Please give us objectives we can aim at
Authors: N. W Goodman
Journal: Journal of the Royal Society of Medicine (2002)

In July, our trust circulated a summary of the Department of Health's SR2002 Public Service Agreement. Appearing originally in the NHS Plan, there are twelve detailed objectives, grouped under three general objectives, which have the overall aim of transforming the system to produce a better service that delivers better health. The summary, on one side of A4, was accompanied by the curt note that these were ‘service standards which the Trust is required to achieve over the next few years’.

Some of them are no more than a modern health service should provide. To cut the maximum wait for hospital treatment to three months is reasonable, although achieving this by 2008 could be a struggle. Similarly for a maximum wait of 4 hours in A&E, intended by 2004. Listing these in isolation as the first and second objectives makes them sound easier than they are. It's not just a question of better A&E facilities, and of more surgeons and more operating theatres. We can expect emergency admissions to continue their inexorable 7% annual rise between now and 2004 and 2008. There will also have to be investment in residential care for the elderly and a reversal of the inability of families to look after aged parents at home. Objective 8 intends exactly that—to improve the quality of life and independence of older people—and would help relieve the constant frustration caused to surgical staff by factors outside their control, such as an inability to do their work because of blocked beds.

But we know what to do to achieve these objectives, which makes them good objectives. Provided that we are given the means at least to aim at them, staff will feel they are worth aiming at. This is not true for some of the other objectives.

We have to ‘enhance accountability to patients and the public’ (how are patients and public different?) and ‘secure improvements in patient experience as measured by independently validated surveys’. We already produce leaflets for everything (which many patients do not read), and the Government is determined to produce a public record of our performance, although except for surgeons nobody has a clue what information will be relevant. What further ‘accountability’ do they want? Is this working towards adherence to protocol-driven NICE-approved medicine? We can understand what is required when we are asked to do more operations or see patients more quickly; but what is accountability and where does it end? And as 85% of people in any survey are satisfied, there will never be evidence of improvement—especially as the recent upsurge of complaints in all spheres of life is a sociological phenomenon, on which the best intentions of healthcare staff will have no effect.

So this objective—number 5 on the list—is intangible. Staff can have a go, but are likely to feel a lack of direction, and vulnerability to sudden changes in opinion by those who judge them.

The sense of hopelessness increases with the need to reduce mortality from heart disease and cancer in the under-75s. Yes, we can increase the prescription of statins and start using expensive cancer drugs, but real reductions depend on our patients, not on us. We can exhort people to stop smoking, but it doesn't seem to work. Even if they do stop smoking, they over-eat and don't take enough exercise. We can encourage, but we cannot coerce, and why should we? People make choices. Funnily enough, the percentage decrease in mortality that is demanded—these are ‘service standards which the Trust is required to achieve’—is 40%, the same percentage Virginia Bottomley wanted for the period 1992-2000 when she put her signature to the Conservatives' The Health of the Nation.

And then, we are told to reduce pregnancies in the under-18s. A recent systematic review has concluded that we simply do not know how to do this: none of the current strategies work. Setting unrealistic objectives is bad; setting objectives that are beyond the system's capabilities is worse; but there can be few things more demoralizing to a committed workforce than setting objectives that depend on knowledge we do not yet have.

In the early 1960s, President Kennedy declared that the USA would land a man on the moon by the end of the decade. The scientists and technicians knew how to get to the moon; they were given the resources, and they did it. President Nixon tried the same thing with curing cancer in the 1970s. This failed not because there was not enough money or enough scientists or doctors, but because nobody knew how to do it. The Department of Health needs to sort out what its healthcare staff can realistically achieve, and encourage us to achieve it. There is nothing wrong with wanting to improve other things as well, but let's be realistic. Let's be pleased if those other things do improve, but not pretend that we necessarily had anything to do with it, nor saddled with guilty consciences or blamed for failure if they continue much as before.