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It looks like targets are back with a bang



This Government doesn’t do targets. Its NHS Operating Framework back in June canned monitoring of the 18-week referral-to-treatment target, downgraded the A&E target and told PCTs they no longer needed to aim for 50% of GP practices offering extended hours.

Again and again, we hear ministers insisting that gone are the days of centralised command and control. So what are we to make of this week’s dramatic revelation in Pulse that GPs are to be expected to deliver huge reductions in unscheduled admissions and A&E attendance by the end of 2013, just nine months into their new lives as commissioners?

The Department of Health is desperate that its efficiency plan – for GPs to drive down unscheduled admissions by 20%, A&E attendances by 10% and to work with hospitals to bring down length of stay by a whopping 25% – should not be portrayed as the launch of a new set of NHS targets. But it is equally keen not to give the impression these reductions are in any way optional. Sir John Oldham, the DH’s clinical lead for quality and productivity, could not have been clearer when asked what would happen if GPs were unable to deliver.

‘There is no plan B,’ he said. ‘These will have to be achieved.’ Well, ministers cannot have it both ways. The satirical duck test proclaims ‘if it looks like a duck and quacks like a duck, we have to at least consider the possibility that it is a duck’. We have to consider the possibility that NHS targets are back in fashion.

But what of these targets? Are they achievable for GPs? Cutting unscheduled admissions has been the holy grail of every health minister of the last decade or longer. In the Labour years, community matrons and the much-hyped Evercare scheme were supposed to finally deliver – by using a risk score to predict exactly who would get seriously ill next year, and targeting them with preventive care.

It never worked, because looking into the future is far harder than the sages liked to suggest. Elderly patients who are frequently admitted one year are not necessarily those who take up hospital beds the next. Some of them get better, some of them die. GPs will view the DH’s latest attempt to convince them that it has attained second sight with healthy scepticism.

A reduction in A&E attendances was also an obsession of the previous government, which insisted on handing out red ratings to practices considered to be doing too little to stop its patients going to hospital. But GPs’ criticism then applies just as well now. A&E attendance is fuelled by a complex mix of factors, from the number of local GP practices to the type of population to whether the A&E department happens to be conveniently nearby. Achieving lasting cuts in visits will require wholesale redesign of the local health economy, which is a huge ask on this timescale.

When the DH first launched its commissioning plans, GPs were intrigued and even excited by the prospect of leading the NHS. But the tasks it is setting general practice are looking more daunting, and less achievable, by the week. It must be careful that these new targets do not leave GPs feeling it is they who are in the crosshairs.

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