NHS league tables: how do performance rankings impact NHS trusts?

 Hello and welcome to the latest edition of Health on the Line, produced by Health Comms Plus on behalf of the NHS Confederation.  

Well, September is here and we are already deep into the throes of winter planning. And with that, looking at how we approach vaccinations, we've got a fantastic webinar coming up, all about improving vaccine uptake with a great panel of experts. So do join us online. Thursday, the 2nd of October with guests including Kate Woolley, director of immunisation and vaccinations for NHS Birmingham Solihull.  

To sign up, go to our website@nhsconfed.org and our events section. The event is open to anyone with an interest increasing vaccination uptake.  

Now, this week you'll have seen the government published new league tables for NHS trusts. We know that back in November 2024, the Secretary of State announced NHS England would assess trusts against a range of performance criteria and publish the results, and now we have them.  

There are interesting aspects to these results - specialist trusts near the top, we see some parts of the country having more ‘highly rated’ trusts than other parts. Some trusts that have got good reputations coming surprisingly far down lead tables.  

So to discuss that, to discuss maybe how things look ahead of winter and various other things that have been happening in the health service, I'm delighted to be joined by our very own Rory Deighton, director of the Confed acute network, and Rebecca Gray, director of our Mental Health Network. Welcome both back to Health on the Line.  

But before we get into any of that, there has been an earthquake in the world of mental health with the resignation of Claire Murdoch, longtime national director of mental health. So Rebecca, I mean, this is the end of an era. 

Rebecca Gray 

It absolutely is. I mean, Claire has been a phenomenal force within the sector and within NHS England, she's really been. I think the term will probably be overused in the next few days, but ‘a fearless voice’ for the mental health sector within national health policy and has driven and supported much of the change that we're starting to see kind of crystallised through some of the stuff that's in the ten-year plan around equipments to mental health support teams in schools and some of the changes in adult community mental health services. So yeah, a very big shift and it will be very interesting to see what happens now.  

Matthew Taylor 

I don't think it's any secret is it that Claire has been a thorn in the side of a variety of administration, secretaries of state and NHSE leaders because she's been a doubty-fighter for mental health. And I think the possibility of her resigning has been around before. I think she maybe, if not directly, she may have implied on a number of occasions over the years, unless mental health was treated in the right way, she wouldn't kind of simply stand by and watch happened. 

But now she's done it. She's actually walked away and she's made pretty clear, I think in the letter that she sent, that this reflects some concerns that she has about mental health.  

Rebecca Gray 

Yeah, I think they're right and I think that they are concerns that are reflective of concerns that exist across the sector. 

A system under the pressure that it's experiencing now with the intense focus, particularly on acute elective weights that is stretching all organisations - acute trusts and broader systems, that there is a risk that mental health services and community physical health services as well as primary care are, despite the ambitions of the ten-year plan, not supported adequately to deliver the left shift that's needed and that people with mental illness who are often very invisible in many senses  in society more broadly, will not be a focus of policy or funding.  

I think there's always different styles and different approaches. Some work better in some circumstances than others. We've seen quite a lot of change in NHS England. There's a very different dynamic I think in both political and in leadership within NHS England and whether Claire felt she was able to make the impact she wanted to, I think is clear from the letter that she didn't feel that at the end of the day it.  

It leaves a gap and I think it's going to be really important that there is effective, confident mental health leadership within NHS England as we start to roll out the ten-year plan and organisations are being expected to drive improvement and productivity very hard, and that needs clear and expert leadership within the centre.  

Matthew Taylor 

And correct me if I'm wrong, but weren't we promised in the ten-year plan that there would be a mental health strategy sometime later this year? Am I right about that? 

Rebecca Gray 

It's an interesting question. We do know that there is going to be something called a modern service framework next year, and actually that's really positive. I think that work will probably be led, or is being led by Adrian James, the national clinical director, who is a great voice for mental health services in that role. 

There has been talk of whether there's a mental health strategy being developed or not, a plan that might sit alongside the ten-year plan for implementation over the next four years. It would be good to know whether that's happening or not and how we can contribute, to be honest.  

Matthew Taylor 

So I guess the onus is going to be on, you know, Jim Mackey and folks at NHSE and also to an extent on Wes Streeting with Claire Murdoch's departure, which will cause ripples across the health service and particularly the mental health world, to do some stuff over the next few weeks to reassure people because while Claire was there, everybody knew there was somebody who was willing to kind of rattle the bars when they needed to be rattled in defense of mental health. And with her gone, people will be worried. So yeah, it'll be interesting to see what happens in that space.  

Now let's turn to league tables. There are big issues around league tables and mental health, which will come to with you in a moment, Rebecca, but before we get into what's been published and what we think of that and what its implications are, Rory, it'd be useful just to kind of remind people the Confed, along with our colleagues NHS Providers, produced, I thought a really good long read on lead tables a few weeks ago.  

Could you just remind people of what we said in that long read in terms of the objectives of lead tables and some of the issues that we needed to be careful about in publishing them. 

Rory Deighton 

Thank you, Matthew. And yeah, I think the first thing about league tables, the first thing that we've always said is that we recognise that league tables are here, they're here to stay, that we're not pushing back against them. This is part of a wider shift towards board accountability and leadership accountability in the NHS and we are comfortable with that and our members are comfortable with that.  

We've always said that league tables can be a useful tool to drive improvement. They encourage healthy competition and they sharpen the focus of trust leaders on some of those national priorities. But, and there's always a ‘but’, history shows us that they can lead to unintended consequences if they're desired poorly, and if they're used to name and shame some of our providers and members.  

And that last bit is a little bit out of the government's control, and this week we've seen a number of examples of the sorts of headlines that leak tables can generate. So ‘Named and shamed Britain's worst hospitals’; ‘The true scale of NHS failure revealed for the first time’. Just a couple of those headlines, and that's unhelpful to our members, to the people delivering great care every day. Unhelpful to the government as well, but they are to a certain extent inevitable. And so it makes it even more important that the lead tables that we have are accurate and robust and reflect the things that matter most to patients.  

When we did the work over the summer and it was really good and thoughtful work, and I think listeners, it's worth a read again.  

We put four tests up there with NHS providers. We asked, do the league tables provide an accurate, an objective account of the organisation's performance? Do they reflect issues that matter to the public? Is it clear what they show and what they don't show? And has the risk of perverse incentives been mitigated? And it's interesting, I think, to talk about what's happened this week through those, those lenses. 

Matthew Taylor 

You are right, of course, Rory, about the headlines that we saw. Pretty lurid headlines in various places. But it was interesting, I thought that the Today Programme featured Lesley Dwyer. She came onto the Today Programme, which I thought was kind of quite brave actually as the chief executive of Kingston Hospital, which was at the very bottom of the league tables, and there was quite an interesting conversation. 

So yeah, I guess to be fair to the league tables, it kind of depends on which media outlet you're talking about. I think the Today Programme helped people to understand why it is that hospitals can have challenges and probably gave people listening some confidence that this was the chief executive who was determined to kind of get to grips with improving performance. 

But other bits of coverage were less informative. I mean, I guess in a way our role at the Confed now league tables are out there, is to try to encourage that more intelligent debate, isn't it?  

Rory Deighton 

Absolutely Matthew, and I think Lesley is a great advocate and a really thoughtful advocate for the service. And I remember you and I talking to their chief operating officer in January, I think you spoke to Lesley in January as well, and King’s Lynn were doing some really fabulous things with patient flow. The relationships they had with their local council were really smart. They were discharging people. They're managing to discharge people earlier and more quickly than they have ever had done before. 

And King’s Lynn is a trust that has just about every disadvantage going in terms of it being a rack reinforced concrete hospital. It is a rural community. It's a coastal community. It's a small trust. It's a district general hospital and it does fabulous things with all of the disadvantages that it has. 

There were a couple of things I think that the league tables really struck about me this week and the importance of league tables to the public I think is a really interesting idea. This is part of the government's aim to be open and transparent with the public. And I think one of the things that lead tables don't quite get right is that they link the aim to be transparent with the public to the oversight framework.  

And I think some of the issues we've seen this week play out is due to that link. On the financial override, for example, so financial management is a really important part of where the NHS is at the moment. It's really important that we start to operate within the money that government has allocated to us. But for patients, that's not necessarily the most important thing. The patients will be interested in the best health outcomes, the best patient experience, and the shortest waits. So the importance of the financial override, butts against perhaps what patients might want to see out of the league table. 

I'm in Halifax today. I wouldn't make my decision to go somewhere else based on those league tables. I would go to my local hospital. And similarly the league tables I'm interested in, league tables that present data at a trust level. Whereas actually, if I look at the Care Quality Commission, I can see ratings by different types of service. So I might choose to look there instead.  

And I think Jacob Lant this week, the chief executive from National Voices, said some really smart things about how perhaps the league tables might shift a little bit to make them a little bit more patient focused and a bit more relate to the things that patients find important. 

Matthew Taylor 

Yes. I think the international evidence suggests that the public don't really set an enormous amount of stall by these tables, and partly because, as you say, they're very aggregate and patients are actually interested in the doctors, the particular services they're going to receive, partly because in many areas of service, there really isn't any alternative, but your local provider.  

But as you say, this is the beginning of a process and we need to try to ensure that if league tables are going to be there, they are more helpful.  

But Rebecca, there's lots of issues. Around these league tables in terms of mental health. But let's start with that point that Rory made about the financial override, which I'm sure most people listening know that if you are in deficit, it means that you can't, however good your other bits of performance are, you can't be in the top two of the four segments.  

I was chatting to you the other day and you said that, and I'm not asking you to name names, but you said that a couple of the mental health trusts that had been pushed down, one or two segments their deficits were absolutely tiny. It was just a few thousand pounds.  

Rebecca Gray 

Yeah, that's absolutely right. So we've spoken to a few members where it may not be deficit, maybe a variation from plan, which is one of the financial metrics, is under £100,000. And one where under £10,000 I've spoken to.  

Now, my understanding is, I can kind of see this as a position that there is a real focus on this incentive to have absolutely zero tolerance around variation from plan and recognising financial deficit. I think the point there is not necessarily how fair or not it is to trusts because I think those trusts will quickly resolve those relatively small issues by the next quarter. I think what it points to is what we'll see is loads of fluctuation in these tables.  

You'll see the financial metrics, particularly in sectors where there's a very small number of metrics overall. So, if you look at the number of metrics is a tiny number of metrics in community mental health services. You take out the financial ones in community health services, you take out the financial ones, and I think you've got two or three metrics. I mean, it's maybe for tiny number in mental health. It might be seven, something like that.  

But we'll see a big change. If you look at the financial schools in this quarter compared to where we get to next quarter, you'll see some of those trusts that automatically flipped into segment three, moving into segment one or two. And as people start to declare probably a more difficult financial position, there'll be trusts that we're in higher segments that will start to move through direct towards the end of the financial year, potentially into to lower segments. 

Now we know that some of this is about driving out that behaviour, getting people to be more honest about their financial position, more transparent about their financial position as early in the year as possible, but these things, and a number of the other metrics, will create enormous fluctuations. 

So Rory, going back to the points that you made, if you're thinking about this table to inform the public about where, successful or failing, trusts are, or to drive, and I think we haven't come to this bit yet, to drive decisions around things like new FT status or the ability to take on broader responsibilities, we're going to get into real difficult areas. You know, I'm all for transparency. I mean, bizarrely, it feels very deja vu to me. I was involved the publication of star ratings a million years ago in something called the Annual Health Check before the CQC existed. And I absolutely think that the publication of benchmark data is good for the system. At the time it was very much meant to be driving choice but patients I don't think that's necessarily what is envisaged as doing that at the moment.  

It's a good thing, but how you present that data and more important, we always say this with data, don't we? how you use it. You need to be clear how data's going to be used before you share it, and the risks around use in order to determine what trust can or can't do. Whether chief execs stay in role or not, are big factors in this.  

You are absolutely right, Matthew, internationally, we know that the public don't really go to published data in order to inform their view of health services. They talk to their neighbours and their friends and people who work in the health service, who they know, but it has a massive impact on staff. 

Some of the biggest concerns of members of raising me in the last few days who have been in the lower end of the table have been the challenges of chief execs, particularly those who may struggle to attract staff more. You know, you talked about rural areas and some of the coastal areas where it may be tougher to attract the staff that organisations need. 

That's the impact that I think is probably being felt more than some of the public scrutiny by leaders at the moment.  

Matthew Taylor 

Yeah. So we'll come back to that, this question of the implications of, of these lead tables. Clearly I don't think anybody would say, and I don’t think even the department, NHS England would say that the data foundation for the rating of mental health trusts, community trusts, ambulance trusts, is yet nearly as kind of comprehensive and balanced as it needs to be to get a picture. 

There was a commitment to get these lead tables out. They're out. But I think with some recognition of some of the limitations of the data.  

But there are other things aren't there, Rory, about these tables, which, which indicate that they may tell you a bit about the quality of leadership and organisations, but they also kind of just tell you about the nature of the organisation. 

So for example, the domination of the acute lead table by specialist trust, many of which don't have the thing, which many general hospitals find the biggest challenge, which is accident and emergency departments.  

Rory Deighton 

Absolutely Matthew. And I think this hint that the space in between the metrics and that's where we need to be looking and where we need to be watching. 

And one of the things that I think that we've heard a lot over the last two or three weeks is the potential impact for league tables to change behaviours and to move us away, at the very time where we need to be collaborating more, integrating more, supporting  different parts of the NHS in different ways, that league tables and the focus on board accountability may well drive behaviours that undermine system collaboration. And I think I've heard that a number of times this week in terms of organisations’ willingness to give up some of their financial surplus, especially rating around elective care pressures and potential for mutual aid and sharing resources and opportunities with neighbours.  

I think that's something to watch and something that I think we've started to see. I met with some provider collaborative leaders earlier in the week and they felt that that was starting to happen a little bit. So that tension between what we all need to be doing as a healthcare system - work more closely together, integrate more - that tension between that and the move towards board accountability, league tables is something that we need to watch. We need to make sure that one way working doesn't directly butt up against another.  

Matthew Taylor 

And then there's Rebecca's point there, Rory, about potential kind of volatility in these tables, particularly in relation to this issue of the financial override. 

Because you and I met a group of acute leaders a few days ago and it was pretty clear from talking to them that they are going into winter feeling that they're being asked to square an impossible circle, which is more activity, preparing for winter and trying to deliver on what were already incredibly stretching, arguably impossibly stretching, cost- improvement programmes. 

I got the sense from that conversation that unless NHS England is suddenly going to announce, well, you don't need to try to reduce your waiting lists anymore. It is very likely that more organisations will be going in into deficit, and there as a consequence, they'll be seeing their league table ratings coming down by a couple of segments. So that financial override could lead to these tables moving around quite dramatically, couldn't they? 

Rory Deighton 

I think these tables will move really dramatically over the next few quarters. Rebecca's already alluded to the idea that some trusts have missed their targets by £8,000. That not going to happen in quarter two. And I think that we'll see significant changes as finance directors understand how to play the game slightly differently and to manage things in a slightly different way. So I think we'll see lots and lots of movement.  

I think to their credit, NHS England have already reached out to us and NHS Providers to ask for feedback and ask for reflections. And I think there's a genuine willingness to make league tables work.  

The one that has really struck me this week is Birmingham community, somewhere that you've been Matthew, somewhere that our Secretary of State has been as well, arguably typifies and exemplifies the sorts of behaviours that we want to see and that the ten-year plan asks us to describe. It's neighbourhood-based working; it's smart integration; it's different ways of bringing different parts of the system together. It's everything that's good about the shift from hospital to community, but it's a trust that because of one metric has ended up right at the bottom of the list. And it was really striking to talk to them this week and listen to the impact that that's had on their staff and a group, a leadership team that's doing fantastic things, having to say to their staff, listen, we used to be right at the top of the tables and now at the bottom, and this is why, and we need to understand that together.  

So I think Rebecca is right. I think you are right. We'll see lots and lots of movement as people change their ways of working and ways of reporting over the next few months.  

Matthew Taylor 

And that, I think Rory, and you hinted at this, Rebecca, that's where I start to get most worried because, we all know that the scandal at mid-Staffs was one of the reasons why previous government moved away from league table type approaches because it was felt that, in that case, the pursuit of particular measures in order to get to FT status had led to a culture where patient care had just almost completely been forgotten by many people within, within that trust.  

So we know where that danger lies. And then you think, well, so here you've got a situation where many trusts will be in financial difficulties. The chief executive and the board of that trust will know that if they can't find a way of massaging the figures to show that they aren't in deficit, that they're in danger of dropping down segments and that that will be in the public, the local newspaper might be saying that they've gone from being in the top group to being in the third or the fourth. There's a lot of pressure, but then it goes beyond that because they'll know that if they're in deficit, that that threatens FT status of the audit or it threatens them getting their FT status renewed. And then beyond that, if they have an aspiration to be an integrated health organisation under the ten-year plan, that too depends upon FT status. 

So you've got people under immense pressure to find a way of presenting things that will have huge importance for the future of their trust.  

I do worry about the incentives that we're creating here. Am I being too alarmist, Rebecca?  

Rebecca Gray  

I don't think so, although I do think that senior leaders in NHS England will tread very carefully in the short term about using these tables as they stand to drive some of those decisions in the short term. So it'd be very interesting to look at what the actual kind of capability process it looks like around these things.  

I think the thing we need to talk about is how do you improve what's there and add in sensible measures which relate to quality? 

I think that there is lots of work to be done. So mental health, you know, there for years people have said the data isn't there. Well there's loads and loads of data. There is a big challenge in mental health about completeness about consistency, about how clean data is and therefore about comparability. 

And I think this will drive a lot of data cleansing and data improvement activity within mental health trusts. We know the history of that is partly because there isn’t the payment-by-activity that drove a lot of the data completeness in other sectors, and it hasn't done so mental health. And there is a challenge there in terms of some of the capability and capacity within trust teams to do that well. But hopefully they are short to medium term issues.  

I think we need to and hopefully we can work with the centre because our members are desperate to contribute, I think, to a more meaningful set of measures. So I'm not a data analytics expert, I'm not the person to define it, but if you take an example, like length of stay in inpatient wards in mental health services, at the moment, that is a measure which looks at how many patients stayed more than 60 days in a mental health unit. That is an important measure; we don't want people staying in hospital for too long.  

But there's two things I think are important in that length of stay without short-term readmission rates are not necessarily a good measure of quality. So what you don't want is people being discharged too early and back in revolving door and bearing the consequence of that for them and their families and the system. 

So, thinking about what do you add into something like this to make it more meaningful? Also, and there'll be a groan from somewhere in an analytics team somewhere when I say this, but thinking about waiting, so length of stay is in mental health unit has a very direct correlation UK and internationally to deprivation. You know, everything mental health has a strong correlation to deprivation. If you have a poorer population, length of stay in wards will be longer. Partly because acuity of ill health is longer, partly because the complexities of getting people home are more challenging with severe mental illness. 

So, thinking about how do you build this, some of this stuff in? Now the centre had been listening to some of this. There was a metric in for mental health around restrictive practice and restraint. You know, we're trying to, in the system and there's been great success in this, gradually decreased the amount of physical restraint of patients on wards. That came out of the final set because the centre heard concerns that what we don't want to drive is people not reporting restraint in order to hit the target. 

I still think something we do need to think about, well, how do we have a measure that looks at, you know, rapid tranquilisation seclusion restraint in mental health services? Because we do want to continue to address that, have transparency on that, and particularly recognise that it affects people from some communities much more extremely than others.  

So, there has got to be some more thinking that can be done and I hope we can work with NHS England and others. You know, NHS Benchmarking have got some brilliant data in mental health, really complete and we should be thinking about the assets we have across the system too to make these better. 

Matthew Taylor 

And we have opened that dialogue and the door does seem to be open to trying to develop a better, broader, more helpful data set for future analysis.  

Look, it's been great talking to you both. I'm just going to end, Rory, with a question for you, which is going back to that conversation that we had with acute leaders a few days ago.  

Nobody ever knows how difficult winter's going to be because it depends to some extent upon how much illness there is around. Some of the data I was seeing from Australia in terms of flu is quite concerning. 

We know that those vaccination rates have fallen, which is also something which increases our vulnerability going into winter. I don't want to use the phrase perfect storm, but certainly the storm clouds are coming over.  

What do you want to hear from our politicians, Rory? We've heard this week from the Treasury for example, that there will be a crackdown on any kind of last-minute emergency funding for things. So you know what used to happen over many years, which was when the NHS faced a real squeeze in terms of its ability to meet need, there would be a bailout. But I think the Treasury made absolutely clear there won't be such a bailout and I think Wes Streeting has talked in the past about how he thinks these kinds of winter to bailouts are very poor practice. 

So given that we've probably got the resources that we've got, but also the pressures that our leaders are talking to us about, what do you think we should hear from our politicians in terms of talking to the public about kind of challenges the health service might face in the winter?  

Rory Deighton  

I think what people want more than anything is honesty. I think that's what we're looking for. I think, years ago the Confed had a role in advocating for additional money, for additional resources for our members. I think our positioning on that has changed significantly. We recognise that additional resourcing is unlikely and that's not what we're asking for anymore. 

But the importance of vaccination programmes over the next three months or so is really, really significant. Getting vaccination levels up as high as they possibly can to mitigate what NHS England called the ‘quad demic’ last year. That's really, really important. Honesty and consistent messaging from government on the way that people use services over that period. 

I listened to a leader acouple of weeks ago just talking about that six week period in January and first two weeks of February, and just saying that the capacity that the NHS has over that period is broadly the same as at any other time of the year, but the demand over that period increases significantly. And our comms colleagues don't like this analogy but she talked about a bank holiday weekend when there is more traffic on the roads, but we don't build more motorways over that period, and it's not a helpful metaphor because this is health and care in people's lives, but how are we honest with the public that the NHS has to deal for six-week period with a significantly increased level of demand of people who are really poorly for that period.  

And we just need honesty as we work through the challenges of reforming social care, as we work through the, the challenges of building a capital programme, that's what we really are looking for from government. It's not the additional money we recognise the additional money isn't coming, but that honesty on the scale of the challenge that our members face, it's probably what we're looking for. 

Matthew Taylor 

Well, thanks Rory, and I think that's something that we will be saying increasingly loudly over the weeks to come. 

Rebecca, Rory, thank you so much for sharing your thoughts with us today.  

And listeners, if you are doing work that you think is particularly exciting or innovative that you want to share with colleagues across the health service and beyond there, please do tell us about it. You know, you might end up being interviewed by me on Health on the Line. If so, contact Health Comms plus@nhsconfed.org.  

Goodbye.  

You've been listening to Health on the Line produced by HealthCommsPlus.  

HealthCommsPlus is a highly effective, innovative, and creative communications agency brought to you by the NHS Confederation. 

We offer creative, professional, and cost-effective service for NHS and public sector organisations across the UK. Any profit we make is reinvested in the support we provide to NHS organisations on wider health and care systems.