Hospital treatment targets have been simplified

BMJ 2015; 350 doi: (Published 05 June 2015) Cite this as: BMJ 2015;350:h3090
  1. Gareth Iacobucci
  1. 1The BMJ

Key NHS targets on waiting times for planned treatment in England are to be abolished, after healthcare leaders adjudged that they were creating “perverse incentives” that penalised patients.

In a letter to health service leaders NHS England’s chief executive, Simon Stevens, said that the current target for patients to receive planned treatment within 18 weeks of being referred by a GP would be simplified to reduce the number of targets from three to one.1

At the moment the target is measured against three standards: in a particular month, the percentage of patients admitted to hospital who started treatment within 18 weeks of referral; the percentage of patients who weren’t admitted who started treatment within 18 weeks; and the percentage of patients still waiting to start treatment at the end of that month who had been waiting more than 18 weeks. The third standard was introduced in 2012 to include every patient on the waiting list, not just those treated in that particular month.

NHS England has now decided to retain the incomplete pathways standard and abandon the admitted and non-admitted standards on the grounds that they penalise hospitals for treating patients who have waited longer than 18 weeks. Making the recommendation,2 NHS England’s national medical director, Bruce Keogh, said, “As soon as a patient has crossed this threshold, a hospital will effectively receive a black mark for treating them. While hospitals may be the ones penalised directly, the true penalty is for the patient. This cannot be right.”

Keogh added, “It has become increasingly clear that within this confusing set of standards there are inbuilt perverse incentives.

“This approach will be simpler [and] more focused, and most importantly it will ensure the NHS concentrates on treating all patients as quickly as possible.”

Keogh’s recommendation to review use of the current target requiring at least 95% of patients to be seen in emergency departments within four hours to potentially include a wider range of clinical measures has also been accepted.

Stevens said that NHS England would implement the changes as soon as possible.

Responding to the announcement, the NHS Confederation’s chief executive, Rob Webster, said, “Simplifying hospital waiting time measures so that providers are no longer penalised for doing the right thing for patients is a welcome step.

“Our members have told us that we need targets which are evidence based, reflect what matters to patients, and don’t create unnecessary paperwork or perverse incentives.”

Nigel Edwards, chief executive of the health policy think tank the Nuffield Trust, also welcomed the move. He said, “Focusing on those still waiting for treatment rather than the numbers of patients treated within a given timeframe makes perfect sense. This should provide a more patient focused measure of care.

“Our recent analysis revealed that problems meeting the 18 week referral to treatment target and the four hour A&E [accident and emergency] target over the past year has affected both the best and worst performing hospitals, suggesting these problems are systemic rather than due to local or managerial failings. This highlighted the need to have a more nuanced approach to managing hospital performance.

“Moreover, we have raised real concern over the negative impact that the reporting culture associated with multiple and high profile targets can have on staff behaviour and, ultimately, on care quality.”

Edwards added, “The proposal to consider the four hour A&E target alongside other clinical measures is therefore also a very positive development. Our analysis suggests this target—which has come to loom above all others in significance—should be viewed alongside richer indicators such as time to treatment, four hour ‘trolley waits,’ and seven day readmission rates.”


Cite this as: BMJ 2015;350:h3090


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