An article on the ‘This is Cheshire’ web site entitled “VOTE: Is hospital admitting A&E patients so it doesn’t breach targets?” is a perfect example of the wider problems that come from targets and incentives based on activity.
Now I don’t know the truth of the accusations made by NHS Warrington but I do know that targets do cause people to cheat. NHS Warrington say,
“There has been an increase in admissions and the number of attendances at A&E is staying the same. […] There has been a 24 per cent increase in admissions this month, of whom the majority then spent less than 24 hours in hospital. […] It seems driven by the fact we have to deliver four hour targets.”
That wouldn’t surprise me in the slightest. There are often reports of people gaming their systems to hit targets to the detriment of the service as a whole.
The hospital was also accused of getting ‘more effective at coding’ so it can receive more money per procedure.
“In a matter of four months there has been almost a 10 per cent increase in the amount that NHS Warrington paid for hospital treatment,” said NHS Warrington chief executive Andrew Burgess.
Why would they want to get more effective at coding? Surely more effective coding is a good thing. We all want better coding. Don’t we?
What we really want is a system designed to meet its purpose. In this case ‘to provide the best care to every patient’ might be a reasonable purpose.
But the problems with targets and payments by activity (which is what the coding argument is all about) are just the start. With this article we have a dysfunctional relationship between the PCT and a hospital trust. Are they very likely to work together to provide excellent services to their public? Are they likely to work together to study demand? Are they likely to make any improvements at all while they argue in public like this?
Worse, the public bickering is just eroding what confidence the local people have in the service.
So the problems of targets and wrong incentives don’t just stop at their immediate effects, they have a profound knock on effect of organisational harmony and the ability to simply get on well enough to work together. This is a vicious circle.
But the other way can be virtuous. Use measures related to purpose, drop all the targets and forget about costs. Then get together with your partners and see how to improve things. Service will improve, costs will fall and managers and staff will enjoy doing a better job, morale will go up and everyone wins.
In short, the environment (the system) is the major cause of behaviour. Change the system and behaviour improves.