This morning, I went head to head with Labour MP John Healey on BBC Look North's news bulletin on the matter of NHS targets. Last night he admitted in a TV debate “We overdid the targets to start with” – sounds good? But unfortunately, Mr Healey qualified this and it all went square… “…but in my opinion, you’ve got to have something … if you want to guarantee patients the treatment”.
Unfortunately, John Healey has got it all wrong. Quite simply there is no good way for the NHS (or any other organisation for that matter!) to set a target, nor is there such a thing as a necessary or good target. No targets will help the patient, and they will almost certainly result in cheating, waste, duplication of effort and demoralized staff… ironically, right at a time when we need public services to be doing more with less!
For example, targets in the NHS represent a whole management factory of internal and external structures undertaking work specifying what needs to be done, as well as monitoring and reporting against targets and explaining any deviation from what has been specified – all this activity is waste which does nothing to improve the health of the nation, but devours resources and demoralises the front line staff delivering the service.
This is because when people know they are going to be judged against meeting of targets, they use their ingenuity and creativity to do whatever it takes to be seen to meet them (and so survive in the system). This can mean cheating, for example by distorting or misreporting data. Let’s look at a couple of examples in maternity services…
So for example, by the end of 2009 there was a government target for all prospective mums to be offered a choice in where their baby was to be born – with home being one of these choices. In reality this doesn’t happen where I live – I was offered a choice of 4 hospitals, and when I asked for a home birth, I was told I “probably wouldn’t be allowed one as they’re only for women who are really low risk” – although there was no medical reason to make me anything other than low risk. Similarly, other mums have reported spurious, emotive, non-evidence based reasons are given to strongly discourage them from home birth (“you’re brave”; “it’s your first birth” “you’re 7 days overdue” etc). When mums to be have dug their heels in, they’ll be lucky to get it - reported stats show that at my local hospital, the homebirth service was withdrawn 42 times between January 2008 & December 2009; midwives are not fully trained in, and are not fully confident in, supporting home deliveries; and there is only provision for one woman in the area to have a homebirth on any one day of the year!
However, if you were to ask the senior managers at the local NHS trusts, they’d probably tell you everyone gets the option to have a home birth. Someone’s not telling the truth, and I imagine it’s not the mums… to me it looks like the frontline staff have to offer a home birth service they’re unable to fulfil due to the way the local maternity care is currently run, so they do what they can to be seen to be offering homebirths.
Another example of cheating is with the target the NHS has to increase the percentage of women who have seen a midwife or a maternity healthcare professional for a health and social care assessment of needs, risks and choices by 12 completed weeks of pregnancy – digging a bit deeper, this seems to be borne out of a desire to get women seen as early as possible in pregnancy so they can access advice to give their babies the best start possible. A sensible target one might think… but what actually happens…?
As I knew I was pregnant ,I rang my local NHS midwives as I wanted to speak to a midwife (as per NHS website advice) ASAP to ensure I did everything I should to give my baby the best start I could. The midwife I spoke to told me they didn’t need to see me for a few weeks as they prefer not to see everyone for their booking appointment until about 10 weeks so they could exceed the government target of 12 weeks. She went on to explain that often babies die in the first few weeks (“it’s heartbreaking really” she said), so it was better to wait a bit longer. Hmmm – so they’d meet their target by seeing me within 12 weeks, and may be saving some time not seeing mums of babies that won’t make it until 12 weeks, but in reality, what they said was against the spirit of the target (see mums as early in pregnancy as you can) and left the patient feeling very upset & without the early advice the target was designed to ensure…
But the staff in the NHS aren’t bad people – they’re just stuck working in a very bad system. Knowing they’re cheating but feeling it is their only option must be awful – no wonder there’s high levels of staff absence, turnover & shortages!!
This is not modernization of the NHS – this is wholesale dismantling of the system we British hold so dear. Moreover, all public services are victims of the same target driven mentality. And what’s frightening is that not one of the political parties seems to understand the best way to make things better!
So what to do? The right thing to do is to abandon all the current targets. Every single one of them! But that doesn’t mean they shouldn’t measure anything – but we need to change the system, design the service against patient needs and measure what really matters to the public: patients, families and relatives! This will lead to a better quality service, systemic improvement of the NHS (rather than its systemic failure), better staff morale, and lower costs – it’s obvious to anyone that it’s in everyone’s interest to do things this way.
In the run up to the election, it’s very easy for politicians of all parties to make promises based on what they think the public want to hear. In the case of the NHS, though, we don’t just want empty promises and the creation of yet more targets and bureaucracy – what we need is a commitment to fundamentally overhaul how health services are designed, delivered and managed.
Politicians and NHS executives need to get close to the work being done on the front line so they can experience first hand the day to day problems encountered by both patients and their carers as well as the things that are going well and not so well.
Patients & frontline NHS staff are the very people that know how to fix the NHS – and the only way politicians can deliver an excellent and cost effective health care service that’s the envy of the rest of the world, is to harness that knowledge. But is anyone willing to listen…? This blogger remains sceptical…
