Seriously, Wes Streeting? After 14 wretched years of Tory austerity, stealth privatisation, draconian outsourcing, the Brexit staff drain and the horror and trauma of Covid from which – as you know – staff haven’t remotely recovered, the big NHS plan is to be … naming and shaming? Complete with inflammatory language that’s designed to scapegoat staff, such as the bad managers you’ve branded the NHS’s “guilty secret”? Do you genuinely think this is constructive?
At a point when Ofsted – having contributed to the suicide of headteacher Ruth Perry – has finally rowed back from its absurdly blunt tool of one-word school inspection ratings, it beggars belief that the new health secretary thinks hospital league tables will help the NHS. Streeting insists the new public rankings are a necessary way of stamping out poor performance. He wants hospitals judged on quantifiable factors such as A&E waits, cancer care and the size of their budget deficits. Trusts will be publicly ranked from best to worst, with the CEOs of the worst offenders facing dismissal. Meanwhile, the best-performing trusts will be rewarded with extra money to buy new equipment or repair facilities, further skewing the playing field.
There is colossal cognitive dissonance at the heart of this plan. Streeting himself is the first to acknowledge the impact of structural inequalities on health, recognising that disadvantaged groups in British society are at greater risk of ill health and premature death. Yet his return to hospital league tables presumes that underperformance is all the fault of those deplorable “bad managers” and somehow divorced from the socioeconomic realities of the population they serve. He must know that hospital performance is intricately bound up with the availability (or not) of social care in a region, the prevalence of poverty, the availability of staff, local unemployment levels and innumerable other factors beyond senior hospital managers’ control. Pretending otherwise is disingenuous.
Worse, league tables are a very blunt and very public form of ritual humiliation – precisely the kind of punitive exercise that has demonstrably negative effects in healthcare. In fact, a “no-blame culture” in medicine has been shown to improve safety by fostering openness, discussion and learning from mistakes – yet Streeting wants blame itself to be embedded in the heart of his reforms. Penalising and shaming struggling hospitals risks demoralising staff and causing patients to lose confidence in their local trust, all while pitting trust against trust in a manner that stokes suspicion and division. Trusts will be pressured into trying to game the system, pouring effort and energy into the only performance standards that “count”, while neglecting other important, yet newly marginalised, aspects of care.
Hospital league tables are, in short, a simplistic and retrograde gimmick. This zombie policy should have died for good in 2005 when league tables were scrapped four years after being unveiled for the first time by Alan Milburn, then Tony Blair’s health secretary and now Streeting’s top adviser at the Department of Health. Perhaps Milburn thinks he didn’t go far enough last time, though this jaded NHS doctor errs towards the definition of insanity attributed to Einstein as “doing the same thing over and over again and expecting different results”.
My prescription for improving NHS performance is diametrically opposed to Streeting’s in that it rests on the principle that virtually nobody arrives at work to do a bad job. In fact – and in healthcare in particular – most people are motivated by a strong and simple desire to do well. They care. This is the root of the discretionary effort that famously used to keep the NHS afloat, but which has all but been exhausted since the height of the Covid pandemic. When staff go above and beyond what is contractually obliged by staying late, performing small acts of kindness, taking time and effort to show patients that they matter, the calibre of healthcare soars. It’s a small example of a wider truth in the NHS – not everything that matters in medicine can be counted, and not everything that can be counted matters.
If Streeting persists in trying to measure performance on spreadsheets and league tables, he will necessarily omit what is unquantifiable – the compassion, the tenderness, the humanity and the quirks that make medicine a uniquely human endeavour. What I do, for example, when I talk through with a dying patient their greatest fears, or explore what helps them feel like life is still worth living – or prescribe a gin and tonic in a glass with ice because it reminds them of the life they love and not the death that bears down. Measuring performance in numerical datasets entails erasing all the parts of healthcare that cannot be counted – and these we devalue and discard at our peril.
Rachel Clarke is a palliative care doctor and the author of Breathtaking: Inside the NHS in a Time of Pandemic
