SVMPharma NHS - Is it time to get rid of NHS targets?
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Transcript of SVMPharma NHS - Is it time to get rid of NHS targets?
Is it time to get rid of NHS targets?
SVMPharma Ltd
CONTACT US [email protected]
+44(0) 1252 417030www.svmpharma.com
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
Tel: +44 (0) 1252 417030
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