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Abolishing “politically motivated targets”. One year on, when is a target a target?

Filed Under (BMA, Health Improvement, Kings Fund, Narrative of reform, Reform of the NHS, Secretary of State) by Paul on 25-07-2011

One of the constant conversations that the current Secretary of State had with the leadership of doctors’ organisations over the six years of his apprenticeship as shadow secretary of state concerned how much they hated waiting times targets.

From 2001 onwards they had railed ineffectually against a Government that won the 2001 and 2005 elections partially on the promise to reduce maximum waiting times for NHS patients. The capability and capacity of the NHS to reduce maximum waiting times was one of the core public reform narratives that brought about change in the NHS over that period.

From 2001 the two ‘sides’ in the narrative were clear. Doctors’ leaders said that the targets set by Government for maximum waiting times by NHS patients – initially at 9 months then 6, and finally at 18 weeks, and the setting of a maximum 4 hour wait at A & E – were all political.

The Government pointed to clear popular mandates for maximum waiting times and claimed that they were mobilising the NHS to provide something that the public really wanted.

Doctors’ leaders claimed that the interference in their right to make decisions by politically motivated waiting time targets was at times wrong for the patients and mobilised media stories to demonstrate that this happened.

The Government pointed to people who did not die while awaiting treatment.

The two narratives clashed for 9 years, and over those 9 years two things happened.

First the NHS succeeded in hitting all of the waiting times. Most commentators and many in the NHS felt that this was not possible. But the NHS demonstrated that as an organisation they could achieve something that most people thought they could not.

Second, the doctors’ leaders lost the battle. An unusual experience for them. But they failed to understand why, on this occasion, they had lost. They lost because reducing maximum waiting times was important to a bigger constituency than the BMA – the public. Throughout this period the Government knew that the reduction of maximum waiting times was the most important public expectation of the NHS.

Throughout the last 6 years of this period, 2004-2010, the current Secretary of State was shadowing the job. He promised that if he became Secretary of State he would abolish politically motivated targets. The leaders of doctors’ organisations loved this promise and it became the first and most significant part of every speech that was made.

The election was won and within weeks the promise made to doctors’ leaders was kept. The new Secretary of State believed that by removing their main irritant – the maximum waiting times targets – doctors’ leaders and the leadership of the BMA would in some way be grateful. This may have been the biggest shock that the new Secretary of State had in his first year. Because with hindsight all of the year on year fuss about reducing ‘politically motivated targets’ seemed not to matter very much. It gained the new Secretary of State no political capital at all with the doctors’ leaders -zero.

In fact over the last year something odd has happened…

First, something that was not odd at all. When the new Strategic Communications Director was appointed to Number 10 in March 2011 he quickly found out from his polling that the one thing about the NHS that really matters to the public is the fear of having to wait a long time for treatment. He reported to his boss that if, over the next few years, there is an increase in maximum waiting times for NHS patients and the public think this has been caused by the abolition targets for waiting times – the public will blame the Government that did away with the targets.

Their reasoning is simple. When there were targets we didn’t have to wait a long time. When the targets were abolished some of us started to have to wait a long time. We don’t like waiting a long time – so the abolition of targets was a mistake.

So in June, in his last speech on the NHS during the policy pause, the Prime Minister (who is a politician) said that they would not let waiting times for NHS patients rise. He and his Government would be looking at them and expecting them to stay low. So within a year the abolition of targets was abolished.

The second thing that has happened is a bit odder. The leadership of doctors’ organisations have had a successful year in turning over a Government. But this summer they recognised that the big issue coming was not the number of hospital doctors on each clinical commissioning group, but the fact that demand for NHS health care is rising faster than the resources required to meet it. This, more than any structural change, is going to change the way in which doctors have to work.

From now on in we will see a lot in the media from doctors’ leaders about ‘cuts in the NHS’ and a lot of argument saying that things are getting worse.

One of the strangest examples of this will be their comments on the way in which maximum waiting times are increasing. Earlier this month the King’s Fund issued a report that showed,

“While they (waiting times) are still low by historical standards and median waits for diagnostic tests and hospital treatment remain reasonably stable, waiting times have risen against a number of key target measures since the coalition government relaxed performance management shortly after coming into office.”

We are going to see at least three more monthly reports on waiting times between now and the next election. If the public experience them as rising, and there is statistical evidence that this is true, the Government will pay a political price for ‘abolishing targets’ (even if they think they haven’t).

But how did doctors’ leaders comment on this? Did they say that having such a target was an irrelevance to their patients? No, they said that it was wrong for patients to wait a long time for treatment. And that rising waiting times would be a sign that the Government was not putting enough resources into the NHS.

This is one of the reasons why the current Secretary of State reaches the Parliamentary recess not a little puzzled. He did after all give the doctors’ leaders exactly what they had said they wanted for 6 years – the abolition of politically motivated targets.

They didn’t seem at all grateful.

Now, a year on, they are attacking him for any lengthening of waiting times.

I wonder if he ever thinks he may have chosen the wrong allies for his reform of the NHS?


2 Responses to “Abolishing “politically motivated targets”. One year on, when is a target a target?”

  1. The trouble with the waiting time statistics is the myriad of ways they can be interpreted to tell essentially whatever story is needed.

    Take the overall 18 week waiting time. It is unlikely that this will drop much below 90% because the majority of conditions have a waiting time much less that 18 weeks. However, if you take some of the more expensive areas such as knee and hip replacements you can clearly see the drop in patients treated within 18 weeks since the June 2010 announcement that the government would stop actively monitoring the target. I would insert some charts to demonstrate if I knew how to but you could check my twitter feed @ssentif to see.

  2. Also worth noting the NHS has just introduced a much more detailed set of “clinical indicators”, targets by another name, for A&E services. Clearly clinical leaders in DH have believe this is how to raise standards.

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