Published 17 July 2008, doi:10.1136/bmj.39604.711146.47
Cite this as: BMJ 2008;337:a885

Views & Reviews

Harms of target driven health care

¹ Bristol Royal Infirmary, Bristol BS2 8HW

I went to listen to a senior member from the Department of Health explain the new "dogma" of target driven health care to our hospital’s consultant group. This was in 2005, as we were coming to terms with the fact of targets and with their use to drive healthcare performance. After her slick presentation I asked how the government was going to measure the harm that these targets would do to patient care. I remember being amazed at the skill with which that question was not answered.

From 2003 to 2006 I was associate clinical director of the emergency department at the Bristol Royal Infirmary. I soon realised that targets were here to stay, and led the unit to accept this and work with them. The phrase "I treat patients, not targets" was consigned to the past. We had to engage with the targets that had been set, and use them to attract the resources we needed to treat patients faster. We had a philosophy in the department that was forward thinking, aiming to find solutions rather than identify problems. The trust recognised this and supported us, and we met the 98% "four hour target" in 2006.

Two years on I believe that the harm these targets have done to patient care is becoming evident. Target driven care has undoubtedly changed the way we practise. However hard we try to remain patient focused, meeting targets is now the predominant driver. We are seeing that good staff, when made to work flat out to meet a deadline, will treat the clock rather than the patient. Of those patients being admitted, most leave the emergency department in the final 20 minutes of the four hour target period (BMJ 2005;330:1188-9; doi: 10.1136/bmj.38440.588449.AE). An internal audit was revealing. A cohort of patients who went to various outlying wards and who subsequently required management from the intensive care outreach team had left the department just before four hours. Without this time pressure they may have stayed longer, their condition made more stable better stabilised, and then transferred to a more appropriate clinical area.

A patient’s history has changed from one that strives to be holistic to one that is problem solving. A patient with chest pain is rapidly classified into "admit" or "discharge" categories, and "cardiac" or "pleuritic" decision routes.

Our ability to listen as medical staff is being challenged. There is now less time for the vulnerable, frightened, and inarticulate patients, who become objects of annoyance rather than subjects of care. It is instructive to stand in our clinical area and listen to the different assessments coming from behind curtains. We hear conversations in which open questions designed to help patients articulate their story are being replaced by closed, leading questions to categorise the patient into a convenient group.

More subtle assessment is lost. When I started in emergency medicine one of the hallmarks of the assessment of any patient with injury or illness was to discern "the story behind the story." Patients presented with one problem and then, having had the relief of analgesia, diagnosis, and care, would tell the story behind the story. This often revealed domestic violence, exploitation, and danger. Our inner city emergency department made regular referrals to housing, employment, or social services. This practice has now virtually ceased; there is no longer the luxury of time to practise such holistic care. The tragedy is that these patients are often vulnerable and need time to trust.

Another victim of targets is the subtle diagnosis. Targets encourage patients to be categorised into management pathways. The patient who doesn’t quite fit and should alert the astute clinician to something unusual, perhaps a rare diagnosis, is now more of an irritation than a fascination. In short, our ability to practise good medicine is undermined by the pressure of time.

It is my belief that targets, while achieving a great deal in terms of resource and timeliness, have done this at the expense of holistic patient care. Targets therefore detract from the pursuit of clinical excellence. I agree that we have more doctors and nurses. I agree that we no longer have patients on ambulance trolleys for hours waiting to be seen, or going to sleep overnight in the minor end waiting room. This is, however, a totalitarian argument in which the health economists argue that patient care for the majority has improved. We as doctors need to be the advocates of the individual in front of us at that time. That certainly is what the patient expects, and to compromise that for the sake of the majority is therefore poor patient care.

I have not considered here the increased stress to staff who work in the "cauldron" of acute care and receive regular requests to "work even harder." Nor has it considered the change in working practice and environment that makes teaching more difficult.

So, what of the future? A two hour target is now being proposed for emergency medicine. This will stir up controversy, but the momentum is there. It will happen, I fear. We must, I believe, ask questions of this. I accept that doctors are resistant to change, but sometimes that resistance is for good reason. Given the harms of target driven health care, it is surely wrong to introduce another more complex target into an already pressured emergency healthcare system.

The instigators of change need to listen to the professional healthcare workers on the front line who provide care and to report this back. The problem is that the present regime is so set in its self belief that this is unlikely to happen. It reminds me again of the government representative who so expertly ignored my question three years ago.

Cite this as: BMJ 2008;337:a885

---

Competing interests: None declared.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    StumbleUpon    Technorati    What's this?

Relevant Articles

Target driven excuses

Irving Cobden
BMJ 2008 337: a1255. [Extract] [Full Text]

The world is watching the English experiment

Fiona Godlee
BMJ 2008 337: a953. [Extract] [Full Text]

Analysis of the distribution of time that patients spend in emergency departments

Thomas E Locker and Suzanne M Mason
BMJ 2005 330: 1188-1189. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

• Rawlinson, J N (2009). Harms of targets. Emerg. Med. J. 26: 389-389 [Full text]  
• Cobden, I. (2008). Target driven excuses. BMJ 337: a1255-a1255 [Full text]  

Rapid Responses:

Read all Rapid Responses

...or harm of Medic driven management?

stephen black
bmj.com, 31 Jul 2008 [Full text]

Target driven excuses

Irving Cobden
bmj.com, 6 Aug 2008 [Full text]

Online poll

Find out more >>