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A tragic story of targets and “Incentives”

When explaining how poor targets and measures destroy common sense, I often cite the case of Accident and Emergency (A&E) times in UK NHS hospitals.

The government (through the Department of Health & Social Services DHSS) were concerned that patients were having long waits within A&E. So, to reduce the time, they imposed a target of 4 hours waiting on all hospital A&E waiting times. Hospitals that failed to meet this target were to be penalised.

Now you can see the logic: We want to reduce waiting times for patients, so lets create a target and incentivise the hospitals to achieve it (or threaten them with punishment for not achieving it.

However, what happened? Well arrivals at A&E are very volatile. Sunday lunchtime is a lot quieter than Saturday night. Its in the nature of A&E that emergencies happen. Demand and supply don’t fit well together. So, to avoid punishments and to achieve the targets with the limited resources they had available, the highly rational doctors, managers, nurses in A&E resorted to ways to achieve the targets (and avoid the punishments).

I am sure there were many rational moves to achieve the targets which were not reported. (The BMJ reports on some short term actions in this article). To avoid the punishments some seemingly irrational behaviours occurred. One solution was to cancel operations to ensure beds were available for A&E patients. Another was to have a patient to stay on the ambulance instead of being admitted. That meant that the clock did not start counting. Of course, it tied up a valuable ambulance, but someone judged that penalty was less that the penalty from the DHSS.

Another solution was to address the discharge end of the problem . You see you need to discharge a patient from A&E (either sending them home or being admitted into a bed) to stop the clock. If beds are not available the patient waits in A&E and the (arbitrary) clock keeps ticking. The solution: Put the patient on a trolley but take the wheels off it and designate it a bed. They are still in A&E but effectively not according to the target. Creative yes. Bizarre no.

I have told these stories many times,. They are rational people trying to do their best in a ridiculous situation that does not consider the whole problem – that of patient care.

However last week I was chatting to an ex-nurse. I asked why she left the NHS and she told me a story that make this even worse.

She said that whilst on a ward she had two critical patients who needed a Doctor’s (Consultant’s) attention. They were critical. Life threatening. However, the doctor choose to serve a non-critical patient in A&E, instead of seeing to the critical ones on the ward, because he was driven by the Governments A&E targets (and punishments) to save a target rather than save a life. She was so appalled by this that she left the NHS.

There are some important things to realise about this story:

a) All the actors in this story are rational and have good intentions.

Yes. I know it sounds daft, but they are. The problem is that the context and situation they have been put in has forced them to act irrationally when the bigger context is considered.

b) Each is trying to improve the piece of the picture that is in their control.

Each player has limited resources, influence and control. The DHSS believe that all they can do is impose targets and penalties. It is all they have in their control and influence. They also believe targets work and change behaviour – and they are right!

The Doctors can only work within the context of A&E and can’t magic beds up. The hospital has only so much time and resource available.

c) They all care desperatly about the patients.

Yes, they all care about the patients. It might not seem it, but they do. Think of the dilemma that that Doctor was in: The hospital loses a large amount of its funding if a target is not met which will affect many patients, for a long period, (and that Doctor gets the blame as it was on his shift) or two patients wait for 45 mins whilst a person is A&E gets attention. Think about it.

Again he is acting rationally in the context in which he has been put.

It is not the hospital that has created this situation, it is the DHSS and to some extent the Hospital management. Perhaps the hospital management could have addressed the problem more effectively earlier – we don’t know.

The others players in this story are doing the same

So what is going wrong and what are the solutions?

Have athink while you wait for a later posting, where I will reveal my analysis.

Phil Jones, Excitant
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