The appalling quality of care provided by Mid Staffordshire NHS Foundation Trust, which has led to more than 400 unnecessary deaths, has shocked us all. It has also added fuel to the debate on whether targets work in a health service and whether NHS organisations should have greater freedom from central control. But these arguments could miss the point of this tragic episode.
It is worth remembering that in the mid-1990s newspapers often carried stories about unacceptable practices, such as patients who waited for more than three years for a quality of life knee-replacement operation or more than 24 hours in A&E. The initial government response was to set targets and, to the credit of the NHS, these have been a great success. In the past ten years the Government has doubled what we spend on the NHS. It now consumes nearly 8 per cent of GDP, or £100 billion a year. And by the end of the year most people will wait less than 18 weeks between GP referral and having an operation. And most wait less than four hours to be treated in A&E.
Very few clinicians would argue that these successes are not a good thing. But some question targets that force clinicians and managers into perverse behaviour, such as adjusting the care package for a patient adversely to meet a target.
Some commentators argue that the greater degree of freedom from central control that foundation trusts enjoy is so intoxicating for these NHS hospitals that their leaders blindly put financial targets over patient care and safety. However, the Healthcare Commission, the NHS regulator of service quality, reports that foundation trusts perform better than non-foundation trusts for service quality and efficient resource use. Moreover, financial measures are only one of a variety of criteria that need to be achieved to secure foundation status.
Whatever these commentators argue, it is clear that targets have been used effectively both nationally and locally to improve performance and encourage positive new behaviours. However, we have to understand that they are a blunt instrument. As our NHS system matures, further improvements can come only from local leadership and accountability, focus on the patient and team values and culture. NHS organisations that have not matured – and that focus slavishly on national targets, or strive only for greater independence from Whitehall – display a massive failure of leadership, culture and values. Thankfully, these are in a tiny minority.
Clinicians and managers need to work together to focus on the joint responsibilities of quality of care and spending our money effectively. All too often clinicians have not seen the latter as their responsibility and vice versa for managers. Most NHS organisations are striving hard to address these challenges.
We should not let the argument about targets get in the way – they have served their purpose. The new focus must be on the quality and capability of both clinical and managerial leadership. The move towards greater local accountability and autonomy will help.
Failures in any system will happen. The big question for the various health and social care regulators is how do we spot them before patients lose their lives.
Andy Mullins leads PA Consulting Group’s public sector health services