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EDITORIALS: Donald M Berwick Measuring NHS productivity BMJ 2005; 330: 975-976 [Full text]

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NHS targets can be counterproductive

R Lewis   (14 May 2005)

NHS targets can be counterproductive 14 May 2005
R Lewis, Consultant cardiologist Yorkshire Send response to journal: Re: NHS targets can be counterproductive	In his article, Berwick asks "how much health for the pound, not how many events for the pound". Recent experience in my clinics suggest that pressure to meet NHS targets can be counterproductive. The following history is based upon the cases of several patients seen over recent months (but does not relate to any one specific individual). A middle-aged female patient developed non-specific chest pain and requested an urgent appointment with her GP. The only available appointment was with a locum, who doesn't appear to have felt that her pain was cardiac in origin, but referred her to the hospital angina clinic "as a precaution". In order to meet the "two week" rule, the consultant cardiologists were unable to see all new referrals to the angina clinic themselves and she was seen by another locum doctor who, at that stage, had relatively little experience in cardiology. He, too, felt that her symptoms were unlikely to be anginal but, through lack of confidence and over-zealous adherence to guidelines, organised an exercise ECG. The exercise ECG showed widespread ST segment changes, but without associated chest pain and was returned to the consultant for reporting. He confirmed the presence of significant abnormality; mindful of the fact that his clinics were overbooked for many months ahead he listed her directly for coronary angiography, intending to review her formally at that time. After waiting for 9 months, she was offered an appointment for angiography at a different hospital under a "waiting list initiative". The procedure was undertaken by another cardiologist whose report to the referring cardiologist stated that there was no significant coronary disease. The report was copied to the general practitioner and no further appointments were arranged at that time. However, because of persisting symptoms she was referred back to the angina clinic approximately 6 months later for "reassessment" culminating in yet another "false positive" exercise ECG. Despite a lot of clinical activity, all of which was undertaken within target waiting times, her care was fragmented, unco-ordinated and inappropriate. Had she presented, say 5 years ago, she may have waited longer for her initial appointments but it is more likely that she would have been seen at the outset by an experienced GP or consultant who, on the basis of a thorough history, may well have decided not to investigate further. Relatively little clinical activity would have been recorded but there would have been an infinitely better clinical outcome at minimal cost. Activity data is not necessarily a good index of quality of care: "activity is not to be confused with progress" Competing interests: None declared