Leading article: Targets have no place in matters of life and death

Box-ticking can be no substitute for judgement, least of all in the NHS

Wednesday 18 March 2009 01:00

The NHS watchdog, the Healthcare Commission, has found that managers at Stafford Hospital pursued targets to the detriment of patients. One result was disgracefully substandard care; another, more shocking, was a sharply increased death rate. The chairman and chief executive of Mid Staffordshire Foundation Trust have resigned; the Health Secretary Alan Johnson has apologised.

We should, perhaps, be thankful for small mercies. The top trust officials did the decent thing and did not wait to be pushed. The Health Secretary said "sorry". Neither, regrettably, can be taken for granted in this age of buck-passing and self-justification. But this is where even the faintest positives stop.

In its damning report, the commission identified a whole chain of problems, from low staffing levels, through poor training, to inadequate follow-up procedures when things went wrong. The difficulties were particularly acute in the accident and emergency department, where unqualified staff made initial assessments and heart monitors were switched off because no one knew how to use them. You could not ask for a clearer example of waste – expensive machines lying idle for want of trained staff – in a service that repeatedly pleads penury.

One of the most galling aspects of the case is that patients and relatives could see clearly what was happening, and often why, but could not get their complaints taken seriously – although they assumed a consistent pattern early on. Such high-handed treatment of the people it is supposed to serve is all too typical of parts of the public sector, but seems especially ingrained in the NHS, where lay opinion is readily dismissed as ill-informed.

It could be argued that such complaints have, to an extent, always been levelled against hospital management. What sets this report apart, however, is its conclusion that meeting government targets took precedence over patients' welfare. So fixated were managers on the penalties that would apply to the trust if it missed targets – and, might we also suggest, on the financial and prestige rewards for exceeding them – that everything else took second place. This included patients' lives.

And while blame undoubtedly attaches to weak managers at every level, and to medical staff who lacked common humanity, those who set the targets also bear some responsibility. Scarcely a target has been set in any organisation that does not eventually have some unintended consequence. Organisations are notoriously adept at re-orientating their paper priorities to fit the criteria required.

Not so long ago, the manipulation of waiting lists was found to be almost endemic across the NHS. Mixed wards were "abolished" by the fiction of curtained partitions. In local government we have seen how Haringey social services contrived to tick all the Government's boxes, while grievously mishandling the case of Baby P. The performance of others, including Doncaster, is now being reassessed.

The revelations about Stafford Hospital are likely to fuel the growing backlash against the so-called target culture. Not that targets are intrinsically bad: a government service, like a business, needs to track how costs relate to results; it needs a gauge for improvement. But they are no substitute for either humanity or common sense, and no excuse for failing to exercise judgement. Once targets take precedence over decisions of life and death, it should be obvious that they have got out of hand.

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