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Dr. Reid: I am not sure that NICE would be the appropriate body to survey all the targets but, as far as I can see, an almost endless array of bodies already examines them, inside and outside Government. I am continually making representations to those bodies, through the Health Committee, the Public Accounts Committee, the Audit Commission and, now, the Commission for Health Audit and Inspection. I assure the hon. Gentleman that the target results are not hidden under a bushel. I could write to him listing the bodies to which we must supply answers.
Mr. Burstow: I look forward to receiving the letter, in which I hope the Secretary of State will also cite the evidence base underpinning each target. The Liberal Democrats have raised that on a number of occasions, but today we have been given no answers to satisfy us or many people outside.
The Public Accounts Committee has examined target setting, not just in the context of the health service but more widely. In a recent report, the Committee said:
- "What we found, however, is that these very laudable aims are in many cases not being fulfilled nor widely recognised as such by those on the front line whose job it is to deliver them. This is not least because of the lack of proper integration between the building of an organisation's capacity through what we call 'the performance culture' and tracking quantitative achievement in the public services through the 'measurement culture'. The result has been tension between those charged with centralised responsibility and those who are responsible for dispersed delivery of public services."
Dr. Fox: The Secretary of State asserted that patients cannot possibly determine the quality of services offered to them without Government targets. Does the hon. Gentleman agree that that is completely untrue? There is a world of difference between measurements, best practice, and the centrally, rigidly driven targets—in effect, management commands—used by the current Government.
Mr. Burstow: What matters is whether we are making a difference to the health care outcomes of individual
patients. I am talking about not just their experience of the system, but whether it adds years to, or saves, their lives. That is what this should be about, but unfortunately the targets being set all too often do not deliver it.
Mr. Hendrick: Will the hon. Gentleman give way?
Mr. Burstow: I will give way shortly, but I hope that the hon. Gentleman will bear with me for a while. I suspect that I shall say several things on which he will want to comment.
Of course we need a performance culture in the NHS. What gets in the way is the measurement culture identified by the Public Accounts Committee—what could be described as a targets and tick-box culture. Too many of the current targets seem to be based on the findings of focus groups, and on process and experience—although experience matters—rather than on patient outcomes. Ministers talk, as the Secretary of State has tonight, about devolution and earned autonomy, but behind and belying all that is the talk of targets. NHS trusts can do whatever they like, provided that they hit the targets. That is the constraint. That is the straitjacket in which the NHS is being required to operate, and in which foundation trusts will be obliged to operate if they ever come into being. It gets in the way of innovation, initiative and clinical judgment. If I may put it simply, what gets measured gets done.
Accident and emergency waiting times are a case in point. That target, which has been mentioned by Members on both sides of the House today, is based on a snapshot taken over a single week. It happened in trusts in my area, and I should be more than happy for the Secretary of State to say something about it when he writes to me. The NHS knew that it was happening, so operations were cancelled, and beds were freed as a result. Agency staff were brought in to increase capacity during that week.
Dr. Reid: I think that the hon. Gentleman has been genuinely misled by some of the reporting. Yes, there was a snapshot target that was published, but the level of 90 per cent. and above has been maintained in every month before and after that. I can send him the figures, if he wishes, and publish them. The week of the snapshot produced the highest level—I think that it was 92 per cent.—but it has now been 90 per cent. for five months. That was not a one-off.
Mr. Burstow: I look forward to the Secretary of State's letter. Perhaps he will also explain the methodology used for the capture of the information, so that we can be confident that it uses a reliable measure. I must say that the analysis that I have read of the way in which the scheme has operated so far told us nothing, except that the best time to go to an A and E department was while the snapshot was being taken. If the Secretary of State can provide the information, I will more than happily acknowledge the achievement, if it is an achievement.
Another example is the target on GP access time, which is even worse in some ways. It is a classic political target. Of course, we all want to see our GP more quickly when we are unwell—no one would dispute
that—but the target does not measure that. It measures the time until the first appointment. It makes no difference if the first offered appointment is inconvenient and cannot be kept. The box gets ticked, the target gets hit, but it misses the point completely, and that is the problem with the targets that are being set.The cancer diagnostic waiting time target—the two-week wait—is a classic case of piecemeal target setting that fails to improve cancer survival rates because it fails to look at the whole patient pathway. Of course, it is stressful to have to wait a long time for a cancer diagnosis. I have no doubt about that but, as The Lancet has reported, diagnosis followed by a long wait for treatment does not help a person's chances of surviving cancer.
Currently, there are few published statistics, although we have heard some of them mentioned tonight, on the time it takes from diagnosis to treatment, except in the case of breast cancer, for example. Such selective publishing of performance data serves only to reinforce the impression that targets are a proxy for delivery, and that they are designed to capture headlines, not to do the important job of saving lives and improving the quality of patients' lives.
On its own, speeding up diagnosis diverts resources from treatment. It is a wasteful and dangerous approach in isolation because those targets distort priorities and get in the way of whole-systems thinking and person-centred care. That concern is expressed by clinicians, not just politicians.
Targets can be misleading. They can give the public a false sense of comfort, whether it is the overall star ratings or the patient environment action team inspections. Those are often presented by Ministers as dealing with issues of cleanliness and hygiene, yet cleanliness is just one of the 19 categories in the PEAT standards. The scoring system is such that a hospital rated badly on cleaning could still get a green light from the scheme. Indeed, the scoring for cleanliness is self-assessed and audited by the NHS trust itself—hardly an objective and independent measure of what has been done on the ground. There is no role for Commission for Health Improvement audited inspection.
It came as no surprise that so many green light hospitals topped the league for methicillin-resistant staphylococcus aureus, or MRSA, infections. Just last year, a report by the Commission for Health Improvement said this about an inspection that it did in West Dorset General Hospitals NHS trust:
- "The trust has experienced a substantial increase in MRSA infections in the last three years. The infections have led to further problems including ward closures. The trust identified a number of risk factors for MRSA infection, but reports that there was only limited success in instituting control measures, primarily because of resource issues. Staff told CHI that the increase in activity and the pressure on meeting targets has resulted in staff not having the time to get the basic infection control procedures in place".
It is time that the Government's obsession with target setting came to an end. To be genuinely responsive to patients and to local community needs, the NHS must
be free to determine local priorities. Of course, performance should be measured and compared, but it should be measured on ill health prevention and health outcomes achieved: the years added to a person's life and the lives saved should be the yardsticks against which NHS performance is measured. However, because the measurement culture is so dominant and what is easy to measure tends to be what gets measured, the focus is always on acute care.I believe strongly that the balance in our health care system needs to shift from disease treatment to disease prevention. Unless much more is done to tackle the root causes of ill health, the costs of health care will continue to climb. When it comes to debating whether health care costs will increase and what the drivers behind that will be, the tendency has been to assume that health care costs will rise as a consequence of a growing elderly population. The Government are to be applauded, because their Wanless inquiry into health care expenditure comprehensively debunked that myth. It is not old age that is going to drive up the costs of the NHS bill. What will be the real driver behind increased health care costs over the next 50 years? It will be the rise of chronic diseases: diabetes—particularly type 2 diabetes—coronary heart disease, arthritis and the many other chronic health conditions that are the direct consequence of the obesity epidemic emerging in this country and across the world.
The challenge is to build a public health service that is capable of leading a revolution in health care, and which tackles the causes of ill health, rather than just treating its consequences. Poverty, poor environment, bad housing, poor diet and lack of exercise are the roots of many chronic diseases in the UK today. That is why Liberal Democrats argue that the health service ought to be commissioned locally by local government, not just bringing health and social care together, but creating the opportunity to tackle those root causes of poor health. That is why we reject the Conservative proposition that a national quango needs to take responsibility for the national health service. We think it wrong to remove from political accountability day-to-day control of the NHS in that way. We reject the idea that we should allow an unelected, unaccountable quango to take charge of the NHS.
Today's debate is really about the Conservatives' proposition and their analysis of the health service. It is a chance—at least, it should be—to showcase their new health policy, but we did not hear a great deal about that. We heard a lot of analysis, but not much prescription. In fact, their new policy, the centrepiece of which is the patient passport, needs to be showcased as much as possible. On this occasion, the Secretary of State is right: it is not so much a passport as an exit visa from the national health service. It would allow those who can afford to go private to withdraw from the NHS 60 per cent. of the NHS cost of the operation.
That figure is an important one to keep in mind, but in truth we are not talking about 60 per cent. of what the patient has to pay, because private operations—surprise, surprise—cost more than they cost within the NHS. Let us consider a hip replacement—just the sort of routine operation for which someone might opt to go privately. A hip operation in the NHS costs some £4,356. The same operation in the private sector can cost up to £9,000; indeed, some say that it can cost a little
more. Sixty per cent. of the NHS cost is £2,614, but that is just 29 per cent. of the cost of going private; the rest has to come from the individual's pocket.
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