NHS Scotland: Targets – learning from experience

The following Report was published in November 2017:

The Foreword began [highlights are mine]:The Report author Sir Harry Burns states: “experience with existing targets and indicators has been positive in many respects. Significant improvements have been seen in many aspects of health and social care following their introduction.” He continues:

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In what follows I present a summary of my experience as an NHS Consultant in relation to the application of one particular Scottish Government target.

Back 8 years ago I found myself under considerable pressure from a GP and Quality Improver to expand the diagnosis of Alzheimer’s disease to include people who do not meet established clinical criteria for dementia. The argument was put forward as follows:

“We realise there is a lack of consensus generally about patients with minimal cognitive impairment but even if this is what the psychometric findings conclude- it would be useful to have an indication of the likely underlying disease process. – ie use Alzheimers disease as working diagnosis if history indicates it even if are not at stage of dementia. This helps patients relatives and primary care colleagues.”

This was at a time when the following HEAT target was being implemented:

One of the consequences of this target was to encourage an approach to the diagnosis of dementia that loosened established clinical criteria necessary for accurate diagnosis.

By 2012 the Scottish Government was pleased to share the “success” of its target, that demonstrated the contrast with England and Wales:

As a result, in March 2012, Scottish Government officials were invited to give evidence to the UK Government:

The full minutes of this All-Party Parliamentary Group can be accessed here. Here are some of the quotes that stood out for me:

“A lot of what we [the Scottish Government] have done is to try to step beyond theorising as to why our numbers might be right and lower, to actually say ‘let’s move the numbers and make them higher'”. “Broadly I would say we have done some very simple things, manifested in a lot of local leadership, and occasionally us  taking one or two key clinicians or managers around the bike sheds”. “We have applied a bit of heat to the system. We have been quite careful to take out saboteurs”.

The Nuffield Council on Bioethics published this report in 2009 but does not seem to have been taken into account in the drawing up or implementation of this particular target:

As a practising NHS doctor I expressed my concerns through a number of channels and ultimately to Scotland’s Secretary for Health. I am still waiting for a response to this letter:

In October 2014 the Chief Executive of Alzheimer’s Society (for England and Wales) exhorted: “Come on England! Scottish Government tells that over 65% of people with dementia have a diagnosis. We must do better, it’s a right.”

Dr Martin Brunet, a GP working in England, had already expressed disquiet about a target-based approach and the consequent risk of over-diagnosis:

Other GPs were expressing similar concerns:

At this time it also began to emerge that services were struggling to meet demand:In response to this Scotland set a new HEAT target:

This headline from July 2014 demonstrates what was happening to patients:

The following official figures were published in January 2017.  No mainland NHS Board area has achieved greater than  54% compliance with this standard:

This was highlighted in the following editorial:

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SUMMARY:

It has been known for some time that target-based approaches can have unintended consequences, some of which have been outlined as below in Intelligent Kindness by Ballatt and Campling:

The Scottish Government, having asked Sir Harry Burns to undertake this Report, would seem to have acknowledged that targets can result in unforeseen consequences. The example I have outlined above illustrates what can happen if clinical priorities are directed by a political target (which may lack consideration of ethics and complexity) rather than the reality of the patient presenting for help. Potential harms include mis-diagnosis, over-diagnosis and services being stretched to a point where those most in need cannot access help. This view is shared by many doctors: