Tom Goodfellow

Today’s NHS problems have their roots in the target-driven culture

When I was a medical student at The London in the late 60’s/70’s a regular lunch time event was the post mortem demonstration in the pathology department. Attached to the PM suite was an observation gallery where about thirty of us would congregate to observe the proceedings.

The PM had usually been completed with the specimen fully displayed. The pathologist would then demonstrate the various pathologies which had contributed to the demise of the subject. It was a useful way to combine the clinical and pathological findings, and of course those were the days before the high resolution imaging available to today’s students and doctors.

My abiding memory is of the colours –reds, yellows, browns and greens made all the brighter by the intense lighting in the room. Once one got over the inevitable squeamishness the interior of the human body seemed incredibly beautiful.

But then the pathologist would show the blackened consolidated lungs, or the liver riddled with metastases, or the perforated colonic cancer, and this brought home in a powerful way the frailties and diseases to which humans are subjected and which finally overcome us.

Which brings me to the current state of the NHS; this week junior doctors, led by the BMA, took strike action, which was quickly followed by the Health Secretary saying he will impose a contract on them.

How has the NHS reached such a dire state, and are we witnessing the imminent demise of the service?

Some will say it all started with Mrs Thatcher and the Griffiths Report into the NHS in 1983 with the introduction of a more robust managerial system. I don’t agree with this – the NHS desperately needs good management and the majority of the managers I have worked with over the years have been deeply committed to the service.

I lay the blame firmly at the door of Tony Blair and his warped “deliverology” approach to the service. His aims on the eve of the 1997 General Election were undoubtedly up beat, “We have 24 hours to save the NHS”. However what resulted from this was a top-down, micro-managed, target-driven, name-blame-and-shame system.

Target culture is a pejorative term used to refer to the perceived negative effects of rigid adherence to performance targets by businesses and organisations.”

All the research in industry demonstrates that target-driven cultures do not work, but on the contrary introduce gaming, cover-up and demotivation, and exactly this has been seen again and again in the modern NHS as managers are forced to achieve targets at the expense of clinical priorities.

The Mid Staffs debacle being a prime example, but there are many more similar situations less well publicised.

Inevitably the target culture results in hospitals and departments “failing”, and this does not produce happy, well-motivated staff, but rather demoralisation and disengagement. In my 41 years in the NHS I have witnessed this again and again.

It also means that the NHS has also become a deeply bullying culture which comes from the top. I remember a conversation with a very senior CEO who told me that he, and other executives, were regularly summoned to Whitehall, or to the offices of the SHA where they would be shouted at by the officials for an hour or so for their perceived failures, which generally meant a politically driven target with an eye to the next election rather than anything to do with quality clinical care.

This bullying culture has passed down the organisation to all levels. I was recently told by a manager that he had been threatened with disciplinary proceedings because he had failed by a whisker to achieve a clinically meaningless target.

Jeremy Hunt continues to bully the doctors (and the juniors are just the first – the GPs and consultants are next in line). If he somehow imagines that imposing a deeply unpopular contract on the juniors will result in happy, motivated staff who will get behind his plans for full seven day working then he really is living in lala land!

Toyota have had their problems in recent years but historically have been one of the most successful and productive companies in the world. Their principles are well known and include getting the long term philosophy right and avoiding short-term thinking (which besets our politicians).

Getting basic processes right and developing staff are also key to motivation. And finally improving productivity by continually solving root problems in the organisation, which cannot be achieved if the all-pervading drive is the externally imposed target.

I believe that aspects of this philosophy would fit well with a rejuvenated and motivated NHS but I doubt there is the political will or vision to develop it.

The entrails of the NHS are currently on display, and despite its many healthy and beautiful features (and yes there are many excellent aspects to the service) the rot is there for all to see. We learned our pathology in the PM room in the most visual way possible. What hope for our politicians? Sadly little I suspect!

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One Response to “Today’s NHS problems have their roots in the target-driven culture”

  1. Blackcats36 says:

    Ultimately and ironically the cause of all todays woes in the NHS is the NHS itself. Its very essence ensures that politicians dictate what happens. Political interference in the delivery of healthcare in this country has been the norm since the day in 1948 when the NHS first opened its doors. Politicians should have no say in the delivery of healthcare at any level. The only way to stop this politicisation of medical practice is to change the way the NHS is funded. Financing the delivery of healthcare from central taxation is the pretext and excuse they need to call the shots. Guidelines ,targets ,slogans and propaganda are all the consequence of an overpowering management bureaucracy licensed by politicians. The only way things are ever going to improve for everyone is to introduce a means-tested insurance based system with doctors working like lawyers in chambers contracting their clinical services out to Trusts under their own terms and conditions without political direction or interference.

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