SIR NIGEL CRISP KCB AND MR HUGH TAYLOR CB

THURSDAY 30 JANUARY 2003

  940. For a chief executive, an honourable public servant to feel under such intense pressure to produce figures that the Department likes to do something like that—
  (Sir Nigel Crisp) I cannot comment at all on an individual. Let me be clear there are very, very many honest, decent public servants running hospitals round this country who are not fiddling and who are producing results that do not fit in with our target regime and others that do produce results that do fit in with our target regime, and that is the vast majority.

  941. Sure. One thing we have heard almost universally when we have had discussions with health people talking about targets is they say knowingly, "Well, of course, you know there are real targets, and the rest". Although you give us a list—you say there are 62 targets, we would like to have your number, if we may—is it the case that some of those are more real than others in terms of the need to deliver on them?
  (Sir Nigel Crisp) What people are referring to is a point which I think your colleague made, which is the ones that are more politically prominent than others and where there is more media interest people will feel more pressure.

  942. Heads may roll. I have heard the expression, a P-45 target
  (Sir Nigel Crisp) Going back to your example of the Good Hope, the man was dismissed in connection with the figures not being reported properly, not with failing to hit the targets, that is not what actually happened in practice. Where people are failing to meet the target in almost all cases, unless this has been long-term, it has actually been an issue about how we put in the support and help people to achieve the way forward, that is the real culture. I do accept that there are some things that are obviously more prominent and they are the ones that tend to be round waiting lists, they are of no significance to all of the people running mental health for example.

  943. Leaving aside the fiddling question, what we have heard universally is there is a standing tendency to distort because of targets, that is that you cease to do some things which you may think are more important because targets have said this is most important. I can give you endless examples, this is a simply a standing worry, is it not?
  (Sir Nigel Crisp) Targets are not everything. Targets do a number of things, they absolutely focus you on certain issues which we are saying are priorities. I go back to my coronary heart disease example, that is not the only management lever we use, it is a management lever amongst others. You are quite right, any management lever can be used badly. What you need to do is make sure you understand the effect that it is having. We have changed targets as a result of people's advice about them.

  944. The classic distortion was the waiting list target, was it not, which was routinely getting less important things done in front of more important things so that the list size could be reduced?
  (Sir Nigel Crisp) I am not sure I would agree with that. The discussion that went on was about saying, what is the most important thing here, it is the length of time people are waiting rather than the number of people on the list and that is where we should put our efforts in and you move on.

  945. It was a poorly set target?
  (Sir Nigel Crisp) We have a better target now

  946. Yes, I think we know what you mean. A previous witness we have just heard from said that he woke up one morning not with his Unison hat on but with his citizen hat on in Brighton to discover that he lived in a no star trust and he then said he wondered what he was supposed to do about it. What was he supposed to do about it?
  (Sir Nigel Crisp) The point about having a performance rating system is that it brings in to the public domain some of the issues about the performance of a local hospital. Let us be clear in Brighton what they have done—some of problems there were about access to the A&E Department, as I recall it—is they have really rallied round and I believe at the last rating they got a two star performance. I think that performance rating in Brighton was a spur to the hospital to make improvements. I do recognise an individual will want to find out the reason why it was a no star hospital—as I say I think in that case it was largely to do with A&E—and then to understand that does not mean to say there were not first-class clinical services there.

  947. We have had universal evidence that the health league tabling with stars is vastly inferior to the kind of league tabling now being developed for local government through the Comprehensive Performance Assessment Regime, which is evaluative, which is judgmental, which brings in inspection reports, it does tell you something about the quality of the organisation. The fact is with the health star system you can have a clinically splendid organisation that falls foul of the star system and therefore produces a distorting account, you may wait a long time in A&E in a place where you get excellent clinical treatment, there is no correlation between what you are measuring here. What people really want to know about the Health Service is, "is it going to kill or cure me?"
  (Sir Nigel Crisp) If you look at the star rating system it does have waiting time issues in there, which are very important, and people may want to know whether the experience in a local hospital is good, bad or is going to be improved but the star rating system also takes into account a whole clinical section, as you may be aware, which picks up some of the clinical issues. It is a system that is developing and there are things that can be learned from the CPA in local government. It is also important to say this system is now moving over and it is going to be run by our health inspectorate. Again I suspect that will widen it out to some extent.

  Chairman: Yes, that is very, very good. Thank you very much for that. We will stop now. We have had some very, very good evidence from you and I am grateful for it. I will take up your offer of the current list of 62 targets so that we can do them the justice they deserve. Thank you very much indeed for coming along.