NHS league tables are back – but turning rankings into better care is harder than it looks

The UK government has launched NHS league tables for every trust in England, promising transparency and an incentive for improvement. The idea is simple: rank providers of health care and reward the best.

But national health care is not a simple thing^[1]. And trying to convert something so complex into a single ladder^[2] of winners and losers could end up distorting medical priorities and resources.

For example, the way waiting times are measured for elective (non-emergency) surgery is (and needs to be) different to how they are measured for cancer treatment and A&E. Mixing these into one overall “score” for waiting times could encourage NHS trusts to focus on the most rank-sensitive elements of healthcare, even when bottlenecks exist elsewhere (such as diagnostics or community care).

This can lead to a kind of tunnel vision, where what’s measured is considered to be what matters most. Previous research on rating shows how rankings can shift hospital managers’ attention^[3] from broad quality to narrow score keeping.

Another challenge is that different NHS trusts operate in very different contexts. Patient populations vary in age, and in levels of affluence and deprivation – factors which can directly influence demand on a hospital and its clinical outcomes.

A hospital serving an older and poorer population may find it much harder to meet targets than one that serves a younger and healthier area. And while league tables are supposed to be compiled in such a way that they account for these kinds of differences, the adjustment calculations are never perfect.

If league tables fail to account for these realities, they risk labelling overstretched hospitals as “poor performers” when they may in fact be delivering strongly against difficult odds^[4].

Evidence^[5] also shows that when patients are given more choice about where they receive their healthcare, some do explore their options. But distance and the availability of transport make a huge difference.

If you can’t get to the hospital you want, the choice is not really there. And “competition” between different trusts falls sharply outside dense urban markets. In practice^[6], many patients simply take their GP’s recommendation and use the nearest viable hospital.

So while league tables designed to encourage choice and stimulate competition may help to raise quality, they also carry risks – most notably amplifying regional inequalities. Such rankings could then become magnets, drawing both patients and staff toward “elite” hospitals.

If rankings trigger “patient outflows” (people choosing to go elsewhere for care) and health professionals being reluctant to work in lower-ranked hospitals, a vicious circle develops, making that low ranking even more difficult to shake off.

And moves towards greater transparency require greater support as well, with extra staffing and diagnostics capacity, as well as targeted recruitment and retention schemes in hard-pressed areas. Otherwise, the policy risks deepening geographical inequalities^[7].

For emergency care, for rural areas, or for people with limited mobility, improvement will depend on better coordination and sufficient capacity, such as ensuring that ambulance services^[8] are well linked to hospitals with intensive care beds.

League tables can shine a light. But light without lenses can distort. (The NHS itself acknowledges the risk^[9] of crude comparisons that league tables can bring.)

To avoid perverse incentives and widening gaps, rankings should be used as a starting point for deeper analysis, not treated as a final verdict. They need to adjust for differences in patient populations so that hospitals treating sicker or more challenging patients are not penalised.

They need to be designed to minimise gaming the system (by preventing hospitals from prioritising easy cases just to hit targets for example). They need to give GPs the tools and authority to direct patients to the most appropriate services, and pair transparency with extra support for areas of highest need.

Done badly, rankings reward already-advantaged hospitals and shift efforts towards chasing the scoreboard. Done well (using risk-adjusted, specialised dashboards^[11]) they can help tackle the real causes of long waits and uneven care.

Performance data needs to be used with caution, linked to GP referral systems where patients actually make choices, and accompanied by targeted support for those areas serving the most complex populations. Without these safeguards, league tables risk distorting behaviour, encouraging tunnel vision and amplifying existing inequalities in the NHS, rather than solving them.

References

1. ^{^} not a simple thing (theconversation.com)
2. ^{^} single ladder (www.gov.uk)
3. ^{^} shift hospital managers’ attention (pubmed.ncbi.nlm.nih.gov)
4. ^{^} against difficult odds (www.kingsfund.org.uk)
5. ^{^} Evidence (www.aeaweb.org)
6. ^{^} In practice (www.kingsfund.org.uk)
7. ^{^} deepening geographical inequalities (www.aeaweb.org)
8. ^{^} ambulance services (bmjopen.bmj.com)
9. ^{^} acknowledges the risk (www.england.nhs.uk)
10. ^{^} Panchenko Vladimir/Shutterstock (www.shutterstock.com)
11. ^{^} dashboards (www.cdc.gov)