The election buzz is simultaneously sending out two messages – that public services are inefficient and need streamlining and that the NHS will be protected from cuts (here’s a tip for party leaders – when you give speeches about protecting the NHS don’t make cutting motions with your hands – it’s unnerving).
It is timely then that targets for health and social care services are back in the press again. This time The College of Emergency Medicines is arguing that the NHS target to treat people visiting accident and emergency units within four hours is compromising care and patient safety.
This is unnerving too – so how does target setting shake down at the frontline? In the book ‘In Stitches’, Dr Nick Edwards, an Accident and Emergency Doctor explains that the four hour rule sparked a fair amount of ‘head banging’ that did lead the team to streamline processes in A&E. There was some improvement in how they worked. Targets do have some value.
But he also describes the little ‘fiddles’ necessary to meet targets. If patients are moved out of A&E and into a corridor with curtained-off enclosures, they can be classed as in an admission ward – the 4 hour target is met. Patients may be referred immediately and sometimes inappropriately to a specialist on a ward thus by passing A&E. Target met.
Edwards gives a specific example. He is treating a patient with only 5 minutes left in the four hour window. He has to decide whether to move her onto a ward without anaesthesia leaving her in a lot of pain for some time (but meeting the target) or spend 15 minutes treating her. If he breaches the 4 hour rule, he argues that the managers will come down on him like a ‘ton of bricks’ and the hospital will receive financial penalties. He decides to treat the patient, breaking the 4 hour rule and later they ‘massage’ the figures logging the time as 3 hours 59 minutes.
So, while ministerial lever pulling can appear to produce the goods from the organisational machine, the effects will be unpredictable and may only produce the illusion of goods delivered. Nick Edwards reports targets improved what they did – this is important to acknowledge and is reassuring. But he also highlights the stress, wasted time and energy spent skewing practice to meet the targets, making decisions to fit the targets and massaging figures to meet the targets.
I take an optimistic conclusion from this as well though. Despite the warning of The College of Emergency Medicine, which I think should be heeded, we should have some faith in the humanity and care of the practitioners who do what it takes to look after people the best they can.