Performance league tables: the NHS deserves better

Abstract

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

Geographical inequalities in lung cancer management and survival in South East England: evidence of variation in access to oncology services?

“…The limitations of performance league tables have been discussed elsewhere (Goldstein and Spiegelhalter, 1996;Adab et al, 2002). We have addressed these criticisms by adjusting for case mix and by fitting statistical models which allowed for the correlation of responses within areas or organisational units.…”

The use of control charts in monitoring postcataract surgery endophthalmitis

“…7 The annual incidence for each year was calculated. The control chart method was used to analyse the data to investigate the pattern of unusual variation and the possibility of an outbreak retrospectively.…”

“…The control chart is a method that has been used widely in healthcare at operational, clinical, strategic, and public policy level [6][7][8][9][10] to effectively detect unusual variations in a system. We feel that this method has a useful role to detect variations in the rates of endophthalmitis and early outbreaks in postcataract surgery endophthalmitis.…”

The Information Transparency Effects of Introducing League Tables in the Health System in Malawi

“…Existing literature describes league tables being applied at various levels of health systems: at the national (ten Asbroek et al, 2004); at the sub-national ; at the provisional (Edward et al, 2011); at the district (Kossi et al, 2013); at the facility (Adab et al, 2002); and at the programme level (African Leaders Malaria Alliance (ALMA), 2013). However, the effects of introducing and implementing league tables on the health information systems as a whole remain relatively unexplored.…”

“…League tables have been used for performance monitoring of health services, along with other monitoring tools such as control charts (Woodall 2006;Marshall et al, 2004;Tekkis et al, 2003;Adab et al, 2002), scorecards ten Asbroek et al, 2004) and dashboards (Ghazisaeidi et al, 2015;Purbey et al, 2007;Yigitbasioglu & Velcu, 2012). While all tools are used for visual presentation of performance measures of organizations, the league table has an added function in that it makes a comparative ranking of indicator scores of organizations units.…”