Monday, August 14, 2006


If New Labour will be remembered for anything, it will be for targets - the key to its endless so-called reforms of public services. It is easy to see why the party is so addicted to them: setting targets reproduces the sense of control that its leaders experienced during those heady years when they reformed their own party and became electable. But, in the case of the NHS, target-mania is not only damaging in the long term, but also a direct threat to patient safety.

Last month's report by the Healthcare Commission on the outbreaks of infectious diarrhoea in Stoke Mandeville hospital, in which 334 patients fell ill and at least 33 died, makes instructive reading. Managers, we learnt, overrode the advice of the expert clinicians on their own staff and thus failed to isolate infected patients to control the outbreak. This active mismanagement was driven by a need to meet targets, in particular the requirement to clear patients from the accident and emergency department within four hours. Patients in A&E with infections were admitted to open wards rather than isolation facilities, which were in short supply.

Almost equally disturbing is the sharp rise in hospital readmission rates - by nearly a quarter since 2002, according to government figures released this week. The most likely explanation is premature discharge of patients by hospital trusts under pressure of targets.

Will this kind of evidence be the death knell for targets and, more importantly, for the arrogance - political power mistaking itself for technical expertise - that lies behind them? Like many bad ideas, targets are intuitively attractive. Surely, it is argued, they enable public services to direct their efforts where need is greatest and to determine whether those needs are being met. The service can be proactive rather than merely reactive. Measurable outcomes mean that reality can be separated from rhetoric; in short, a better deal all round.

So much for the theory. In practice, the impact of targets has been damaging and must bear some of the blame for the failure of the vast and welcome increase in NHS funding to deliver a proportionate increase in care. Yes, waiting lists for operations have been dramatically reduced, but the hidden costs of targets have not been measured and their impact on overall activity have been costly and in some respects malign.

It is sometimes forgotten that if one kind of activity is prioritised then all others are "posteriorised". For example, the initial focus on coronary heart disease meant that development of services for cardiac arrhythmias andnon-cardiac conditions was held back. Conditions that are not prioritised still have to be treated. Secondly, priorities determined by the discomfort of a minister at the dispatch box may not match clinical priorities. Thirdly, meeting targets will itself become the overall priority: resources are commandered for this even if it is not cost-effective. The collateral damage to the care of patients with non-targeted conditions will be all the greater.

The greatest damage will be to aspects of care that cannot be measured - human kindness, listening and talking that patients value enormously and that are so important in chronic disease. When targets are set the measurable always displaces the immeasurable.

There are other less obvious, but no less serious, adverse effects of centrally determined targets. The implicit contempt for the competence and motivation of the professionals in the service is profoundly demoralising. A recent study by Frank Blackler, of Lancaster University, confirmed what one might have expected - that the target culture has led to poor leadership and paralysis among hospital trust managers. And it is not difficult to imagine the impact on clinicians who are at the receiving end of its puerile simplifications, remote from the complex realities of clinical care.

The assumption that clinicians will not try to improve their services without political "incentivisation" - carrots and Semtex - is profoundly irritating, not to say exasperating, for those who have being trying to improve their services for many years and found the experience to be rather like riding a bicycle up a sand dune. To be finger-wagged into doing something that one has been endeavouring to do without support is almost as bad for morale as being forced to act on priorities determined by political rather than clinical need.

And then there is the dangerously distracting effect of changing targets - one aspect of the unending "redisorganisation" of healthcare. The Healthcare Commission criticised the management of Stoke Mandeville for "taking their eye off the ball". More likely they were transfixed by a particular ball - the political agenda - that was in constant, unpredictable motion.

Targets are also corrupting, creating a parallel world of delivery that is remote from the real world. In the Soviet Union, when targets for screw production were set in terms of the numbers of screws produced, factories manufactured millions of screws the size of iron filings. Target met. When targets were set according to weight, the factory workers produced one massive screw. Target met. It is hardly necessary to say that this did not add to the wealth of the country.

Will the Stoke Mandeville outbreak be the beginning of the end of the micro-mismanagement of public services that has been such a feature of new Labour? It is devoutly to be wished. Though it may require the unfolding fiasco of NHS information technology - brewed in No 10, constantly exposed to political interference and rarely reality-checked with professionals expected to use the systems - to reach a climax before arrogance-inspired "reforms" come to an end. By then, I fear, the damage done may be irreversible.


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