Medical Life

The bonfire of NHS targets is blazing nicely. Cast into the flames are the 18-week limit on waiting times from GP referral to operation, the four-hour limit on A&E waits (relaxed before being scrapped next year), the 48-hour limit on appointments with GPs (though in reality this was never a formal target, and bonus payments for hitting it remain).

Does this matter? Andrew Lansley, health secretary, thinks not. In place of targets, backed by NHS enforcers, come "quality measures" covering, initially, stroke, dementia and thrombosis (blood clots). Details are still hazy but these are supposed to be a more gentlemanly way of doing business – setting aspirations rather than laying down rules which, when breached, attract instant penalties. The idea is that ministers indicate the direction of travel, and leave doctors to decide how to reach the destination.

This is music to the ears of the medical profession, which has protested at the perverse incentives created by targets for a decade. Yet anyone who doubts their importance should listen to former health secretary Alan Milburn on the subject of NHS waiting lists.

Polling that the Department of Health did in the run-up to the NHS Plan launch in 2000 showed waiting was the public's number one concern. But it was not the staff's – it ranked only seventh out of the 10 most important changes they wanted to see. Alan Milburn, speaking to the Financial Times, said: "What really struck me is that for the public, waiting was the thing. They were suffering it and wanted it changed. But when we polled the staff it wasn't. The [people working in the NHS] had just got used to it."

Milburn's phrase "The people working in the NHS had just got used to it" was striking. Waiting wasn't a problem for the doctors, only for the patients. It is common to every profession and trade – the more absorbed in it you become, the less you can see it as others do. The same was true of hospital infections such as MRSA and C Difficile – doctors did not rate them as significant threats because they had become used to seeing and treating them. In one sense, they were right – there are bigger problems and bigger killers. And as a senior Health Protection Agency scientist once ruefully admitted, doctors had underplayed the problem because "we had antibiotics."

But patients saw it differently. They understood there was a risk a treatment might not work, but they did not expect the hospital itself to make them sick. Hospitals were supposed to make you better, not worse. Targets helped redress this balance. They gave the patients' priorities prominence and reminded us that the medical perspective is not the only one. Their loss is a significant weakening of the patients' voice.

There is a further worry. Without the pressure to meet targets, standards may slip. There is no simpler way of saving cash than letting waiting times stretch. At times of pressure, as now, it is the rationing mechanism of first resort.