David Hare is Chief Executive of the Independent Healthcare Providers Network
David Prior, former Conservative Health Minister and now chair of NHS England, has never been one to mince his words.
But his recent comments that NHS targets have “had their day” raised many eyebrows in the health world, not least given he was speaking on the same day where hospital A&E performance reached its worst level on record.
The NHS hasn’t met it’s four-hour A&E target since summer 2015, the 18-week referral to treatment target for elective care since 2016, and the 62-day Cancer target has not been consistently met since 2013. But does this necessarily mean that these targets have “had their day”?
Before we address this, it’s worth looking back at why NHS access targets were introduced in the first place. This year marks the 15th anniversary of the introduction of the 18-week target for elective treatment in the NHS, which stipulated that 95 per cent of patients should not wait longer than 18 weeks between a GP referral and receiving hospital treatment (now downgraded to 92 per cent) for procedures such as hip and knee replacements and cataracts.
While there was significant uncertainty about whether this could be achieved, with people waiting as long as three years for care at the time, a combination of the introduction of the target, more money, and added capacity through the private sector radically reduced average waiting times for patients accessing NHS care.
At the heart of this target was the simple aim of freeing people from pain and discomfort. Waiting for care is not just inconvenient: in delaying a patient’s treatment by months or in some cases years, it can lead to a patient’s condition deteriorating and even to severe medical complications.
Equally, the four-hour A&E Standard was introduced into the NHS in England in 2004 as a measure to combat overcrowding in emergency departments, which has consistently been associated with increased mortality and long hospital stays.
In addition to ensuring that patients receive timely and safe care, waiting time targets are also key in ensuring accountability. They give patients and the public clear information on what their taxes are being used for and what they can expect from the Health Service, as well as providing a clear incentive for hospitals to make care as accessible as possible. All key principles which any health service fit for the 21st Century should surely adhere to?
Another target in Lord Prior’s recent speech was the “dysfunctional” and “deliberately fragmented” system, which he argued had been a feature of the NHS for the last 25 years and which fostered ‘competition’.
Again, these points are worth considering, for many NHS patients will recognise Lord Prior’s description of care fragmentation. Too often they have to repeat their stories to different healthcare professionals and find that communication between different parts of the service has fallen down.
But the key to ending fragmentation is not removing the ability of NHS commissioners to tender services where there is persistent failure or a lack of existing capability, but to actually solve the real barriers to joining up services.
This would include: ensuring information is shared so that clinicians have a full picture about a patient’s health; coordinating appointments so that patients don’t have to make multiple visits on different days to different places; and addressing patients’ needs in their totality and signposting them towards other sources of help.
Unfortunately, the debate around “integration” can tend towards prioritising incumbency and monopoly provision over quality and sophisticated supply chain management. If combined with a watering down or wholesale removal of targets, this would make it nigh on impossible either for the public to know how the NHS is performing or commissioners to drive service improvement on behalf of patients.
As Matt Hancock, the Secretary of State for Health and Social Care, said at the Health Select Committee last month, the key question for health services is “how to get the best integration you can while retaining accountability… otherwise you are just giving an area a large amount of money and saying, “Do your best.””
With an extra £20 billion being invested into the NHS over the next five years, it’s never been more vital that the Health Service is as transparent as possible and has clear mechanisms in place to drive up performance. Whilst imperfect, targets and competition can and do play a big role in improving patients’ experience of the NHS, and as it evolves to meet the future needs of the population and improve the coordination of care services, they must not be replaced by opacity and unresponsiveness.