY: We went back to Oxford to hear from doctors how the pressure to meet waiting time targets is stopping them treating patients with the most urgent clinical need. Our first conversation was with a Professor of medicine. As a doctor, do you have any choice about whether you see the more urgent case, or the less urgent case? JOHN WASS Professor of Medicine Oxford Radcliffe Trust We try and prioritise them, but we've been told that it's not an option not to get to the targets that we've been set. BARCLAY: You're told by whom? WASS: By the management, but they're obviously under immense pressure. I mean I feel really sorry for them because they are under immense pressure, the targets that they have been set mean whether or not the Trust gets 1, 2 or 3 stars. BARCLAY: Professor John Wass is an international expert in hormonal disorders. He says that earlier this month he discovered that hospital managers had told patients due to see him for follow up appointments that he wasn't available, cancelled their appointments and replaced them with new patients about to breach the waiting time target. WASS: What happened, an few days ago, was that we found that our clinic had been altered without any consultation with the consultants who's clinic it is. They put new patients into follow up slots, these are the patients who are being followed up pituitary tumours and we want to see whether they're repairing So they can't easily be delayed and they shouldn't be delayed at all. BARCLAY: But you're being told, are you, that it's the new patients who take priority. WASS: This is the new.. yes, the new patients and the targets and the follow ups are not the targets and that's creating a really difficult problem for us in fitting everybody in. BARCLAY: This former NHS manager from another hospital admitted waiting time targets often came first. NHS MANAGER: We would prioritise people who were coming up to the edge of the 'waiting list breach' as we used to call it. BARCLAY: What do you think about that? NHS MANAGER: It's a difficult one. I don’t know. You just distance yourself from it. BARCLAY: How did you?. Former NHS Manager Words spoken by an actor Well the problem is, is that you can't justify it to yourself, or I can't justify it to myself. And it's even more difficult trying to justify it to a consultant who might be standing in your office and saying "This is not clinically appropriate". BARCLAY: When people say that targets interfere with clinical priorities, what you're saying is that that is correct. WASS: I think they do interfere with what.. yes.. I suppose that is correct. That is correct. BARCLAY: How do you feel about that? WASS: Well I'm happy because what we're trying to do, actually we go into medicine positively. Our particular specialty is something where you can help people to get better. But because of the way in which we have to work, that makes it much more difficult. BARCLAY: Our next conversation was with one of the country's leading trauma surgeons, a doctor who advises the Department of Health. He believes in targets but only if they make what he calls "clinical sense". KEITH WILLETT Consultant Trauma Surgeon Oxford Radcliffe Trust Some patients are being compromised because of the blunt targets that are set. BARCLAY: Keith Willet has clinical proof that NHS targets have damaged some of his patients. WILLETT: What we've got here is a typical high energy road traffic accident in a young person. Here's the hip, which is a ball and socket joint. You can see the ball there, and there's the socket. The socket is shattered and the ball is displaced.. dislocated out of the socket, and the socket is shattered into various pieces. The surgery is very complex, it's very specialist. Getting in there and moving the fragments to rebuild the hip you can do in the first ten days. While the fracture is fresh we can manipulate and move the fragments, we can access that area, and we have an 80% chance of being able to give that patient essentially a normal hip for life. BARCLAY: Until the introduction of waiting time targets, that's what Mr Willett was able to do for most of his patients. Now, most have to wait more than ten days and the outcome is far less certain. WILLETT: Beyond ten days the fracture starts to heal, the scar tissue binds down those vital structures. The result with either be that you can't do the surgery, or we may have complications, or we just may fail to get the sort of accurate reconstruction that is necessary to change the patient's outcome. The patient will be disabled for life and there will be a burden on the NHS for the rest of their lives. BARCLAY: What do you tell the patient? WILLETT: I have to tell them that the chances of me being able to reconstruct the hip are less than they were. I have to tell them that the risks associated with the surgery are greater, and the complication rate is higher, and that I may not be successful, and I find that personally very difficult with patients because most of these are young people, average age of 35, often with families, they're the breadwinner. With the limited resources we have, those patients now cannot get the priority over patients with NHS targets. BARCLAY: Are there people walking around now who would have made a full recovery? WILLETT: You mean are they hobbling around now and would have walked? Yes. BARCLAY: With so many different targets to meet, many NHS managers are finding it difficult to keep the show on the road, according to a recent report from the Commission for Health Improvement. Former Chief Executive Words spoken by an actor The pressure was extreme. Not least because the number of targets were so high, but the tension between some of the targets also made it almost impossible to deliver everything. And also, because of that, you get a strange tension. Because, if you're going to try and attempt to deliver your financial targets, you run the risk of failing in some of your clinical or performance targets. JAMES STRACHAN Chairman, Audit Commission One is quite baffled by this desire to constantly meet 100% of your targets. Targets are simply means, they're not ends in themselves, and therefore if you hit 80-90% of all your targets, I mean you are doing fantastically, and instead of them being beaten up, they should be praised to high heaven. BARCLAY: The story of David Highton and what happened when he failed to meet some of his key targets sent shock waves through the NHS because so many people recognised the dilemma he faced. He had a successful track record as an NHS Chief Executive. But when he was brought in to sort out the Oxford Radcliffe Trust 3 years ago, he faced his biggest challenge. The John Radcliffe Hospital had some of the worst A&E waiting times in the country and a shortage of around 200 nurses. PETER BAGNALL Former Chairman Oxford Radcliffe Trust It was a very difficult task. The hospital had a lot of financial pressure on it, it also had a lot of difficulties in its Accident and Emergency and in its cancelled operations largely because of staffing shortages. BARCLAY: We understand that senior managers outside the Trust encouraged David Highton to sort out A&E and fast. The Trust got its first star for meeting seven 7 out of 9 key targets. Then it paid the price. A soaring financial deficit. In March Mr Highton resigned. By then the deficit was £20 million. BAGNALL: The NHS needs to be very, very careful that a culture of blame leading to arbitrary removal of people doesn't become too general because I think it will be very destructive for the morale of both managers and of clinicians. It is too easy for people to be pilloried for failing to achieve targets that really are pretty difficult. And to some extent may be aspirational. BARCLAY: David Highton told colleagues that meeting every NHS target was almost impossible. The Trust declined to be interviewed. Is the price that's being paid justifiable in terms of the improvements that have been made in the NHS? Former Chief Executive Words spoken by an actor Highly debatable I would say, highly debatable. Again, there have been some improvements and it would be wrong to say there haven't. Whether those improvements can justify what has occurred with some individuals and some organisations, I think that's far less clear. BARCLAY: The NHS Confederation, which represents managers, says: "Current targets and league tables do not provide useful information for the public, and their effects on the public perception of services can be misleading." But there's not much sign that Alan Milburn's successor is planning a U-turn on targets. [Speaking at NHS Confederation] Dr JOHN REID Health Secretary There's only one thing more difficult in carrying through a radical programme of improvement, and that is to be told half way through it that there's going to be a radical and abrupt change of direction. That isn't going to happen. The hard news is, that the challenge of the struggle for improvement will continue and the momentum will be maintained. BARCLAY: The Health Secretary declined to be interviewed by Panorama. We wanted to ask him whether the public should trust the figures used to claim NHS as meeting its targets when there's so much gaming and fiddling going on, and whether he thought it was acceptable that clinical priorities were being distorted in order to meet the targets. STRACHAN: The more people talk about this, the more people debate it, the better. Whether the tied has turned on target culture remains to be seen, but we must keep talking about this because otherwise there is a real danger that a lot of the new money allocated to improve public services will not be spent as well as it might have been. BARCLAY: If that happens, the real casualty will be the NHS itself. Its future undermined by the very people who promised to modernise it – the politicians. WILLETT: In medicine, in nursing, we aren't allowed to bring in new therapies or treatment without fully evaluating them. They have to be evidence-based. We have to look at whether they achieve what they set out to achieve and what the side effects might be in that body. It would be lovely to see some evidence- based politics in the Health Service. BARCLAY: Next week, 25 years on from the birth of the world's first test tube baby. Panorama investigates the baby business and lifts the lid on what's happening inside some fertility clinics. If you work in the NHS or want to comment on tonight's programme, please contact us at our website. _________ www.bbc.co.uk/panorama CREDITS Reporter Sarah Barclay Film Camera Peter George Nick Plowright Original Music Elizabeth Parker VT Editor Boyd Nagle Dubbing Mixer Damian Reynolds Production Co-ordinator Emma Hill Production Assistant Ruth Sanders Web Producers Anita Rice Adam Flinter Film Research Kate Redman Research Kathlyn Posner Graphic Design Liz Vinson Key Yip Lam Post Production Co-ordinator Ginny Williams Unit Manager Laura Govett Film Editor Ian Lavelle Assistant Producers Shabnam Grewal Matt Cottingham Stephen Barrett Producer Nick London Deputy Editors Andrew Bell Sam Collyns Editor Mike Robinson 11 _____________________________________________________________________________________________ Transcribed: 1-Stop Express Tel: 020 7724 7953 Fax: 020 7402 8434 E-mail: onestopexpress@hotmail.com