Jeremy Laurance: This time, the doctors didn't know best

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The Independent Online

For the last decade the NHS has been involved in a giant management experiment. The new approach, dubbed dismissively "P45 targets", was adopted by Labour after years in which ministers had run the service from their Whitehall HQ using old-fashioned command management to deliver instructions to the front line.

Under the new strategy, chief executives were given centrally set targets, which they were required to meet, or face the axe. The best known were the 18-week target for hospital admission and the four-hour target for A&E waits, but there were dozens of others.

Crucially, however, after devolution in 1999, Scotland, Wales and Northern Ireland did not follow England's example. They introduced targets but did not pursue them with the same vigour as England, instead retaining the old style of command management.

Today's report from the Nuffield Trust is the first to compare the outcomes in the four countries – and it makes sobering reading. To take a single, stunning statistic: Scotland had 50 per cent more nurses than the North-east of England in 2006 yet the North-east of England treated 50 per cent more hospital in-patients. How to explain such a gap?

Targets were hated from the start. Managers loathed them because they tied their hands and doctors protested they interfered with their clinical freedom. But "clinical freedom" had, for decades, meant doctors repeatedly pushing routine cases to the back of the queue in favour of more urgent (and more interesting) ones, resulting in some patients waiting up to two years for treatment. Targets concentrate minds.

Critics claim the NHS is failing to deliver sufficient bang for the bucks, after a decade of unparalleled government largesse, during which the budget has more than doubled in real terms. But if England has performed poorly, the Nuffield Trust's figures show that the real spendthrifts are the devolved nations. Despite spending £100-£200 a head more than England, Scotland, Wales and Northern Ireland deliver a slower, less efficient service.

The Tories have promised a bonfire of targets and their replacement with "outcome measures" that show whether patients get better. Labour have said they will keep some.

Targets should be an aid to, not a substitute for, good management. But if the findings of this report are confirmed, it would be a foolhardy government that ditched them.

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