Flawed league tables risk confusion and harm

When health and social care secretary Wes Streeting announced the return of league tables last November, it was always going to ruffle feathers in some quarters.

At the time, he was under pressure to reassure the public and his peers that increased NHS funding would deliver results. His message was clear: there would be “no more rewards for failure”. The government’s 10 Year Health Plan has since confirmed that league tables will be a central part of its strategy.

But league tables are a double-edged sword. At their worst, they can result in 'naming and shaming' and closed organisational practices. If carefully designed and implemented, though, they could help drive healthy competition, strengthen local accountability and sharpen the focus of NHS leaders on national priorities.

Here, it likely won’t be a case of either/or – they will probably fall somewhere along that spectrum. And they will spark debate no matter what.

Many ICB and trust leaders we’ve spoken to in recent weeks support the principle of league tables. But rather than debating whether they should exist, the focus now must be on getting them right: maximising their potential while avoiding the well-documented pitfalls.

To that end, we have developed a four-point test the government and NHS England could use to help ensure they are fit for purpose.

Are they accurate and objective?

The value of any league table lies in whether what is being measured is meaningful. Yet, we’ve recently seen low scores allocated to trusts widely regarded as high performing, and vice versa, leaving leaders puzzled.

"The intention is understandable, but the execution is flawed..."

Concerns have been raised in particular about the Oversight Framework’s financial override mechanism, which uses a binary approach – in deficit or not – to limit organisations from progressing beyond a lower performance category known as “segment three”.

The intention is understandable, but the execution is flawed, with numerous examples of high-performing trusts being penalised for taking on stretch targets to support wider system recovery. We need to encourage rather than penalise collaboration. The override must be refined to more reliably identify organisations experiencing genuine financial challenges.

It is really important to get the indicators right so they accurately reflect how well the organisation is doing. There remain concerns to address, particularly for mental health, community, and ambulance services.

There are also persistent issues with data quality across sectors. This undermines the reliability of comparisons and risks drawing unfair conclusions. Where this is the case, NHS England should consider alternative metrics, and provide targeted support to help trusts generate consistently high-quality performance data.

Are they issues that matter most to the public?

We are very supportive of the 10 Year Health Plan’s commitment to public transparency, but the first question must be: are we presenting what matters most to the public? Tying league tables too closely to the Oversight Framework risks conflating the needs of two distinct audiences: patients and regulators. While their interests will often overlap, they are not the same. The Oversight Framework is designed to keep patients safe and help organisations improve. League tables, by contrast, are intended to inform the public, drive accountability and encourage choice.

For example, while financial management is clearly an important part of organisational performance, it is perhaps less material to the public than receiving high-quality, timely care. Yet, under the current system, any organisation in deficit will be limited to the bottom half of the league table, regardless of the experience or outcomes of patients under their care.

Do they provide clarity and context?

As well as choosing the right metrics, it is then important to present that information to the public in a way that makes clear what league tables do and do not show.

Without context and careful framing, league tables could lead to poorly informed decisions...

Without context and careful framing, league tables could lead to poorly informed decisions by patients, and misdirected scrutiny from politicians and the media.

There are things the government can – and should – do to protect against misuse and misinterpretation. For instance, when the public-facing dashboard is launched, NHSE could consider providing a clear and accessible explanation on its website of the data’s purpose and limitations.

League tables could also begin to incorporate metrics which measure improvements over longer time periods. Acknowledging longer-term improvement trajectories could help encourage high-performing leaders to take roles in more challenged organisations.

Do they drive perverse incentives?

When pressure to meet performance targets and a fear of being named and shamed in league tables create a high-stress environment for staff, there is a risk of changed behaviours, closed cultures, and distorted reporting, to improve the appearance of performance without improving patient outcomes or experience.

So actively monitoring the impact of league tables for unintended consequences, including any effects on system collaboration, staff wellbeing, quality and safety and recruitment to 'challenged' organisations, should be encouraged.

Where next?

While publishing league tables alone won’t improve performance, when based on robust metrics, and with the right safeguards in place, they can become a valuable tool for performance improvement and public engagement – rather than a source of confusion or even unintended harm.

Matthew Taylor is chief executive of the NHS Confederation. David Elkeles is chief executive of NHS Providers.