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Is it time to get rid of targets?

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Concerns have been raised that continuing government focus on targets for the NHS is having a negative effect on nursing care.

NHS targets have so far been the bedrock of the new Labour government’s plan to improve the health service.

Inheriting waiting lists that exceeded two years in some specialties, the government decided that targets could be used as the stick with which to bring NHS organisations into line, reduce waiting lists and win votes in the process.

Media stories of patients waiting for hours on trolleys in emergency departments were commonplace in the 1990s, as were reports of ‘bed-blocking’ – officially termed delayed discharge – with patients unable to leave hospital due to lack of resources in the community.

Ten years on and the picture has changed. NHS organisations are more or less meeting the A&E four-hour target and delayed discharges have, the Department of Health claims, largely disappeared.

The heat is now on to meet the 18-week GP referral to treatment target by December 2008 in England, which the government says it is confident the NHS will do. Additionally, the Scottish Government said last week that it too had significantly reduced the number of people waiting 18 weeks for either a first appointment or inpatient treatment under its own target system (NT News, 3 June, p5).

However, the question remains as to how much the emphasis on meeting such targets, while supposedly benefiting patients, is actually having the exact opposite effect and jeopardising quality of care and patient safety.

An opinion paper, commissioned by the NHS Confederation, last week argued that compassion was missing out at the expense of policies based on incentives and penalties.

Meanwhile, the RCN has warned that targets could be having a negative impact across the board, from infection control to patient dignity. It is so concerned about the drive to meet the four-hour A&E target that it has launched a campaign calling for it to be lowered from 98% of patients being seen within the time-frame to 95% (NT News, 27 May, p2).

A recent college survey showed that 78% of 500 respondents said they believed the target had led to the care of patients with complex or multiple needs being rushed or compromised.

Although half of the respondents admitted that the target had some positive impact on care, 75% said patients were regularly admitted to inappropriate wards in order to meet it.

In an interview with NT in April, RCN president Peter Carter expressed his personal concerns about the A&E target. ‘Sometimes people are being moved on to meet the four-hour target when people know, if they could be left there another hour, something more sensible could be sorted out,’ he said.

He suggested patients would understand the practicalities of the situation if it was busy or a major accident came in. ‘I believe that if it’s explained to a member of the public that: “look

I’m sorry you’re coming up to four hours but actually you will be sorted out in the next 35 minutes”, I think most people would say: “yeah fine”. So I do think a reappraisal of that would be in everyone’s interests.’

Earlier this month, representatives from the RCN met with Sir George Alberti, the government’s national director for emergency care access, to discuss their concerns about the inflexibility of the A&E target.

But Sir George refused to consider changes to the target, according to Mike Hayward, the college’s professional nurse adviser for emergency and acute care. As a result, the RCN is now seeking a meeting with a health minister to discuss the problem in greater detail.

It is not the first time the target has come under scrutiny. A report from the London School of Economics in February 2006 said it was hard to know if the targets had been beneficial due to ‘gaming’ by trusts – for example patients waiting in ambulances until staff were confident of meeting the target.

Anecdotal evidence collected by the RCN also suggests that infection control is being compromised as a result of the drive to meet the target, bringing it into conflict with another high profile area of concern.

Mr Hayward said: ‘Nurses are telling us that with so much pressure put on them moving patients from A to B, to C to D, wards are being cleaned but not as thoroughly as they would want them to be.’

This is not the view of everyone, however. A&E nurse Jim Rawcliffe, a clinical skills tutor at Manchester University, says nurses and their trusts
have had five years to get used to the pressures of meeting the four-hour target.

‘Some trusts, wards and individuals have not seen the need to make the types of changes to the wards to improve efficiency and help them meet the challenges the target brings,’ he says (Letters, p14). ‘Maybe the fault is not with the target but with the type of nurse who cannot adapt to change.’

However, RCN Scotland director Theresa Fyffe says she would like to see evidence gathered on how meeting targets affected patient outcomes. ‘We need to know what percentage of patients does it do more harm to or reduce the quality of their patient experience? I think the targets currently in place should be widely reviewed,’ she said.

Ms Fyffe adds that it is also important to listen to staff views about the effect of targets on the provision of services.

‘It is important to hear staff if they are saying they don’t believe that certain targets are in the best interest of their patients,’ she said.

Speaking at a conference in London last week on food in hospitals, RCN Nutrition Now project lead Debbie Dzik-Jurasz also warned that the A&E and other targets may jeopardise the provision of adequate food and nutrition for patients.

‘We are currently running a campaign to improve nutrition. Nurses are telling us that because of conflicting things like meeting targets, they often do not have enough time to provide safe nutrition,’ she said.

The DH, however, is clear that ‘clinical priority and high quality patient care’ remain their first considerations. A spokesperson told NT: ‘There is no evidence whatsoever to suggest improvements in waiting times have come at the cost of clinicians exercising judgement or at the expense of patient care.’

The DH was equally unmoved by concerns over targets jeopardising infection control. ‘Hospitals that do well on reducing waits are just as likely to have an improving record on healthcare-associated infections as those that don’t,’ the spokesperson said.

However, it could be argued that the time may have come to reappraise whether NHS targets should be so rigid and set centrally.

‘Targets in themselves have been helpful to an extent but there have been very clear unintended consequences as well,’ says RCN director of policy Howard Catton. ‘There needs to be some relaxation of absolute targets to take account of professional judgement and clinical need.’

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