Adam Townsend
COO of VUITThe debate around the trade-off between the impact on performance of publishing NHS performance ‘League Tables’ and the impact on individuals and outcomes over time is high on the agenda of the NHS and DHSC at the moment. In this article we will explore the opportunities to deliver this in a different way: with a more nuanced and a more accurate reflection of true performance in terms of the impact on patients, the organisation and the public purse.
The Plus Side of Publishing Metrics
Publishing performance metrics creates a system where NHS organisations are held accountable for the quality and efficiency of the care they provide. By making data accessible to the public, the NHS:
– Builds Trust: Patients and the public gain insights into how well the system operates, reinforcing confidence in the NHS and demonstrating a commitment to openness.
– Empowers Choice: Patients can use metrics to make informed decisions about where to seek care, potentially driving improvements through market-like forces within the system.
– Supports Early Detection of Issues: Transparent data highlights variations in performance, enabling stakeholders to identify and address issues before they escalate into system-wide problems.
– Encourages Competition for Improvement: Public performance metrics can incentivise organisations to improve outcomes and efficiency, fostering a culture of continuous improvement.
The Risks of Publishing Performance Metrics
While performance metrics aim to improve transparency and accountability, they can sometimes lead to unintended consequences:
– “Hitting the Target but Missing the Point”: Organisations may focus narrowly on meeting specific metrics, often at the expense of broader objectives. For instance, reducing waiting times might inadvertently lead to rushed consultations or neglect of complex cases.
– Gaming the System: Metrics can be manipulated to present an organisation in a more favourable light, such as scheduling unnecessary follow-ups to improve perceived efficiency or selectively treating patients likely to achieve better outcomes.
– Stress on Staff and Organisations: The pressure to perform can create a culture of fear among staff and management, reducing morale and encouraging short-term fixes over sustainable improvements.
Data Misinterpretation
Publishing metrics without sufficient context can lead to misinterpretation by the public or media, resulting in:
– Reputational Damage: Organisations may face unwarranted criticism for poor performance on metrics that don’t fully reflect the complexity of their work.
– Skewed Perceptions: A single negative metric might overshadow other areas where an organization excels, reducing public confidence unfairly.
Striking the Balance: Recommendations for Effective Metric Use
To balance the benefits of transparency with the risks of unintended consequences, the NHS must adopt a nuanced approach to performance metrics:
1. Adopt a Balanced Scorecard: Metrics should incorporate cost, quality, and delivery equally, providing a comprehensive view of organisational performance.
2. Ensure Contextualisation: Data must be accompanied by explanatory information to prevent misinterpretation and highlight nuances.
3. Promote System-Wide Objectives: Metrics should encourage collaboration rather than competition, aligning organisations to shared NHS goals.
4. Regularly Review Metrics: The NHS should periodically review and refine metrics to ensure they remain relevant, accurate, and resistant to gaming.
5. Incorporate Stakeholder Feedback: Engage patients, staff, and system partners in designing metrics to ensure they reflect on-the-ground realities and broader health outcomes.
A Balanced Scorecard Perspective: Thoughtful Metric Design to Mitigate Risks
Critics argue that performance metrics can incentivise counterproductive behaviours, such as an overemphasis on specific targets at the expense of broader goals. However, when metrics are thoughtfully designed using a balanced scorecard approach—encompassing cost, quality, and delivery—they can create a more holistic picture of NHS performance.
– Cost, Quality, and Delivery Alignment: A balanced scorecard ensures that metrics do not disproportionately prioritise one aspect of performance. For example, a focus on efficiency (cost) is tempered by metrics on patient outcomes (quality) and access (delivery). This prevents “hitting the target but missing the point.”
– Comprehensive Metric Design: By expanding metrics to cover all aspects of NHS delivery, including patient experience, equity, and innovation, the risk of unintended consequences is minimised. Managers and organisations are less likely to game the system when the data set is robust and interlinked.
– System-Level Incentives: Balanced scorecards shift the emphasis from individual organisational performance to system-wide objectives. This encourages collaboration rather than competition and ensures that all parts of the NHS are aligned in their efforts to improve patient care.
This approach recognises that while no metric is perfect, designing them thoughtfully and in alignment with broader NHS goals can mitigate many of the risks associated with publishing performance data.
A Worked Example – Elective Care – Cardiology:
Here we will look at an example of how elective surgical performance could be reported and managed.
Final Thought: Transparency with Accountability and Thoughtful Design
Publishing performance metrics is both a responsibility and a challenge for the NHS. Transparency fosters trust, accountability, and improvement, but poorly designed metrics can incentivise behaviours that undermine broader objectives. By adopting a balanced scorecard approach that aligns cost, quality, and delivery, and by contextualising and refining metrics regularly, the NHS can harness the benefits of transparency while minimising its risks.
The goal is not just to measure performance but to ensure that what gets measured truly matters. Through thoughtful design and careful implementation, performance metrics can drive real improvements in care delivery and outcomes while maintaining public confidence in the NHS.
For more of Curia UK’s analysis on healthcare, please click here.
To find out more about becoming a part of Curia UK’s Health, Care and Life Sciences Research Group, please email team@curiauk.com.