In many ways, the NHS is one of the world's most successful organisations. Healthcare is getting better, not worse, meaning that we are caring for increasing numbers of elderly patients. But many dedicated and gifted individuals working tirelessly to give excellent clinical care to their patients are being badly betrayed by those that manage them at both a local and political level.

The problem is that we simply don't have a sensible debate about the problems of the health service. Attention is focused on setting targets, as if by merely setting a target you can solve difficult and intractable problems. All the current system does is to create a culture where any expression of doubts or dissent by senior staff and mangers about the organisations ability to achieve them, is stifled.

A hospital's primary task is easy to define; it exists to alleviate pain and suffering experienced by those that live in its catchment area. It does this by offering medical services organised in a way that achieves the most for patients from available resources. This simple objective is easily distorted if the attainment of targets is allowed to become the sole focus of hospital managements.

If the first priority of managers is to reduce waiting lists, then the temptation to do this at the expense of other medical priorities becomes overwhelming. Pressure is brought to bear on clinicians to make sure that no patient waits longer than the prescribed period - but this may mean that more urgent cases may be shifted back in the queue, or indeed in the case of specialist hospitals that some patients may not be admitted at all. Because the NHS sweats its assets so heavily, with bed occupancy often running at over 90%, it is impossible for the current system of target setting to operate in any other way. This situation could only be corrected if the government was prepared to build in spare capacity to cope with the peaks and troughs of clinical demand, so that the downside of target setting could be managed in a way that was less harmful to patients.

I have bitter personal experience of how obsessed hospital managements can become about attaining arbitrary targets. I lost my job as finance director of one of the country's biggest hospitals after flagging up the fraudulent reporting of cancelled operations figures and reporting the potential impact of trying to comply with the requirements of a flawed bureaucratic financial target. This could have resulted in the reduction of health care services to some of the most frail and vulnerable patients that the NHS has to care for. These problems came about because of the reticence of senior managers to tell those further up the hierarchy that there is a limit to what can be done when demand is infinite but resources are not.

Ministers and the NHS Chief Executive may make public pronouncements about how they will take steps to remove those managers who fraudulently alter waiting list figures, but the reality - as many senior NHS managers know - is that if politically disappointing figures are passed back to the NHS, the individual responsible will see their chances for advancement within the service effectively ended.

It is this "silent pressure" which is so damaging to the NHS: making truth the first casualty and encouraging managers to falsify their returns in order to get a good "Star Rating".

The reality is that if you feed a problem up the line you are making it a problem for the NHS and ultimately for the politicians. You are effectively saying 'look, we are doing our best locally, but because of problems outside of our control we can't make the system work and we are looking for help from Government to help solve our problem'. In effect, you are drawing attention to a potentially embarrassing problem for the NHS as a whole.

And so, instead, many play the "Silent Pressure" game and fraudulently alter figures, or conceal the truth. The chances are that you will never be found out and your career can keep on moving, and you will probably even get a pat on the back for achieving a "good performance". However, if you are unlucky enough for your fraud to be discovered, the NHS is protected. An investigation into the issue will come to the conclusion that that the misreporting was merely a failure of local management. The culprits can be sacked or moved to other senior positions in the NHS - as has been the case in the past. Everyone is happy - except the patients who had their operations cancelled, or the frail geriatric patients who find that the number of hospital beds available for their care has been reduced.

So how can we get out of this trap? In my view improvement will only be achieved when hospital managers feel free to report problems up the line and not believe that their careers will be ruined if they speak openly and honestly about the problems that they experience every day.

Unless the "silent pressure" is removed and hospital managers genuinely believe that the sanctions for telling an unpalatable truth are significantly less than those imposed for fiddling figures, the system is not going to improve.

The reality is that the NHS is always going to be juggling with resources and priorities. It is important that the decisions, which need to be made in relation to this, are taken on the basis of an analysis of the real problems afflicting individual hospitals and not on the basis of false returns being made to ensure that all problems that arise can be easily brushed aside as a failure of local management.

We need to move towards an NHS where decisions are made based on intelligent consideration of the difficult issues that society needs to face up to. We need to decide what level of health care we can expect the NHS to provide. The situation will not be improved by the imposition of arbitrary activity targets that will merely deflect management effort into claiming that targets have been achieved when, in reality, the effort has gone into making it difficult for patients to qualify to be recorded on the lists in the first place - and then fraudulently removing them from the lists if all else has failed.

We need to replace the targets culture with a system of "intelligent accountability", where as Onora O'Neil said in last year's Dimbleby lecture, "those who are called to account should give an account of what they have done and of their successes or failures to others who have sufficient time and experience to assess the evidence and report on it. Real accountability provides substantive and knowledgeable, independent judgement of an institution's or professional's work".

Medical professionals need to make a stand which emphasises the need for this more intelligent form of accountability within the health service. We need to show that it is still possible to stand up and tell the truth in the NHS without the fear of being penalised for having done so.

Send us your views

Do NHS targets create a culture of secrecy? Email us with your views and experiences at debate@observer.co.uk.

You can contact the author of this piece at ianperkin@blueyonder.co.uk, or write to Observer health editor Jo Revill at jo.revill@observer.co.uk.