They have a target; they are bound to cheat. That is what people do.

Carol told Polly that,

She was told to cancel operations for anyone who was already waiting over 18 weeks, and instead to fill that theatre time with people closest to breaching the 18-week limit. “I was told to call people who had already gone over the 18 weeks and pretend there was no longer theatre time for their operation, and not give them a new date.”

What amazes me is that people are so ingenious. What could happen if that creativity was turned to improving the system of treating patients? Well you could make a mockery of the 18 week target for a start. And give better care to boot.

Carol also reports that,

The worst was when she was told to call a mother of three young children to offer her a short-notice slot for Christmas Eve, knowing she would refuse and so could be knocked off the list for refusing.

At least Carol had a conscience, since she quit over what they made her do. But the saddest, most frustrating part of the article is this:

She protested first to her line manager, then to the one above and finally to the one above that. “I said I wanted these instructions in writing before I would lie to patients. Of course they said it could never be written down. But the manager in charge of operating theatres said other hospitals were all doing it, so we had to too. There’s no other way to stay within target.”

That final part is worth repeating:

“There’s no other way to stay within target.”

That’s what makes me mad. There is another way (to paraphrase Deming).

All the effort, time and creativity that is going into making phone calls to mothers, lying to patients, fiddling the figures, messing with the types of operations could be going into making things better. That trust, and others around the country would have shorter waiting times and no need of a target if they simply:

1) Did what the patient needed,

2) When they needed it,

3) With no waste, errors or delay

All the monitoring, expediting, lying, cheating and fiddling would melt into the air, and they would have a nice clean, simple system for treating the public that would smash the targets they are currently desperately trying to meet by any means necessary.

Best,

Rob

As Lansley squats in front of the idol created by the Labour tribe, the danger he has faced melts from his thoughts as he is calmed by the simplicity of the creation that sits quietly before him.

He is still.

But Lansley knows that he is not out of danger yet. He steadies himself and mentally weighs the golden object before him. He takes a bag in his right hand and measures the policy ideas it contains. He looks again at the idol and back to the bag. He takes a fistful of directives from the bag and drops them to the stone floor. He glances back at the statue and then discards a few more diktats from the bag. He is ready. His right hand holds the bag as close as possible to the idol, his left hand poised on the other side.

One more breath.

As the last wisp of air leaves his lungs he smartly tips the idol off the plinth, simultaneously rolling the sandbag into its place with a gap that could never be noticed. Or so he hopes.

Lansley pauses. Waits. Listens. His body still taut.

Nothing.

His shoulders drop a fraction and he allows a small smile of relief and victory to creep across his face. He starts to stand to leave with his prize. For a fleeting moment he has done it. He has removed the Golden Idol of the NHS 18-Week Treatment Target. No one thought he could do it. Even he wasn’t sure. He knew it was the right thing to do. But has he forgotten something from the ancient legends?

Lansley tenses. A deep, distant rumble. In a moment the roof of the cavern is crashing down. The floor cracks beneath his feet. The altar explodes in his face. He must run.

As he dodges more darts and nearly loses his Fedora to spear flying out of a wall beside him, his mind rushes back to the warnings of the old man in the village. The sage said that you can’t just remove a target and replace it with sand. “It is right,” said the man, “to remove the 18-week target. The Labour tribe wouldn’t listen when it was said they shouldn’t create the evil target idol in the first place. The problem is that targets appear to magically work even if they are really dysfunctional. But if it is to be removed it needs to be replaced with a proper method. So if you take it away, as you must, you need to leave in its place a sustainable way to treat patients well. Only the timely and appropriate delivery of treatment in the NHS will stop the whole thing collapsing. Only then will the 18-week target not be required, and it can be beaten in in ways no one could imagine.”

All at once, Lansley screeches to a halt amid all the chaos and dashes back through the flying debris. Swinging the 18-week target high he brings it crashing down onto the splintered remains of the altar. “Come on!!” he shouts. Surely putting the 18-week target idol back will stop the pandemonium and collapse? Nothing changes. In fact the disintegration of the NHS seems to hasten.

Indiana Lansley rushes for the fast dropping door. If he doesn’t make it he will be crushed by the rubble of the NHS, never to be seen again. As he runs he can feel the glow of the 18-week idol behind him. Its power burning into his spine as he flees. The door falls ever faster.

He has always got there in time before…

Andrew Lansley has said that the 48 hour GP target, the 4 hour A&E target and the 18 week GP to treatment target are to be gradually scrapped by his department.

Former NHS trust chairman Roy Lilley said:

“Targets have made managers’ jobs really tough. They have taken a lot of criticism about additional bureaucracy and box ticking. I thought they would be pleased to see the back of them. Not so! Managers are proud of the fact they have delivered most of the targets and dumping targets is turning the clock back.”

Targets make managers jobs tough because they prevent managers working on what is important to the patient. They are instead distracted by having to hit the target. They should be glad to see the back of the targets since now they can run their services on the basis of giving value to patients. They shouldn’t be proud of delivering targets that make performance worse.

More importantly with the freedom from arbitrary targets, the clock can move forward apace. That freedom shouldn’t see the clock turned back to long waiting times, rather without having to appease an unjustifiable target they can now innovate to provide services that no-one would ever dream of setting as a target.

Why 18 weeks? Why not 18 days or 18 hours? There was no reason and there is even less reason now with the burden of centrally imposed targets removed.

Another manager said,

“Targets do, at least, stimulate productivity. Areas without targets tend to get sidelined. Without targets, for many people, it is human nature to ‘do what is easiest’, rather than what is best for patients.”

Firstly, targets don’t stimulate productivity, they stimulate activity, which is not the same thing at all.

Secondly, the quote shows a very cynical view of people. This is a view that staff are inherently lazy and don’t want the best for patients. I don’t believe that and I think that the only thing holding back improvement is a lack of sound method. But there is plenty of good ways of improving if managers look for it. It is not laziness that is the problem, is the laziness of thinking that assumes that people are slothful and will shirk the responsibility to improve things for the public. It is just that some of them don’t know how to do it yet.

Best,

Rob

Human rights activist Parvez Imroz was interviewed in an article by The Guardian where he said that soldiers received bonuses for each kill. He added that,

“There are vested interests that have developed in the conflict. The army have been given these incentives and so they kill non-combatants.”

I have heard many stories of people fiddling figures, cheating processes and changing what they do to get rewards, but I think of all the indcidents of targets and bonuses distorting behaviour this is the most extreme I have ever come across.

It just goes to show that the power of rewards to twist how people act should not be underestimated.

Best,

Rob

About one in five of the nearly 600 surgeons questioned by Bournemouth University reported being involved in incidents, during a two-week period, where patients were harmed.

Using the figures further on in the article of 549 surgeons questioned and 19% seeing harm, that means that in two weeks, 104 surgeons saw a patient harmed. I wouldn’t even like to start extrapolating that figure to all the surgeons and all year long.

Apart from the fact that

When asked about what gets in the way of patient safety, many said they did not feel in full clinical control, because of pressure from managers to get through operating lists.

The report author said that

surgeons often come under pressure to “slip in” extra patients on their lists

These are systemic problems. The management are putting pressure on the individual surgeons to make up for the lack of systemic thinking about how patients are treated. “Slipping in” patients to surgery lists means that not only are the lists tampered with but so is the whole patient flow. There is probably a lack of understanding of demand and little or no flow of patients or continuity of care which is leading to these comments.

Many [surgeons] complained of having to operate on patients they had not seen before

If patients came to see a surgeon and their surgery was scheduled quickly, then this would occur much less frequently.

The bottom line is that surgeons, managers and all staff involved in the care of patients having operations need to be aware of and contribute to the end-to-end system that patients experience. No one section of the flow should start blaming the others, they all have a responsibility to get together to improve. The problem is that there are currently no structures in the NHS that assist them to do that. Combining GPs, PCTs, SHAs, hospital trusts and the other agencies that affect these flows is a mammoth task that is not being addressed yet.

We shall continue to see these kind of articles until something brings these systems all together.

Best,

Rob

The Tories’ critisism of targets indicates that they do not understand the basic quality principle of plan, do, study, act.

I would counter that the writer of the statement above does not understand that to set a target is not a plan. There is no proper ‘do’ other than set the arbitrary target then stand back. The ‘study’ is reduced to the useless, “see if we hit the target” and the ‘act’ can only be to change the level of the target, drop it or add a new one to counter the perverse unintended effects of the first one.

A proper plan has method. Things you are going to study to understand your situation so you can make changes with knowledge. Targets do not give knowledge, only fear and pressure.

Best,

Rob

This is good news, but it remains to be seen what the alternative will be. It is hoped there will be some sort of method behind it this time. By method I mean a practical way of improving that is not ideological or dogmatic, but implementable by hospital trusts based on their own needs.

Best,

Rob

Previous posts:
NHS A&E target “risks patient safety”
Targets in A&E make people cheat
A&E targets distort behaviour
More on 4 hour target in A&E

If you battle your way through the Stats Wales web site you can get the actual data series for this figure and it looks like this.

• Apr 09 – 65.5%
• May 09 – 66.5%
• Jun 09 – 66.7%
• Jul 09 – 63.9%
• Aug 09 – 54.6%
• Sep 09 – 67.1%
• Oct 09 – 66.4%
• Nov 09 – 65.8%
• Dec 09 – 59.4%
• Jan 10 – 58.5.%
• Feb 10 – 65.3%
• Mar 10 – 69.2%
• Apr 10 – 70.5%

Aug 09 doesn’t look so great. I bet they had some explaining to do that month, and the last month is really good. If you look at the last four months there has been a definite improvement. Or has there?

If we take these figures and plot them on a run chart we see this:

We can see that the percentages are up and down month by month. Again Aug 09 is bad and the latest is good. But quite jumpy nonetheless.

Now let’s show the mean on the chart to provide a bit of balance:

That just gives us a bit of perspective. We can see the points bouncing above and below the mean. There are some questions that we can ask:

• Why does it seem so variable?
• Is that variation excessive?
• Where is the variation coming from?

A technique which can help us answer this question is called Statistical Process Control. It gives a method to calculate limits from the data. If the data points lie within the limits then the variation is “common cause” i.e. normal variation due to the system and if points lie outside the limits then the variation is “special cause” i.e. due to some one off circumstance that can be pointed to as a particular cause of a very high or low figure.

Let’s apply these limits to our chart.

We can see that all the data points lie within the limits. It is worth emphasising that any data point that lies within the limits is entirely expected and is thus assumed to be due to normal variation within the system.

So we can conclude that the Mar 10 figure of 70.5% is within the limits. There is no special cause and there is no shift in the system and so that month’s figure is nothing special in the same way that the Aug 09 figure of 54.6% is also within the expectations of normal system caused variation.

Therefore the Welsh Ambulance emergency call response rates show no improvement.

In fact next month’s figure would be expected to fall anywhere between the limits of 54.3% and 74.9%. (Perhaps a keen reader could remind me to check up on that!)

So what do the Welsh Ambulance service need to do? They need to change the system to 1) move the average and 2) reduce the variation. It would be good to see a shift like this

Where we can clearly see a change in the system causing not only a shift in the mean but a reduction of variation.

This is the evidence of change that we need, not the clutching at straws that accompanies a month-by-month examination of figures.

But also something worse happens when you can’t judge whether the last month’s figure is due to common variation. If it is good, but within the limits, then the temptation is to congratulate people and to rest on our laurels, while all along nothing has really changed. The opposite case is as bad. If the figure is bad, we go looking to blame someone, to find fault, when again, if it is within the limits it is just due to normal variation. In both cases we are tampering, mistaking common variation for something special and acting on it (congratulating or blaming) when in fact we should just ignore it and look at the system as a whole and how we can change it for the better.

Understanding variation due to a system using the techniques described above is the first step toward taking action that is effective.

Best,

Rob

But this has been covered in previous posts (here, here and here) and actually the more interesting point is hidden near the end of the article.This is a hint that health care is a system.

Ambulance bosses are desperately trying to find ways to cope with rising demand for emergency services, with the number of calls increasing by more than 250,000 a year amid failings in GP out-of-hour services.

For years the UK health care has been treated as pockets of services that don’t link up. This is just another example. As general practitioners (GPs) are providing less and less out-of-hours service so the slack is being taken up by the ambulance service. The ambulance services react to this and the fact that they still have the same old targets, by changing the type of response, even though this response may not be appropriate for the patient. This isn’t the fault of the ambulance service neither are the GPs to blame. The problem is that nobody is viewing health provision as a system.

In theory the Strategic Health Authority (SHA) is supposed to do this along with the Primary Care Trusts (PCTs). But in reality, the SHAs are too far from the action and the PCTs are driven by the commissioning process to consider cost of provision before they think about linking services together to serve the health demand.

The story in the Telegraph criticises the Department of Health’s Emergency Call Prioritisation Group, but really what needs to happen is that this group is disbanded so no-one can tell local ambulance trusts how to deal with the calls in their area. Instead, ambulance trusts need to co-ordinate with their PCT, GPs and acute trusts to understand the local demand and have vehicles and staff and skills to meet that demand.

Local understanding of and responses to local demand are the answer to this problem, not better decisions by a group in central government.

Best,

Rob

Before the election in May, the three health spokesmen for the major parties debated on television. Obviously the question of targets came up and Andrew Lansley said he would scrap “politically motivated” NHS targets but keep those that were “clinically justified”.

The problem is that there is no such thing as a clinically justified target. The reason is that targets are arbitrary and make performance worse. That is never clinically justifiable.

A target to have every suspected cancer patient seen within two weeks has behind it a laudable goal – that patients with serious conditions should get the best treatment possible. There is nothing wrong with that goal but everything wrong with having a target.

Study Demand

To achieve the goal you would start by looking at demand. “How many suspected cancer patients do we get every day/week/month?” You would then look at the current system to see how this demand was dealt with and you would measure it from the patients’ point of view. They want to be seen quickly, they want to get the right treatment and have the best outcome possible. Also they want dignity, respect and to be treated like human beings.

If you are thinking of hitting a target your mind is filled with resources, measures and reporting. I went to Exeter to help run a workshop on how to meet the 18 week target from diagnosis to treatment. One of the questions from the floor was about what monitoring should be put in place to spot when patients are just about to breach the target and so fast-track them so they won’t breach. If you put that monitoring in you are moving resource from the core flow of diagnosis and treatment and over to monitoring. If then you add a fast-track expediting of patients just about to breach you add a further complication to the system where suddenly certain patients jump the queue to make the trust’s figures look better. But remember that patient has jumped over other patients who are now delayed and so more likely to get close to breach. If they get close to breaching they will jump the queue and so the cycle continues. You are in effect increasing the variation in the system while at the same time reducing the resources available to the core flow.

Measures of Purpose

The correct approach is not to have monitoring of near breaches but to measure the end-to-end times of patients from diagnosis to treatment, while also measuring the type of treatment given. You will see that the end-to-end time will vary. This variation is normal in any system. Your first job is to remove any abnormal variation until the system is stable (which is not to say it is yet effective – just stable) then work on the flow of the patient through the system to remove the batching, waiting, errors and rework so as to reduce the variation and improve the system to get the time from diagnosis to right treatment as short as possible.

This method will leave any target setting in the dust. Why 18 weeks? Why not 18 days? Why not 18 hours?

Why two weeks for cancer patients? Why not two days?

Method Not Targets

Targets don’t help you to improve, in fact they distract from improvement. People set targets when they have no method. When they have a effective methods, they get results that would be seen as ludicrous to set as a target.

Best,

Rob