Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Where is all this heading?
- T K S Ram (30 July 2003)
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NHS staff cheat to hit government targets- "target centred" medicine fails the patient.
- Anthony A D'Sa, Sapna Agrawal, Alistair Tindall, Alfred Franklin (1 August 2003)
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Targets and fraud allegations - more positive action needed from Dr Reid
- Nigel Dudley (16 August 2003)
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T K S Ram, Urologist Tunbridge Wells TN4 8AT
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The targets and league tables do not achieve anything, since nobody believes or trusts them. The star ratings do not achieve anything, since........ There are several managers in the NHS who do not achieve anything, since...... Mandatory clinical governance meetings do not achieve anything, since the majority....... I can't understand why the NHS is failing miserably!!! Competing interests: None declared |
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Anthony A D'Sa, Orthopaedic Department,SHO Princess Royal University Hospital, Farnborough Common, Orpington, Kent, BR6 8ND, Sapna Agrawal, Alistair Tindall, Alfred Franklin
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Editor - We read with interest your news item "NHS staff cheat to hit government targets, MP's say" - BMJ 2003;327:179 (26 July). Many readers will not be surprised to read of stories of wheels being removed to re- name a trolley as a bed, but there is a more serious side to this problem. Through the use of punitive targets, the government have tried to lead us from the gold standard of patient centred care to a new "target centred" brand of medicine. The targets seem chosen for their ease of measurement rather than their clinical effectiveness. Where is the evidence base for these targets? Why is the same target used for a minor graze as for a polytrauma case? In our experience we have had numerous examples of patients being admitted purely to avoid breaching the 4-hour Accident and Emergency wait. At best this has ended in an immediate discharge for an inappropriate admission with all the attendant increase in costs and decrease in free beds. At worst the patient is transferred without the resuscitation and immediate treatment they need. With such severe financial penalties associated with multiple breaches it is not surprising to hear these stories. As long A+E waits are due to understaffing, setting a magical 4- hour cut off will not improve patient care. We welcome MP's questioning the value of the targets. However they should not accuse NHS staff of cheating to overcome the ludicrous targets they have set. The only people really being cheated are the patients. We would be interested to hear if others amongst your readership have had a similar experience. Dr Anthony D'Sa - SHO Orthopaedics, Princess Royal University Hospital, Farnborough Dr Sapna Agrawal - SHO Accident and Emergency Mr Alistair Tindall - Orthopaedic SpR Mr A Franklin - Orhopaedic Consultant Competing interests: None declared |
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Nigel Dudley, Consultant in Elderly Medicine ST James's University Hospital, LEEDS. LS9 7TF
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A trust chief executive sanctions deliberate falsification and manipulation of waiting list performance data to hit Department targets. A chief executive effectively condones such actions by turning a blind eye. The trust's performance appears better on paper than it is in real life. The gaming, because that's what some people feel more comfortable calling deception and cheating, around performance data means targets are hit and star rating is influenced. Hypothetical scenarios or reality? The trust's true performance against government's targets is kept secret from the board's non-executives who make up the remuneration committee. They decide executive and senior manager pay awards and whether performance was good enough to merit payments beyond the government's fair pay guidance. The remuneration committee grants rises above the guidance limit. Performance bonuses are awarded in some cases. The decisions on using taxpayers' money on pay awards rather than frontline care and NHS modernisation has been influenced by the deliberate deception. The chief executive has signed the Department of Health's accountable officer memorandum and has thereby explicitly signed up to the standards of professional conduct laid down in the 1994 corporate governance codes for NHS boards. These demand trust, integrity, and honesty in relation to financial matters including pay awards. The chief executive is responsible for promoting adherence to such standards of professional conduct by all board members and managers. The senior managers and executives are aware that their pay awards are not based on true success in hitting targets but an illusion of success created by deliberate performance data manipulation and falsification. The pay awards are nevertheless knowingly accepted. Hypothetical scenario or reality? These stories come from a variety of public reports and investigations considered by the Public Accounts Committee. In January 2002 the MPs of the Committee of Public Accounts made repeated allegations to Department of Health civil servants that fraud could have taken place in relation to remuneration in NHS trusts involved in inappropriate adjustments to waiting list data. The MPs were told by the civil servants that there was no evidence. No NHS Counter Fraud Service investigation had taken place to accurately inform that response. Following the explicit fraud allegations made by the MPs the Department's ministers did not order a fraud investigation. When further evidence of deliberate data manipulation was uncovered a few months later the responsible ministers still failed to order a fraud investigation. In December 2002 the BMJ was told by a Department of Health spokesman that, "Whenever a suspicion of fraud arises concerning waiting lists and bonuses, which may have been paid to senior NHS staff, the NHS Counter Fraud Service (NHS CFS) will conduct a professional and objective investigation, as done with any suspicion of fraud in the NHS."[1] Were the MPs' suspicions of fraud in relation to waiting list deception not good enough in January 2002? None of the above inspires public trust and confidence in the way health service managers are held to account by trust management or even the Department of Health using the 1994 corporate governance codes. Nor does it inspire trust and confidence in the way fraud allegations are investigated by the Department. Dr Reid has already listened to concerns and taken positive steps to get NHS reform and modernisation back on track by dealing effectively with consultant problems. He now needs to deal swiftly and effectively with management accountability and regulation problems by: (1) introducing the register and regulatory body as proposed by Professor Sir Ian Kennedy and his team of experts following the Bristol Inquiry so that both the public and health service professionals can have trust and confidence in senior managers leading health services, and; (2) transferring responsibility for decisions about fraud investigations and prosecutions from the Department of Health to the office of the Attorney-General so as to remove any public concerns or suspicion of political interference in matters relating to possible NHS fraud. After Bristol the culture of the whole of the NHS should have changed to one of openness and honesty. That has yet to happen. Learning from past mistakes and proper reform of health service manager regulation rather than yet more codes is now required if the NHS is to move forward rather than be semi-paralysed by lack of trust and confidence in Health Department decisions. [1] Ferriman A. Health department to improve investigation of waiting list fiddles. BMJ 2002;325:1322. The views and opinions expressed are my own and do not represnt those of my employing organisation. Competing interests: None declared |
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