Targets Are Not Management

The Government has made much of its decision to scrap a couple of NHS targets: the "48 hour target" within which time a patients is guaranteed to see a GP; and the "18 week rule" within which time a patient should have been treated in hospital following a referral from a GP. I really disliked these targets but perversely, I am sorry to see them go.

Firstly, what didn't I like?

Well, let's start with the 48-hour target. The way in which GPs fiddled their appointment systems didn't really sort out the structural confilct between seeing the GP when it suits (a future appointment) and seeing the GP "now - it's an emergency" (even though it almost never is!).

Some of the outcomes of the 18-week rule were frankly, bizzare. If a patient tried to change a hospital appointment, they were "discharged back to their GP" (NHSspeak for taken off the system) and invited to join the queue from the start when a further 18 weeks could be counted. This is clearly poor care and there is no excuse or justification for it.

So, why am I sorry to see them go?

I should explain that I am not opposed to quantitative measurements of performance to inform management. Looked at in isolation, these targets are reasonable; if you in some distress it is reasonable to be able to obtain medical help within two working days. Four months ought to be enough time for a patient to pass through the hospital system and be treated (providing there have been no unforeseeable delays).

The problem is not the targets but the way in which The Health Kremlin uses them.

Targets are not management or a substitute for management yet this is precisely how they are used. The orthodoxy is that we set these targets and leave the front-line to reorganise themselves to meet them. What doesn't happen is sensible pragmatic supervision and management of the behaviour of GPs and hospitals that are aspiring to these targets. Providing the PCT or Hospital can let their local Politburo tick the correct box, then the target has worked, even when a short stroll around the patch would reveal some of the nonsenses that have been carried on since the targets first appeared.

Another classic: the "no more than 4 hours in A&E target".

Introduced after countless lurid headlines of patients left lying on trollies in corridors for hours, days, weeks, etc. The target has resulted in a huge surge of patients admitted as in-patients because the precautionary test results (x-ray, whatever) wasn't available within 4 hours; all of this at considerable additional cost and inconvenience to everyone.

Before we had targets and no management.

Now we don't even have the targets!

It Only Works because It Doesn't

In the left corner:

Our PCT, insisting that we provide ever more appointments that have to be bookable two weeks in advance; also insisting that we see patients immediately when they say it's "urgent" even when it's clear it isn't; and also providing minimum number of appointments each GP must provide each week. Their targets are ambitious but we do our best.

In the right corner:

The BMA Guidance on child Protection which says amongst all the other excellent advice: "Doctors have a key role to play in child protection (case) conferences and the BMA considers it important that , as far as possible, doctors attend in person, in addition to sending in a written report containing relevant information such as ..."

In the middle:

The GP. We usually receive less than 48 hours notice of a case conference (that's because best practice is to convene it a.s.a.p). So the GP has usually already got fifteen or so patients each with a ten-minute appointment booked up to two weeks in advance, exercising their right to see the doctor of their choice.

The Outcome.

We rarely attend case conferences and until someone works out the realities of the conflicting demands made of GPs, that situation won't change.

The Moan

It's one of the things that really gets my goat. Managers have produced glossy (and expensive) books containing impressive procedures that are faultless in ambition, aiming for very best practice and overflowing with care. They simply don't work and nothing will change until they look at the realities of general practice. Try asking us - that would be a start.

Uncle Noel RIP

Yesterday I went to the funeral of the last of my mother's seven siblings. Uncle Noel died peacefully at the splendid age of 93. He started as a miner at the age of 14 but continued his education and after the war became the Deputy Master of Worcester Workhouse. What a splendid title! Pure Dickens, porridge and all. For the rest of his working life, together with my aunt, they cared for old people and they did it really well. My Aunty Mair's cooking was legendary!

When Mair sank into the swamp of dementia, it was all the more frustrating (polite version) to see the lack of care that she received despite the determined afforts of a feisty eighty-odd year old husband. Hospitals trying to discharge her because she "wasn't ill as such" and local authorities acting with a complete lack of urgency. After all, Uncle Noel could help (no, they hadn't noticed he was crippled by two very arthritic hips).

After Mair's death, Noel moved into a care home run by MHA (a methodist charity). At last, he received the sort of care that he and Mair had given to others. So thank you to MHA, the staff at Norwood, Ipswich and to Noel and Mair for lives spent providing real care for people not clients.