Lots of managers but not much management

The meeting had lasted 1½ hours and was drawing to a close. We had been discussing the improvements in performance of a screening service that our PCT had taken over and then completely buggered up. Right at the end, they produced their performance report and in it were two graphs (which I have combined into one shown on the right).

You will see that routine referrals by the service to hospital consulants (the top line) oscillated between 38 and 225 a month. Urgent referrals also varied between 1 and 39 a month.

Everybody was really impressed with the report but then I spoilt it. I asked why there were such large variations from month to month.

Not a bloody clue!

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!

Tidy processes but untidy outcomes

General Practice is managed by its local Primary Care Trust. Our PCT has a population of 330,000 patients and spends hundreds of millions of pounds of your money and mine. They are responsible not just for ensuring we are performing our duties properly, but also for introducing new services and the procedures to support them. They also commission new buildings; they modify and adapt the complex arrangements that are involved as a patient moves through the system from GP to hospital or to a specialist clinic, and then back again. From a general practice perspective, virtually everybody with who we come into contact is a "manager".

It may come as a surprise to you that so many of them have no specific previous relevant experience that they can apply to the tasks for which they have been recruited. The important essential criterion seems to be the ability to produce impressive word-processed reports with lots of tables accompanied by a multi-page spreadsheet with lots of colours. Too often, it is the triumph of style over substance.

Don't believe me? Then consider the following:

Yesterday I attended a meeting of a group meant to be steering an important screening service for people suffering from complaint found frequently in our population. There were seven of us managers and we all like to think we have the best interests of patients at the heart of everything we do. We were discussing the local hosptials failure to achieve a fourteen-day target for seeing urgent referrals.

Nice manager from the hospital: "We have a high rate (40%) of non-attendance in clinics."
Nice assistant director of PCT: "What are you doing about it?"
Nice manager from the hospital: "We're recruting a locum consultant to work thought the backlog".
Nice PCT service manager: "That's good to know. How long will it take?"
Nice man from hospital: "We are recruiting now and we believe it will soon make a signficant improvement".
Nice assistant director: "That's good to know."
Me: "Hang on a minute. If two in every five people aren't turning up for their appointment, why get more capacity when the capacity you've got sits unemployed for 40% of their clinic time?"
Nice man from hospital: "The consultants won't let us double book clinics".

Apart from the inherent nonsense of the consultants' stance, nobody else seemed the least bothered. They had dealt with the problem i.e. they had pushed and prodded it a bit (but not too hard) and had a response to write in the minutes.

Meanwhile, patients are still not getting urgent appointments within two weeks, and there is no date given at which it is forecast that this entirely avoidable situation will improve.

Their process is nice and neat but the outcomes which were poor are no better.