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It’s a funny thing - targets. Like many bad ideas, they are intuitively attractive. Surely, it will be argued, they enable public services to direct their efforts where need is greatest and to determine whether those needs are actually being met. The service can be pro-active rather than merely reactive. Measurable outcomes mean that reality can be separated from rhetoric - in short, a better deal all round.

So much for the theory. In practice, the overall impact of targets has been very damaging and they must bear some of the blame for the failure of the vast and welcome increase in NHS funding to deliver proportionate increase in care, particularly for older people. Yes, waiting lists for hip operations and so on have been dramatically reduced - though it is not very clear whether median waiting times have been reduced quite so dramatically - but the hidden costs have not been measured and its impact on overall activity has been very expensive and in some respects, malign. Many of those hidden costs have been borne by older people whose conditions do not fit neatly into targettable entities.

It is sometimes forgotten that prioritising one kind of activity means relatively ‘posterioritising’ everything else. Secondly, choice of priorities - often determined by the discomfort of a minister at the despatch box - may not match clinical priorities. Thirdly, meeting targets will itself become the priority of priorities: they can therefore command whatever resources are required, however cost-ineffective this may be. I vividly remember when I was on the acute wards, the frantic activity that would gather round patients who have been in A&E for 3 hours 59 minutes. No effort or expense was spared to get them out - so that older people with physician-type problems would find themselves on the surgical wards being made very unwelcome or on the labour wards, being asked to push...because no expense is spared, the collateral damage to the care of patients with non-targeted conditions will be all the greater. The greatest damage will be done to non-measurable aspects of care, which patients value enormously and which is of over-riding importance in the case of chronic disease. When targets are being set, the measurable will always displace the immeasurable.

One thing that really irritates me is the assumption that we clinicians will not try to improve our services without political ‘incentivisation’ - carrots and Semtex. This is not only irritating: it is also exasperating for those who have been trying to upgrade their services for many years and found the experience to be rather like riding a bicycle up a vertical sand-dune or doing a can can in a marsh. To be finger-wagged into doing something one has been endeavouring to do without support is almost as bad for morale as being forced to act on priorities determined by political rather than clinical need.

Targets are also corrupting, creating a parallel world of delivery which is remote from the real world. When in the USSR targets for screw production were set in terms of the numbers of screws produced, factories produced millions of screws the size of iron fillings. Target met. When targets were set according to weight, the factory workers produced one massive screw. Target met. It is hardly necessary to say that this did not actually add to the economic health of the country.

Marginalising the professionals
Targets are just one example of health care policy that has been developed without consulting the profession. There are many others. Increasingly, we doctors are being marginalised, it being assumed that our views are neither expert nor disinterested, merely self-interested. We need to re-assert the authority of the medical profession and their leadership. This will not be easy for many reasons. Firstly, we have lost a lot of ground. It was this sense that doctors were no longer regarded seriously as leaders by policy makers and that prompted the RCP to commission a report in partnership with other bodies, on professionalism in medicine - Doctors in Society. Medicine in a Changing World - which everyone who hasn’t, must read. I was on the Working Group and I think we have produced something that will point the way forward. One of the things we emphasised was the need for a single body that would represent medical opinion over things that are of common concern - something rather more effective than the Academy of Medical Royal Colleges. Unfortunately - and this is my second point - doctors shall be busy acting on the 32 pages of recommendations for ensuring that we are safe, lovely to patients and honest, in the CMO’s report Good Doctors, Safe patients. The processes of relicensing, re-certification and re-validation will be very time consuming, not only for the licensee, the certified and the validated, but also for those who are going to do all this. Thirdly, our attempts to hold back the most stupid reforms have been presented by politicians and in the press as at best, merely a hostility to change - our innate conservatism (you would think that medicine hasn’t evolved fantastically over the last 20 - 30 years), and at worst, self-interested.

Most importantly, however, the new consultant contract has changed the role of the consultant - hitherto the mover and shaker, glue in the trust - in the direction of someone who follows the printed directions transmitted from Whitehall via the CEO. Of course, this is a gross exaggeration and I think in this respect, central control has peaked. The suggestion that the NHS might be managed by an arms’ length agency - a bit like the BBC (an idea, by the way, first put forward in the Porrit Report in 1966) - in a recent policy document and reiterated by Gordon Brown, is very encouraging. New Labour has at last recognised that its micro-mismanagement of the NHS is not delivering the kinds of things it had hoped and that even doctors have something useful to say about health care delivery and clinical priorities.

However, the new contract increasingly places pressure on consultants not to be troublemakers, to tow the party line, and not to suggest unfashionable non-government backed priorities to Trusts in debt. Dare I say it, the close link between delivering on the political prescriptions and clinical excellence awards can make one less willing to be a troublemaker, even when trouble needs to be made. Of course, our political masters would like doctors to be obedient shift workers, directed by puppet managers who are in turn manipulated from Whitehall. And it is a similar story with teachers. But I do believe the tide is turning. All three main political parties are now acknowledging that the professions have been ignored far to long and that the results of this have been profoundly unsatsifactory.

So, perhaps fighting the iniquities and stupidities of the politicians with their endless puerile and often dangerous ideas won’t be left to people like me who have no more hope of advancement. There is a lovely passage in one of Grimley Evans’ many beautiful essays, when he talks about the role of older people in society. Far from being ‘a social incubus, the new caste of older people freed from the tangling nets of employment and patronage could be the grey guardians of all our freedoms’. As the nets of employment and patronage become more densely woven, we need these guardians more than ever. But as I have said, I think the tide is turning.

Do more than wear purple
And about time too. The assaults on our freedoms over the last decade in particular, have come from many directions. They go beyond the legislation that, in the name of fighting terror has turned public buildings into fortresses, and placed us all under surveillance from DNA registers, CCTV cameras and databases. More insidious has been the ensnaring of those who might traditionally have defended freedoms in a liana of bureaucracy, ever-closer regulation, and patronage that depends on being on-message. The terror of being found politically incorrect, off-message, or simply unfashionable, now make self-censorship so natural, that it hardly noticed.

Traditionally, the challenge to the power of the authorities and the ‘tyranny of the majority’ in democracies has come from professionals, from academics and intellectuals, from the media, and from the young. These countervailing forces have all been seriously weakened. I have already mentioned the professions. We may look in vain to academics for a coherent critique of the current threats to our freedoms. After a very dark period in which humanist intellectuals took pride in denying that there was such a thing as truth, in spreading indiscriminate paranoia, and in publishing work that used opacity to simulate profundity, they have now moved on. Unfortunately, the discipline of the Research Assessment Exercise, embraced by universities in which the shots are called by managers rather than teachers, has ensured that academics in humanities departments concentrate on over-producing ‘high impact’ publications that are read by very few, not even their closest colleagues.

With some honourable exceptions, the media, by giving equal prominence to the serious and the trivial, and often lacking proportion and perspective, have greatly weakened their ability to document and challenge the erosion of personal freedoms by an increasingly corrupt, intrusive and centralised state apparatus. A misplaced egalitarianism, which gives equal hearing to the views of the well-informed and to angry vocalisations of the ill-informed, along with a frequently expressed hostility to professionals and experts - usually called ‘so-called experts’ - also serves the purposes of governments bent on extending their powers.

As for the young - well, of course we can look to them for a clear-eyed excoriation of the status quo. Unfortunately this is often evidence-free and experience-free. Besides, the dissidence of the young is mixed up with other things: rebellions against parents, attracting partners, and sorting out who and what one is.

Where, then, are we to look for the guardians of our newly endangered freedoms? This is where the growing cadre of healthy elderly people may be increasingly important. They have no hope or expectation of advancement or preferment. They are not required to bite their tongue or grovel. They have no targets to deliver on, no need to devote themselves to the futile productivity of academe, no asinine mission statements to write or respond to. They are at liberty to think and to say what they like. They can, therefore, shout out what those who have families to feed and careers to promote - and so must remain on-message at all costs - would not dare mutter in their sleep.

Because they have nothing to lose by speaking the truth; because they may be better able to bear the stigma that results when one casts timidity and calculation to the winds, they are (to use the jargon) a ‘precious resource’ we can ill afford to overlook. Elderly mavericks, by the way, should not be expected to squander themselves on the futile, unthreatening rebellious gestures such as ‘wearing the colour purple’ that Jenny Joseph envisaged in her over-anthologised poem.

This is not an argument for a cognitive gerontocracy but a call for this new and growing generation of rentiers to take up the battle to defend the freedoms they have enjoyed but which, if present trends are unopposed, their grandchildren may not. And so you geriatricians lie at the forefront of the endeavour to create and maintain and keep in good nick, the new class who will fight the good fight for freedoms...

Ray Tallis
speaking at the BGS Autumn Meeting dinner 2006