Saturday, August 12, 2006

Missing the Target

In the Times (UK), an eloquent critique of target setting in the National Health Service by Raymond Tallis:

in the case of the NHS, target-mania is not only damaging in the long term, but also a direct threat to patient safety.

Last month’s report by the Healthcare Commission on the outbreaks of infectious diarrhoea in Stoke Mandeville hospital, in which 334 patients fell ill and at least 33 died, makes instructive reading. Managers, we learnt, overrode the advice of the expert clinicians on their own staff and thus failed to isolate infected patients to control the outbreak. This active mismanagement was driven by a need to meet targets, in particular the requirement to clear patients from the accident and emergency department within four hours. Patients in A&E with infections were admitted to open wards rather than isolation facilities, which were in short supply.

Will this kind of evidence be the death knell for targets and, more importantly, for the arrogance — political power mistaking itself for technical expertise — that lies behind them? Like many bad ideas, targets are intuitively attractive.
In practice, the impact of targets has been damaging and must bear some of the blame for the failure of the vast and welcome increase in NHS funding to deliver a proportionate increase in care.

It is sometimes forgotten that if one kind of activity is prioritised then all others are “posteriorised”. For example, the initial focus on coronary heart disease meant that development of services for cardiac arrhythmias andnon-cardiac conditions was held back. Conditions that are not prioritised still have to be treated. Secondly, priorities determined by the discomfort of a minister at the dispatch box may not match clinical priorities. Thirdly, meeting targets will itself become the overall priority: resources are commandered for this even if it is not cost-effective. The collateral damage to the care of patients with non-targeted conditions will be all the greater.

The greatest damage will be to aspects of care that cannot be measured — human kindness, listening and talking that patients value enormously and that are so important in chronic disease. When targets are set the measurable always displaces the immeasurable.
There are other less obvious, but no less serious, adverse effects of centrally determined targets. The implicit contempt for the competence and motivation of the professionals in the service is profoundly demoralising. A recent study by Frank Blackler, of Lancaster University, confirmed what one might have expected — that the target culture has led to poor leadership and paralysis among hospital trust managers. And it is not difficult to imagine the impact on clinicians who are at the receiving end of its puerile simplifications, remote from the complex realities of clinical care.

The assumption that clinicians will not try to improve their services without political “incentivisation” — carrots and Semtex — is profoundly irritating, not to say exasperating, for those who have being trying to improve their services for many years and found the experience to be rather like riding a bicycle up a sand dune. To be finger-wagged into doing something that one has been endeavouring to do without support is almost as bad for morale as being forced to act on priorities determined by political rather than clinical need.

And then there is the dangerously distracting effect of changing targets — one aspect of the unending “redisorganisation” of healthcare. The Healthcare Commission criticised the management of Stoke Mandeville for “taking their eye off the ball”. More likely they were transfixed by a particular ball — the political agenda — that was in constant, unpredictable motion.

Targets are also corrupting, creating a parallel world of delivery that is remote from the real world. In the Soviet Union, when targets for screw production were set in terms of the numbers of screws produced, factories manufactured millions of screws the size of iron filings. Target met. When targets were set according to weight, the factory workers produced one massive screw. Target met. It is hardly necessary to say that this did not add to the wealth of the country.
As the saying goes, read the whole thing.

In case anyone thinks that this issue is relevant only in the UK - the currently fashionable "pay for performance" (P4P) movement in the US is a sub-species of target setting. (See previous post here and here.) Maybe we in the US should look at the British experience before rushing off to implement P4P.

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