Kevan Christie: How NHS target culture may be bad for our health

The review by Professor Sir Harry Burns into the use of targets in health and social care is long overdue and shines a light on the arbitrary nature of these mechanisms, which are often used as a stick to beat beleaguered NHS staff.

While the former Chief Medical Officer doesn’t favour doing away with targets, he understands that they are often not a good way to measure how health and social care services are performing.

The bigger picture, which Professor Burns has picked up on, centres around a more holistic approach to medicine which can’t be broken down into how long someone waits for treatment.

Key health targets include the 18-week referral-to-treatment standard, the 12-week treatment time legal guarantee, separate goals for cancer care and the four-hour A&E waiting time target.

The review warns that we need to look across the whole experience of care and not, in the words of Professor Burns, “just take a snapshot of isolated bits of it”.

A major concern noted by BMA Scotland in their reaction to the report is that inappropriate targets can skew clinical priorities. Basically, this means more attention is given to areas covered by targets to the detriment of others that are not.

At present, targets are measured on a weekly basis. Any that are missed can be instantly seized upon by opposition politicians looking to ramp up pressure on the Scottish Government and health secretary Shona Robison in particular.

This is understandable and, in agreeing the NHS Local Delivery Plan Standards that replaced the old “Heat” targets, the government has made a rod for its own back. The harsh reality is that some people may have to get used to the idea of waiting a bit longer for, say, a knee replacement. This is where we all have to be a bit more realistic when it comes to the services our outstanding NHS provides.

However, the report rightly notes that targets have an important place in the NHS and there are certain standards, such as the four-hour A&E target and cancer-care targets which patients have the right to expect to be met.

Interestingly, Professor Burns highlights the need for an effective set of indicators measuring the health of children and the social and economic circumstances of people living with deprivation. He sets out the challenge of dealing with widening socio-economic inequality and the erosion of social cohesion which he says is attributed by some to industrial policy in the latter half of the 20th century.

He says the concept of managing public services using targets emerged in the 1980s as the government set about improving the efficiency of public services by making them more business-like.

This new “public management” approach created a market in healthcare aimed at creating competition between the public and private sector. Some management scientists go as far to argue that targets are nothing more than the remnants of a discredited command-and-control system which demotivate staff and causes them to focus on the wrong aspects of their work.

However, it looks like targets are here to stay in all shapes and sizes with Ms Robison saying “we must shift emphasis to ensure we have a more sophisticated approach”. Good luck measuring that one.