New target, new perversity

by Rob Findlay

The Government has listened, understood, and acted. The new RTT waiting times target is aimed directly at cutting the backlog of long-waiters, and elbows aside a target regime which actually punishes hospitals for treating long-waiting patients. The change, long called-for in this blog, is very welcome.

But no target is perfect. Targets always create problems of their own, distorting incentives and encouraging undesirable behaviours. Now that the perversities of the current regime have had their day, can we predict the nasties that the new target is going to throw up?

Happily, we don’t need to pull out our crystal ball. The new target is similar enough to the maximum waiting time targets of the 1990s that we just need to cast our minds back a few years. The two biggest problems then, and in the future, are likely to be distorted clinical priorities and hidden waiting lists.

Distorted clinical priorities

Point a TV camera at any NHS manager, and ask them: which is more important, clinical priorities or waiting time targets? They will rightly answer “clinical priorities”.

Now take the camera away, threaten them with loss of income or employment if they fail to treat their long-waiting patients, and turn a blind eye if clinical priorities are delayed. The consequences are as obvious as they are shameful. But delaying urgent patients to make room for long-waiters has happened before, and it may happen again.

Hidden waiting lists

Then there is the temptation to create “hidden” waiting lists, so that long-waiting patients don’t show up on the incomplete pathway figures.

This can be done blatantly (hiding referrals in drawers, creating “pending lists”, reclassifying patients as “planned”, or offering unreasonable appointments). Sometimes it happens through inattention (post-treatment follow-up backlogs). Sometimes it is the result of deliberate local policy (misusing low-effectiveness criteria to block or delay referrals).


So the new target, welcome though it is, leads us to new challenges and new dangers. They cannot be dealt with by national targets and national data collections; they must be tackled locally.

Good planning and management are clearly essential. But so is openness about local practices and policies; if patients and clinicians understand what is being done and why, you can be sure they will protest loudly and often if target-chasing ever dominates over basic fairness and clinical safety.

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