Why NHS targets don't always work

Tory leader David Cameron has pledged to make the Conservatives the party of the NHS. That’s a bold move but with the backing of experienced people, like shadow Health Secretary Andrew Lansley, and bright advisors at his side Mr Cameron might be well-placed to have a decent crack at it.

He was interviewed on the Today programme yesterday morning explaining that the way to make the NHS better is by placing more emphasis on patient outcomes, rather than relying on centrally-imposed targets. The Tories have cottoned on to the idea that giving greater emphasis to the patient voice fits rather well with their free market principles. What better way to ration healthcare than to make the patient/customer King.

Targets can have unintended consequences as the current government is only too aware. It has been very fond of imposing targets without really understanding the consequences. That’s why it had to back-peddle furiously by getting respected clinicians like Lord Ara Darzi involved in bringing round disaffected NHS workers.

Take the four hour A&E target for instance. Long queues in A&E are bad for patient morale and bad for headlines. Stipulating that every patient must be seen within four hours seems sensible. However, unless you have worked in an A&E department, or have listened to someone who does, you wouldn’t know that this target could have unintended consequences.

Figures produced by the CHKS Group and reported in The Times recently reveal that over the past five years 2 million extra patients were admitted to hospital through A&E units in England – a rise of 20 per cent. There was no rise in Scotland or Northern Ireland where the target has not been imposed. In Wales, where the target was delayed, admissions started rising in 2005.

One explanation is that patients often need to be monitored for complications – making a diagnosis straight away without seeing test results is perilous. So rather the having patients lying around in corridors it’s best to get them on to a ward. This happens to work in the hospital’s favour since under the NHS tariff it gets paid substantially more for an admission rather than if a patient is treated in A&E.

Hospitals will of course deny gaming but you can understand the motivation given they are now having to compete with one another and other providers. Payment by Results is actually payment by activity.

The four hour target might work in some respects but not in others which means Mr Cameron is right to think about other incentives. But patient outcomes data has to be handled with integrity and the Tories should tread carefully if they think they’ve stumbled on to a winner.

Disclaimer: the author has a commercial relationship with the CHKS Group