Setting Targets for Health Care Performance: Lessons from a Case Study of the English NHS

Abstract

This paper examines problems of setting targets for health care performance in which the centre sets a uniform set of targets and levels of performance. The case study examined by the paper is from the system of performance assessment of ‘star ratings’ that was introduced from 2001 by the Department of Health to give each organisation in the NHS in England a single summary score from zero rating to three stars. Star ratings were directed at holding trusts' chief executives to account for the local delivery of national priorities through a process of ‘naming and shaming’, in which Chief Executives of zero-rated organisations were at risk of losing their jobs. This paper outlines the underlying model and its three underlying assumptions: the centre can determine a scoring system to prioritise what matters; failures of performance that are not reflected in the scoring system do not matter; and the advantages of a system of scoring on accountable targets outweigh the disadvantages of various types of gaming responses. This paper examines the application of the model of star ratings to a case study of Primary Care Trusts (PCTs), which are complex organisations with three diverse sets of responsibilities: delivering primary care, commissioning secondary care, and supervising public health. It outlines an alternative model and the issues this raises for governance of health care performance.