Measuring NHS productivityBMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7498.975 (Published 28 April 2005) Cite this as: BMJ 2005;330:975
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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
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"
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: No competing interests