According to a report from the Picker Institute, an international think tank that has surveyed nearly a million NHS patients since 1998, the NHS has improved when subjected to government targets, but not otherwise. In some cases the service has become worse. Quoted in The Times, Angela Coulter, chief executive of the charity, said: “The most disappointing thing is that all the rhetoric about creating patient-centred care hasn’t led to improvements across the board. Only where specific targets have been set — in waiting times and in cancer and heart disease — are we seeing big improvements. Where there are no targets, in areas such as cleanliness and access to a GP, the service has not improved and in some cases has got worse. Many aspects of patients’ experience still need urgent attention.”
Scottish experience has been similar. The Scottish Assembly has not targeted waiting lists, but focused more on public health issues. In Scotland waiting lists are going up, suggesting that hospital managers respond to direct pressure by focusing effort on target compliance at the expense of services or activities not visible to the target setters.
What is missing is a constant, unrelenting pressure to provide the best service for customers. Public sector monopoly with targets is an improvement on public sector monopoly with no such targets, but a system based on competition would be better still. The imperfections of the human condition mean that without pressure to perform, the producers are likely to settle for a quiet life. More important still, by allowing scope for invention and experimentation, a competitive system allows standards to improve through a process of mutual emulation.