BMA Annual Representative Meeting: NHS targets are distorting clinical need
Authors: Linda Beecham
Journal: BMJ (2003)

Doctors believe that most of the targets imposed by the Department of Health do not benefit patients and are damaging relations between doctors and managers, between doctors and patients, and between GPs and hospital doctors. There was overwhelming support for a motion that said that the auditing of waiting times in emergency departments and the four hour target had a negative effect on the care of patients, and the meeting called on the BMA to lobby the government to change the system. Dr Emma Bywaters, who works in accident and emergency medicine, told the meeting that although she did not like patients having to wait for up to eight hours to be seen or treated, the requirement that all patients had to be dealt with within four hours was damaging. It might, for example, take more than four hours to resuscitate and stabilise a patient, and other patients might require observation before being admitted to a hospital ward. A specialist registrar in accident and emergency medicine, Mr Simon Eccles, said that patients were being hoodwinked. Many were moved to inappropriate wards to meet the target, and their care was being compromised. But Dr Andrew Fielden, a consultant anaesthetist in Reading, did not think that the four hour targets have a negative effect. The care of patients in his trust had improved with a careful use of audit. A project team had been set up, and the number of people being seen in less than four hours had increased. He pointed out that at night most emergency departments were staffed by senior house officers, so it was preferable for patients to be admitted. According to Dr Chand Nagpaul, a GP in north London, targets reflected only a small proportion of the work done in hospitals. They were unrealistic and did not measure what patients really needed. Although it was good that patients with suspected cancer were seen within two weeks, it was not good that they had to wait weeks or months for treatment. And he deplored what he called creative passivity, whereby patients were asked if they still wanted their operation. If there was no reply they were removed from the waiting list, and little attempt was made to follow them up. Managers are being put under pressure to achieve these politically set targets, and the BMA has condemned this pressure, which it believes sometimes leads to dishonesty. In his opening address to the meeting the outgoing chairman of council, Dr Ian Bogle, gave examples of some of the fiddling that managers had resorted to. Managers believed that their jobs would be on the line and they would be unemployed or unemployable. These fears were evidenced in the Panorama programme on 29 June in which many of the managers' views were given by actors because the managers feared they might be victimised (5 July, p 58). Dr Bogle called this an example of corporate bullying. Managers were honest people who were tempted to do things that they would not normally do, and he thought that the pressures were getting worse. He invited the government to discuss with the profession how to ensure that any target benefited patients.