Editor’s blog Thursday 3 June 2010: Targets or no targets?

What is the official government policy now on national NHS targets?

And are Prime Minister David Cameron and Health Secretary Andrew Lansley singing from the same hymn sheet?

There are reasonable arguments on both sides of the targets debate in healthcare. In a 2009 debate feature in the BMJ, Gwyn Bevan of the LSE suggested that targets are broadly unproblematic; James Gubb of Civitas had many reservations.

Prior to the election and coalition, PM David Cameron was unequivocal in telling doctors, “those targets you hate, they’re gone”.

Asked yesterday during Prime Minister's Questions by Peter Bone MP about ”the amount of money that some senior NHS managers are receiving”, Mr Cameron told the House,

“By having transparency, we are able to see for the first time who is earning what in the public sector. That will create pressure on top people’s pay in the public sector, to keep that pay down. That is the first thing.

“In the NHS specifically, as he knows, our plans are all about removing the centralised bureaucracy, partly by removing many of the centralised targets that have caused that bureaucracy to grow.

“Our ambition is to ensure that the priority is the people on the front line—the nurses, the doctors, the people involved in clinical care—instead of the endless increase in management that we have seen in recent years”.

In a traditionally polite debate on the Queen’s Speech (also here), Health Secretary Andrew Lansley set out his policy stall:

“what we need to achieve that quality is a change from a command-and-control, top-down system of running our schools, hospitals, health care and social care services to one that is built on standards of delivering quality ...

"We have to give patients greater information, choice and control over the health care that they receive, and in all the public services that we are talking about, we must provide those who deliver them with a much greater sense of ownership.

“It is all very well for the right hon. Member for Leigh to talk about what has been achieved in the NHS over recent years, and I have never been one to diminish what has been achieved. However, many who work in the service, notwithstanding the fact that they are better paid than they were and know that they have had an unprecedented increase in resources to deliver improvements, still feel demoralised and that they are not in control of the service that they provide.

"They cannot give the care that they want to give, and they know that they are not yet matching the standard of care that they could achieve given the opportunity to do so. It is our responsibility to make that happen and I do not doubt the commitment of Government Members to do so”

The aforementioned hon member for Leigh, Labour’s shadow health minister Andy Burnham pointed out in reply, “this afternoon at the Dispatch Box, the Prime Minister said that the targets would be going. Let me tell the Health Secretary directly that if those targets are removed from the National Health Service, people everywhere who depend on a good service from the NHS will no longer be able to count on that.

"Those standards, which Labour introduced, have given us a National Health Service that provides a good standard of care to people right across the country. They are good standards to have in a National Health Service.

“The Secretary of State needs to come clean at the Dispatch Box. Is he going to back up those standards, or does he have something else in mind? Is he going to keep the 18-week target, the two-week target for cancer, and the four-hour A and E target? He needs to give a direct answer”.

And answer came there none
Lansley did not give a direct answer. He did not even venture an indirect one.

But the answer, when it comes matters greatly. Management learning is clear that what gets measured gets done – or at least, its failure gets noted. There are always down-side gaming and other risks to targets – thresholds matter. And having targets for everything means effectively having no targets.

Nonetheless, targets mean measurement. Measurement should mean peer review, analysis, reflection – and no place to hide among anecdotal explanations why you just can’t work any differently.

One piece of learning from Sweden is that the abolition of healthcare targets there resulted in the return of waiting lists.

Other interesting points from the debate
Burnham told the house that the newly-released McKinsey Report “was not commissioned by me or by Ministers but by the former director of commissioning in the Department, who left before I arrived”. Mark Britnell, take a bow.

And Andrew Lansley would seem to be making a precedent of hints about what supposedly independent arms’ length bodies will say, telling the House, “We cannot make announcements about the Royal Liverpool and Broadgreen, or about Monitor in relation in Alder Hey as a foundation trust, but I hope that we will be able to do so soon”.

Mmm. Does that should like someone who wants the NHS run by an arms’ length independent board (a quango, in the old money) to you?

Perhaps Mr Lansley’s just got very short arms. Would that make him ‘slight of hand’?