Is it time to get rid of NHS targets?

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IS IT TIME TO GET RID OF NHS TARGETS?

© 2015 SVMPharma Ltd. All rights reserved. 2

Contents

EXECUTIVE SUMMARY 3

THE CASE FOR TARGETS 4

KEY NHS TARGETS 4

THE JURY IS STILL OUT 5

CONCLUSION 6

REFERENCES 7

IS IT TIME TO GET RID OF NHS TARGETS?

© 2015 SVMPharma Ltd. All rights reserved. 3

Executive Summary

Every organisation large or small works to set targets and the NHS is no different .

Working to targets has become a part of NHS work culture and a daily reality for the

managers, administrators, and commissioners responsible for health service delivery .

Indeed many of these targets are to be found in the NHS constitution and enshrined in

law as part of the patient rights regarding what they can expect from the health

service.1

There are severe financial penalties for missing targets and even though hospitals

work hard to avoid these, inevitably many find themselves in breach of one target or

the other. Only last month the media reported that hospitals in South West England

were fined millions of pounds over missed targets despite some of them battling huge

deficits.2 NHS data made available in the same month revealed that the NHS in

England met its A&E waiting time target for the first time since the previous

September. The desired 95% target had been missed for 33 weeks consecutively .3, 4

Where majority of trusts are failing to meet this and other targets, perhaps the time is

right for reform.

This article identifies and defines some key targets which feature in current discourse

about the NHS and questions their relevance to the realities facing the health service.

Maintain targets in areas where evidence

shows that they drive quality

and enhance performance

Less fixation on a single unit of

measurement when

evaluating performance

Allow for

local flexibility (within acceptable limits) when evaluating performance

Setting targets without adequate investment in

infrastructure and workforce places undue stress on NHS staff and can result in harm to patients

Targets which focus on

patient outcomes can be inherently more motivational to staff

5 ways to make targets work

IS IT TIME TO GET RID OF NHS TARGETS?

© 2015 SVMPharma Ltd. All rights reserved. 4

The case for targets

ince the inception of the NHS, different

governments have introduced various policy

initiatives to improve service quality and

outcomes within the organisation. Many of the

targets which exist today were introduced in the

late 1990s and early 2000s by the New Labour

government that set about to rigorously pursue a

regime of performance-driven targets in order to

combat falling efficiency and quality standards in

the NHS.5,6 Targets are used by NHS commissioners

as a mechanism to drive operational performance

and improve financial accountability of health

service providers and

there is some evidence

to show that strict

implementation of

targets can lead to

improved

performance. The

targets introduced by

the government in the

early 2000s are

credited for significant improvements in treatment

waiting times in England in the years following

their introduction.7 However, missing targets can

have significant financial or reputational

implications for the organisations affected. In

2014, according to a Channel 4 Dispatches

program, more than £1 billion pounds had been

withheld from NHS hospitals in England since 2010

as penalty for not achieving set targets, effectively

depriving these hospitals of much needed

finances.8 This serves to highlight some of the

controversy that has accompanied the widespread

use of targets in the NHS and raises the question

whether withholding funds from hospitals, many of

which already operate under huge financial

constraint, may be counter-productive.

Key NHS Targets

The most high profile targets used in the NHS are

those that relate to the time which patients have

to wait before they receive care. Key amongst

these is the four hour Accident and Emergency

(A&E) waiting time target, a standard contractual

requirement for all NHS hospitals.9 The four hours

measures the time from arrival at the A&E unit to

admission, transfer or discharge, and hospitals are

expected to see 95% of attending patients within

this time. This target is considered by many to be

the NHS’ flagship target because it is seen as an

indicator (rightly or wrongly) of NHS overall

performance. It has been the subject of increased

media scrutiny recently because of a consistent

breach by hospitals. Last winter’s A&E waiting

times were reported to be at their worst levels in a

decade.10 Also, in February 2015, Monitor, the

health sector regulator in England, reported that in

the third quarter of the 2014/15 financial year,

there was an unprecedented increase in the

number of NHS foundation trusts that breached

the A&E target when compared to the same period

in the previous year (from 33 to 66).11 See Figure 1.

Figure 1- Number of Foundation Trusts breaching A&E target. (Source: Monitor 2015)

Another key waiting time target is the 18-week

referral to treatment time. This target protects

patients’ right to gain access to consultant led

treatment for non-urgent conditions within a

maximum of 18 weeks from referral. This right is

protected in law and applies to both inpatient (for

procedures that require a stay in hospital) and

outpatient (routine and minor procedures which

only require a day visit to hospital) referrals.12

Hospitals are expected to provide treatment for

90% of inpatients and 95% of outpatients within 18

weeks of referral from their GP. In 2012, a third

referral to treatment standard known as the

‘incomplete pathway’ was introduced to measure

all patients still waiting at the end of each month.

Its purpose was to incentivise hospitals to treat

those patients who had waited the longest, and

S

Missing targets

can have

significant

financial or

reputational

implications for

the organisations

affected

IS IT TIME TO GET RID OF NHS TARGETS?

© 2015 SVMPharma Ltd. All rights reserved. 5

stipulates that 92% of all patients waiting to start

treatment should have been waiting for no more

than 18 weeks.13 Barring a dip in performance

when these targets were suspended by the

coalition government in 2010/11, they have largely

been met since their introduction in early 2010.14

However, recently the NHS has struggled to

maintain this trend and since 2014 there has been

a slight decline in performance below set levels.15

See Figure 2.

Figure 2- Percentage of Foundation Trust patients seen within 18 weeks (Source: Monitor 2015)

Closely linked to the 18-week referral target is the

diagnostic waiting time target which measures the

time it takes to wait for a diagnostic test after

referral. Current guidance states that patients

waiting for a diagnostic test are expected to wait

for no more than 6 weeks after referral and

hospitals are expected to offer tests to 99% of

referred patients within this timeframe.16 Meeting

the diagnostic waiting time target has a significant

impact on achieving the 18-week referral target

and this may be a reason why many hospitals tend

to perform relatively well on this indicator.

Within the NHS, cancer patients can expect to be

seen and receive treatment more quickly.

Consequently, there are numerous cancer waiting

time targets. Prominent amongst these are the

following: 17, 18

(a) A maximum two-week wait for urgent GP

referrals to a specialist where cancer is suspected

(otherwise known as the two-week pathway).

Providers are required to meet a target of 93% of

patients referred via this pathway.

(b) A maximum 62-day wait to the start of

treatment for patients who receive a positive

cancer diagnosis via the two-week pathway in at

least 85% of these patients.

(c) A maximum 31-day wait from diagnosis to first

definitive treatment for all cancers (irrespective of

the referral pathway). Performance on this

standard is measured against a 96% target.

Cancer is an emotive

subject and NHS

performance on cancer

treatment often

generates a great deal

of attention. Recent

analysis by Macmillan

Cancer Support, a

prominent cancer

charity (which showed

that UK five year

survival rates for many common cancers were

‘stuck in the 1990s’ when compared against those

in many other European countries) has brought the

disease into even sharper focus.19 The report also

coincided with release of data which showed that

some NHS cancer waiting time targets had been

breached.20

The jury is still out

The jury is still out on whether targets are good for

long term sustainable performance or not.

Advocates maintain that targets have been

associated with significant improvements in

service delivery and that without them the quality

of NHS care would rapidly fall to unacceptable

levels. As an example, they highlight the marked

rise in the number of patients that waited for

longer than usual to receive NHS treatment

following the suspension of the 18-week referral to

treatment target in 2010.21 The government was

forced to re-instate the target in an attempt to

reduce the number of patients that had waited for

treatment for longer than 18 weeks.22

On the other side of the divide, there are questions

about the clinical justification behind many targets

and the argument that too much focus is placed on

them to the detriment of other outcomes based

measures of care (which may be more meaningful

to patients and clinicians). The view is that while a

Cancer is an

emotive subject

and NHS

performance on

cancer

treatment often

generates a

great deal of

attention

IS IT TIME TO GET RID OF NHS TARGETS?

© 2015 SVMPharma Ltd. All rights reserved. 6

heavily target driven healthcare system may result

in short term positive improvements in care

processes, these gains are cosmetic and often fail

to tackle underlying systemic inadequacies and

hold back real transformation of the health service.

Moreover, it seems rather contradictory that

hospitals continue to be hit with huge fines for

missing targets at a time when NHS service

providers find it hard to juggle responsibilities and

balance books. See Figure 3.

Figure 3 - Trusts in deficit (Source: The Kings Fund 2015)

Although local Clinical Commissioning Groups

(CCGs) are charged with redirecting monies

obtained from fines to other parts of the NHS,

hospitals have little say about how these funds are

administered.

Conclusions

It is not a bad thing for the NHS to maintain targets

in areas where there is evidence to show that they

drive quality and enhance performance. However

a more sustainable approach requires less fixation

on a single unit of measurement and greater

opportunity for local flexibility (within acceptable

limits) when evaluating performance. For instance,

while evidence shows that people who stay longer

at A&E have worse outcomes,23 there is no

apparent justification for making a maximum of 4

(or indeed 3.5 or 5) hours the acceptable period of

time for all patients

to wait before

receiving treatment

at A&E. It might be

more productive for

both patients and

clinicians if hospitals

are allowed to

exercise some

flexibility based on

clinical priority. In

addition, the introduction of targets that focus on

patient outcomes can be inherently more

motivational to staff and help to identify areas

where locally relevant improvements to care might

be made. The NHS Friends and Family Test which

aims to measure the experience of care amongst

patients and NHS staff is a step in the right

direction, when managed properly and with some

degree of local flexibility.24

Finally, setting targets without adequate

investment in infrastructure and workforce places

undue stress on NHS staff and can result in harm to

patients as highlighted in the Francis Report on the

Mid-Staffordshire Hospital scandal.25 Simon

Stevens, Chief Executive of the NHS, acknowledges

that in order for the NHS to cope with ever

increasing demand and continue to make

efficiency gains, significant operational investment

is required.26 Without solid financial backing from

the government of the day, the NHS will find it even

harder to meet its commitments.

Hospitals continue

to be hit with huge

fines for missing

targets at a time

when NHS service

providers find it

hard to juggle

responsibilities and

balance their books

CONTACT US

Real World Evidence Influence Mapping Patient Experience Healthcare Data Analytics

IS IT TIME TO GET RID OF NHS TARGETS?

© 2015 SVMPharma Ltd. All rights reserved. 7

References

1. Department of Health. The NHS Constitution. 2013. www.gov.uk/government/uploads/system/uploads/attachment_data/file/170656/NHS_Constitution.pdf

2. BBC News. South west hospitals fined millions over missed targets. May 2015. www.bbc.co.uk/news/uk-england-cornwall-32773485

3. NHS England. Attendances and Emergency Admission. 2015 www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2015/04/2015.05.24-AE-TimeseriesTiCjx.xls

4. BBC News. A&E in England hits waiting-time target. Jun 2015. www.bbc.co.uk/news/health-32960499

5. Department of Health. The New NHS –Modern, Dependable. 1997 www.gov.uk/government/uploads/system/uploads/attachment_data/file/266003/newnhs.pdf

6. NHS. The NHS Plan - A plan for investment. A plan for reform. 2000. http://pns.dgs.pt/files/2010/03/pnsuk1.pdf

7. Connolly et al. Funding and performance of health care systems in the four countries of the UK. The Nuffield Trust. 2010. www.nuffieldtrust.org.uk/sites/files/nuffield/Funding_and_Performance_of_Healthcare_Services.pdf

8. Channel 4. £1 billion NHS funds withheld Channel 4 Dispatches. 2014. www.channel4.com/info/press/news/1-billion-nhs-funds-withheld-dispatches

9. NHS. The NHS Service Commissioning Board and CCG (Responsibilities and Standing Rules). 2012. www.nhs.uk/choiceintheNHS/Rightsandpledges/Waitingtimes/Documents/nhs-england-and-ccg-regulations.pdf

10. BBC News. A&E waiting in England worst for a decade. Jan 2015. www.bbc.co.uk/news/health-30679949

11. Monitor. Quarterly report on the performance of the NHS foundation trust sector. 2015. www.gov.uk/government/uploads/system/uploads/attachment_data/file/405880/BM1516_Quarterly_Performance_of_the_NHSFT_sector_amended_version.pdf

12. NHS. The Handbook to the NHS Constitution for England. 2013. www.nhs.uk/choiceinthenhs/rightsandpledges/nhsconstitution/documents/2013/handbook-to-the-nhs-constitution.pdf

13. House of Commons Library. Waiting Times for Hospital Treatment. Mar 2015. www.parliament.uk/briefing-papers/sn07009.pdf

14. Blunt et al. Access to hospital care: is the NHS on target? The Nuffield Trust. 2015. www.nuffieldtrust.org.uk/sites/files/nuffield/publication/policy-briefing-4-hospital-access-targets-web-version.pdf

15. The Kings Fund. What's going on in A&E? - The key questions answered. 2015 www.kingsfund.org.uk/projects/urgent-emergency-care/urgent-and-emergency-care-mythbusters

16. Department of Health. The Operating Framework for the NHS in England 2012/13. 2011.

www.gov.uk/government/uploads/system/uploads/attachment_data/file/216590/dh_131428.pdf

17. NHS England. Cancer waiting times. 2015. www.england.nhs.uk/statistics/statistical-work-areas/cancer-waiting-times/

18. House of Commons Library. Cancer: Waiting Times for

Diagnosis and Treatment. Feb 2015.

www.parliament.uk/briefing-papers/SN07043.pdf

19. Macmillan Cancer Support. Cancer survival in the UK and Europe, 1995-2009. 2015. www.macmillan.org.uk/Documents/AboutUs/Newsroom/10yearsbehind.doc

20. Mundasad S. NHS misses urgent cancer therapy targets for whole year. BBC News. Feb 2015. www.bbc.co.uk/news/health-31518817

21. Ramesh R. NHS waiting-time targets scrapped by Andrew Lansley. The Guardian 21 June. 2010. www.theguardian.com/politics/2010/jun/21/nhs-waiting-time-targets-scrapped

22. Campbell D, Ball J. NHS waiting times force coalition U-turn on targets. The Guardian. Nov 2011. www.theguardian.com/society/2011/nov/17/nhs-waiting-times-u-turn

23. Carter et al. The relationship between emergency department crowding and patient outcomes: a systematic review. Journal of Nursing Scholarship. 2014.

24. NHS England. Review of the NHS Friends and Family Test. www.england.nhs.uk/wp-content/uploads/2014/07/fft-rev1.pdf

25. The Mid Staffordshire NHS Foundation Trust Public Inquiry. Executive Summary. 2013. http://webarchive.nationalarchives.gov.uk/20150407084003/http://www.midstaffspublicinquiry.com/report

26. NHS England. Five Year Forward View. 2014. www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

CONTACT SVMPHARMA

Vaneet NayarDirector SVMPharma

enquiry@svmpharma.com

Tel: +44 (0) 1252 417030

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