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League tables are frequently used to depict comparative performance in sport and commerce. However, extension of their use to rank services provided by healthcare agencies has attracted resistance, criticism, and anxiety. In this article we discuss the benefits and drawbacks of league tables and suggest that an alternative technique, based on statistical process control, could be introduced in their place. We believe that this technique would have the dual advantage of being less threatening to providers of health services and would be more easily understood and correctly interpreted by patients, auditors, and commissioners of services. League tablesFor many years league tables have been used to rank the quality of goods or services provided by competing organisations. They are commonly published in the popular press and magazines, specialist journals, and the internet. These tables range from those that simply rank crude performance on indicators to those that report sophisticated comparisons of summary adjusted statistics (such as those with uncertainty intervals around the rank). The public is prepared to pay intermediaries, such as financial advisers, or consumer organisations for this information. One of the best known UK organisations is the Consumers' Association. Its main publication, Which?, produces several league table equivalents each month (fig 1). Nearly half a million subscribers pay £37 annually (and many more subscribe to similar organisations) to study these tables in the belief that they will then make more informed purchasing decisions.The popularity of such league tables suggests that they are easily interpreted and valued by subscribers, which may, in part, explain the rapidity with which they were introduced in a modified form to rank the performance of public sector and similar organisations. Examples are the schools performance tables prepared by the Department for Education and Employment, the Home Office crime statistics tables, and the NHS high level performance indicators (fig 2). These NHS performance league tables are accompanied by explanatory notes, including the following statement: "In interpreting these types of graphs, it should be noted that if a Trust's confidence intervals do not overlap with the England rate, it is likely that their indicator values are genuinely different from the national rate." 1 Although these performance league tables (fig 2) resemble traditional league tables (fig 1), they have some important differences. A major difference is that the performance league tables include 95% confidence intervals around each provider's performance score. In

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Objective To develop a model to determine resource costs and health benefits of implementing guidelines for the prevention of cardiovascular disease in primary care.

Aim:The sphygmomanometer is an essential piece of diagnostic equipment, used in many routine consultations in primary care. Its accuracy depends on correct maintenance and calibration. This study was designed to: (1) assess the maintenance and calibration of sphygmomanometers in use in primary care; (2) assess the clinical, ethical, legal and public health implications of our findings. Method: A researcher assessed the accuracy of mercury and aneroid sphygmomanometers in use in 231 English general practices. He also made enquires about arrangements for the maintenance and calibration of sphygmomanometers. We conducted a small telephone survey in general practices across the country to determine maintenance and calibration arrangements across the country. We carried out a modelling exercise to explore the clinical, ethical and public health implications of our findings.