Comment / Target tolerance

There is a philosophical debate whether targets are or should be aspirational stretching goals or absolutes. As the year end has passed, chief executives and directors of finance will be counting, literally, the cost of success or failure in achieving a key targets.

There are rumours that some key targets (18 weeks referral to treat; 31 and 62 day cancer targets; and the four hour A&E target) may have been missed, albeit by not very much. If this turns out to be the case, we might need to brace ourselves for a summer of discontent at the Department of Health. While targets have been missed before, the backdrop this time is an estimated £1.8bn under spending on the NHS revenue account.

This will refocus attention on why the NHS needs to generate surpluses. Finance professionals understand why surpluses represent sound financial management. However, surpluses are only a positive development if they are used to invest in and develop services for patients. For this to happen – to get the desired investment response – the NHS financial regimes need to be right. The HFMA has been looking at why trusts are not spending, or indeed borrowing, for capital investment. The big issue is one of confidence in the future.

This particularly applies to acute trusts. The implications of Our Health, Our Care, Our Say, Darzi, downward pressure on the tariff and the as yet unknown impact of new healthcare resource groups (HRG4) all reduce the confidence of boards to make those investment decisions.

For trusts with private finance initiatives, designed and contracted in different times, there is the added concern that they have already over invested. As with any commercial organisation, trusts are opting for a cautious investment strategy.

While the majority of surpluses are being managed by strategic health authorities, the only way trusts can spend previous years’ surpluses on revenue is to overspend. Monitor’s regime supports this; the Department of Health’s does not.

Failing to achieve vital service targets is disappointing, given the huge staff and management effort and resources. But it is important not to lose sight of what has been accomplished. When the 18 month wait target was announced, it was viewed as impossible by many. Yet, in a very short period, the NHS has come close to achieving an 18-week total treatment time. Perhaps more important, the service now believes that it could improve further.

Less defensible is why the NHS did not believe in itself sufficiently to drive for these patient-based service targets without imposition from above.

There is inevitably a political dimension to missing targets. But what we must not do is wallow in disappointment. If targets are rightly stretching, then falling slightly short should not constitute failure.

Rather than being beaten up – or beating ourselves up – for a near miss, we should focus on the huge progress that has been made. If there is a lesson, it is that the NHS should increase its self belief about what it can achieve when it puts its heart, soul and funds into delivering an objective.

You can contact the chairman via his email, [email protected]


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