On the unintended consequences of new Government targets

This is something of a cautionary tale. I think it's about time I explained why the financial crisis completely passed me by, except as a mildly interesting news item. The truth is, I was ill at the time. At the end of October 2007, after I had spent several months waiting for scans and doctor's appointments, and nearly 2 months waiting to see an NHS consultant, that consultant told me in no uncertain terms that I needed a major operation and why hadn't I been to see him sooner. Sigh. NHS bureaucracy.....

Anyway, I signed up for the operation and was told that the waiting list was 4 months, during which time I would be provided with drugs to keep me going. Those drugs made me feel terrible but at least they kept me functioning, though I gradually became iller, of course - time doesn't stand still when you are on a waiting list. I continued working - with some difficulty - and waited for the call.

In January 2008 I received the long-awaited call. But it wasn't from the consultant's secretary to arrange my op. It was from someone offering me the option of switching to a private hospital some distance away from my home, with the incentive that I would have the needed operation quicker - as I recall they said within 2 weeks.

Naively I agreed to this, because it meant I could get the whole business over with and get back to normality. Because the private hospital was in a different area, the operation would be performed by a different consultant. I assumed that my notes would be sent to the new consultant. And since the time until the operation was short, I expected to hear from the new consultant within a few days. So when I hadn't heard anything after a week I rang the new consultant myself.

I was horrified. Not only did this new consultant know nothing about me, he insisted that before he could do any operation he had to see me and make his own diagnosis, and until then he couldn't give me any timescale for my operation or even confirm that I would have it at all. And the earliest appointment he could give me for the consultation was in 3 weeks' time.

It dawned on me that after waiting for over 2 months, I had simply been removed from the waiting list.

I didn't know why. And I didn't know what to do.

Fortuitously I saw a client a few days later who told me that she was on the waiting list for the same operation. She had gone on to the waiting list more recently than me and therefore came under the Government's new Patient Pathway scheme, which specified a maximum time of 18 weeks from referral to treatment. In conversation with her, it became clear that the new Patient Pathway did not apply to me, because I was already on the waiting list when it was introduced. It began to look as if I had been removed from the list to make way for patients who had to be treated sooner to comply with the new government targets.

Well, I am not one to put up with being treated like that, so I rang the original NHS hospital and demanded to be reinstated on the waiting list. This time I spoke to the consultant's secretary, who was happy to reinstate me at my original position. And she also asked me who had contacted me to offer me the transfer to private treatment. So I gave her the name of the person who had rung me.

"That's odd", she said. "No-one of that name works here. But we've had external advisors in to help us manage our waiting lists in the light of the new Government targets. Maybe it's one of them".

I left it with her to investigate who had been responsible for removing me from the waiting list, and resumed my wait. A couple of weeks passed and she rang me again, offering me a choice of two dates for the operation. I opted for the one that suited me best. Then she made this devastating remark:

"We want to thank you for drawing this to our attention...."

It turned out that the "external advisors" had been contacting people like me and offering them treatment that they had no authority to offer, purely in order to reduce the waiting lists and enable the hospital to meet the new targets. I don't know how many people were affected, and whether anyone else complained. But many people are more accepting of disruption than I am. To this day I wonder whether there were others who simply accepted the offer without question, and what happened to them.....

There are two morals to this story. The first is that Government targets designed to improve outcomes can perversely make outcomes worse for some people. Particularly when the Government employs private providers to help the public sector to meet those targets, pays them on results, and doesn't supervise them properly.

And the second moral is that being stubborn and bloody-minded can be a very good thing.

Related links:

Final report from the inquiry into the Mid Staffordshire NHS Foundation Trust - Francis
Perverse incentives and productivity (updated version) - Coppola Comment
The Work Programme - DWP


  1. This is the kind of thing that happens when politicians afford outsourced companies, impenetrable to FOI requests as they shelter under the cloak of 'commercial confidentiality', leave to operate under 'black box' regimens. One shudders to think what's happening in the Work Programme at the moment...

    1. And, sadly, we have this to look forward to in the United States.

      I shared your tale with my 'legions' of readers. Hope a few actually take time to read it.

      Wonderful blog, by the way. Always informative!

    2. Old South,

      The problem in this case was not the NHS. The problem was a well-meaning Government trying to bring down waiting list times - which is a good thing - but unfortunately using external and I suspect ill-informed "advisors" who went beyond their remit and weren't properly supervised. The NHS staff in this were beyond reproach, and even the system, although slow and bureaucratic, worked. The problem was that the attempt to change it had unintended consequences.

      I would not want the US system in the UK. We have a system that is free to all at the point of delivery irrespective of income levels and whether or not they have insurance. That is something that I, for one, am immensely proud of and I feel the US would do well to copy. I didn't like the suggestion on your blog that the NHS is bad and Obamacare would reduce the US system to the UK level. That is a monstrous misrepresentation of the situation I described in my post.

  2. Something is missing from the contracts used to engage these "external advisors" - naming, shaming and bloody great fines for such transgressions.

  3. They used to call these charlatans "Snake oil salesmen"

    At least that was a more honest term?

  4. Targets. Used way too often for just about anything that can't be targeted.

    Like arrests. It depends on what crimes are committed which the police have no say in. Unless police start forcing criminals to own up to crimes they didn't commit, or make up crimes and "solve" them.

    You can't have targets for waiting lists when you have no control of the diseases and accidents and health problems that people have. When the proper way to lessen waiting times is to perform more operations which because targets are inappropriate does not work, people will work out ways of reaching the targets using other means - reclassifying, removing, re-purposing.

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  6. this was truely a wonderful read. wish more blogs were more like this blog.


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