What will replace targets and terror?

Catherine Foot

The new Secretary of State’s revisions to the 2010/11 NHS Operating Framework have been published today and, as expected, the government is scaling back access targets.

Central performance management is to be taken away immediately from the 48-hour target for primary care and the 18-week target for elective care. The four-hour A&E target gets a stay of execution, but only for the rest of this year, and with a reduced threshold of 95 per cent. The goal is to free the NHS from ‘clinically unjustified’ process targets and their associated bureaucracy, so that it can focus more on other aspects of quality, particularly clinical outcomes.

So how will providers respond to these changes? The temptation to allow waiting times to rise, particularly given the pressure to make financial savings, will be strong. 

However, the Secretary of State is at pains to stress that this is not the message he wants to send, saying, ‘this is not a signal that a deterioration of patients’ experiences is acceptable’ and, with a double negative, ‘this is not a signal that clinically unjustified waits are acceptable’. In other words, while the pressure from the centre is gone, providers should still see enabling patients to get prompt access to care as important.

Free from departmental diktat then, how will providers be held to account for their waiting times in future? The theory is that a combination of local GP-commissioners, greater publicity about waiting times and other performance measures, and patient choice will together deliver local accountability and ensure that waiting times do not rise.

But the NHS does not have a strong track record on effective local accountability, and we know from our recent research that patient choice has yet to succeed as a lever to improve quality.

A non-executive director of a trust I know recently described the strength of the signal on waiting times from the Department of Health as being like having Wembley next door on cup final day (maybe that should be updated to a stadium full of vuvuzelas); the signal coming from patient choice and patient feedback is more like having a mouse in the corner of the room.

Shifting this balance of power to patients will take time, and may never deliver the same powerful incentives that central targets have done. Removing targets will certainly cut bureaucracy, and avoid the risk of hitting the targets, but missing the point. The big challenge now is to amplify the voice of patients and the public that will take their place.

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