Some things never change. Sometimes something you consider long gone resurfaces when you least expect it. It’s even worse when all the evidence suggests that its demise was a good thing. So it is with the recent government announcement1 about hospital league tables, resurrected after nearly 20 years. Do we really need to run another destructive experiment just to prove something we already know – that this will make things worse, not better, for patients?
A league table establishes a hospital’s position with regard to all the others based on an arbitrary set of measures. This aggregation of indicators and ranking of performance is supposed to drive up standards and performance and so improve outcomes for patients. But it is a smokescreen. League tables will be sold as a mechanism for improving accountability to the public by helping them be better informed but in reality they represent a tightening of the leash of government control. Fear of failure will become the primary driver, with performance indictors the yardstick by which failure will be judged.
Introducing league tables will also shift the aim of the game. Suddenly the very thing you are supposed to focus on – patient outcomes – becomes less important than achieving the required standard – target – for each indicator. The two are not the same thing. An author could focus 100% on meeting an arbitrary daily writing word count and never once articulate an interesting idea worth reading. The measure is only ever a proxy for the real thing, which can’t be aggregated and made sense of because every patient, every hospital, offers a different context. Is the hospital large or small? Historically well funded or underfunded? Serving a relatively affluent population or a poor one? With high staff turnover or low? In an urban setting or a rural one? And so on.
Many of the measures will, in all likelihood, have little to do with actual patient outcomes and focus on quantifiable processes and things (such as waiting times, budget deficits) that are apparently important (read: easier) to measure. Despite this, all the evidence shows that managers do what is measured, regardless of whether or not it is the right thing to do2. Careers can hinge on making the targets3, regardless of what that means for patient care, as Rachel Clarke4 synthesises: “league tables are a very blunt and very public form of ritual humiliation – precisely the kind of punitive exercise that has demonstrably negative effects in healthcare”. And so the target becomes the focus, not doing what is right at any given time. Hit the target, miss the point.
Another core issue raising its head is prevention. Recent research evidences the negative impacts of closing children’s centres in underprivileged neighbourhoods in the 2010s. Not only did outcomes for young people worsen, but the Institute for Fiscal Studies report5 showed that for every £1 saved, there were associated costs of £2.85 accruing to other aspects of the public sector, such as criminal justice and education. In other words a set of actions designed to save public money actually cost the taxpayer significantly more than it saved.
As austerity took a strangle hold on local authorities, the cuts had to be made somewhere and young people we an easy target given they don’t vote, the impact wouldn’t be felt for years, it wasn’t a statutory (and therefore protected) service, and so on. But more importantly it illustrates a failing of those in Whitehall to take a joined-up, systems view of local public services. By slashing funding to Local authorities by over 50% during this time, Government was abdicating the responsibility for deciding where to make funding cuts, creating a double-bind for Local Authorities. They were left with little choice6. The false economy of savings in one part of the public sector only serves to drive up costs in another.
At first sight these can appear as two loosely linked and perhaps slightly niche issues around how we invest in and manage public services. But it runs deeper than that. When the focus of your work is driven by performance indicators and league tables, or making budget cuts and managing the retreat of the state, you are focused on process and not outcomes. They inevitably drive a myopic and predominantly insular view of what needs to be done and the prioritisation of time and resources that follows.
It’s unlikely, with reputation and perhaps careers at stake, that someone running a hospital (or closing a community facility) will have much time in their week or capacity in their thinking to contemplate the long-term generational impact of their decisions on population health (or young people’s life chances). And since transformational change requires us to get upstream of the presenting issues to address their root causes, the very performance regime proposed to help create change and improve health outcomes will have the opposite effect.
We need to let go of what doesn’t work and avoid the compelling desire to return to past mechanisms, particularly when their efficacy remains unproven. Perhaps it’s easier to stick with the known over the uncertainty of something different. But can we not be a little more imaginative in the way we mange our public services and in the accountability mechanisms that we build in to them? It’s time we figured out what that looked like in practice. This could be foundational to a new social settlement, one which articulates the relationship between people and the state, resets expectations, and is focused on how we make our public services fit for the 2050s.
3 https://www.theguardian.com/local-government-network/2013/feb/01/payment-results-staff-fictions
6 https://www.theguardian.com/commentisfree/2024/nov/17/britain-austerity-labour-uk-economy-councils
Ian Burbidge. 
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