Competition vs collaboration: will an NHS league table drive improvement?

Much to the health secretary’s relief, the NHS did well out of last month’s budget, certainly when compared with other spending departments. But this relative largesse comes with its own burdens, not least a clear expectation from the Chancellor that it will be used to deliver ‘improved productivity’ and ‘value for money’. 

Health secretary Wes Streeting’s response a few weeks ago in a speech to NHS Providers contains plenty of substance. Welcome moves include granting NHS trusts ‘greater freedom and flexibility to innovate’ and ‘manage their own affairs’ and a pledge to scale back the forest of competing and distracting targets trusts face. Also encouraging is his commitment to give the leaders of high-performing organisations the licence to reinvest surpluses locally rather than see the money clawed back by the centre. If Wes Streeting follows through on his pledge, the NHS will be the better off for it. 

But these commitments were overshadowed by the controversial announcement of a league table type approach to distinguish between the best and worst performing providers. Critics have called into question its effectiveness as a means of improving performance, with some pointing to the short-lived star rating system brought in by the last Labour government as proof of its possible shortcomings. The system was scrapped in 2004 by the then Healthcare Commission, which felt it was too crude to be an effective measure of overall trust performance. 

What impact might a league table approach have on providers?

Research on the star rating system in fact shows a mixed picture. There is some evidence it improved performance, but the fact it was launched at a time of significant increases in NHS funding, coupled with other major policy changes, means it’s hard to draw any definitive conclusion about its impact. There are also a host of practical challenges associated with the design and implementation of a league table approach. Picking metrics that provide a rounded picture of performance – and don’t lead to a loss of focus on areas not measured – is one such challenge. Further, the risk of ‘gaming behaviours’ by organisations shouldn’t be ignored, nor indeed the likely negative impact on the workforce of NHS trusts deemed to be underperforming. Evidence shows that a positive workplace culture and good morale are critical for improvement and high performance, and that organisations struggle without them.

The timing of the league table announcement also raises some questions. When star ratings were introduced in the early 2000s, they were at least consistent with the prevailing culture of competition between providers that ministers saw as key to improving care quality. Introducing league tables today, at a time when NHS trusts are working ever more closely together, not only seems counterintuitive but could risk destabilising a range of collaborative working currently underway. 

Will it risk the current collaborative environment?

As well as collaborating through statutory bodies such as integrated care systems and acute care collaboratives, an increasing number of trusts are now choosing to work together through group structures and shared leadership arrangements. Competition, let’s be clear, hasn’t gone away entirely. There are still provider leaders who make no bones about prioritising the needs of their organisation above those of others and see the world in terms of organisational winners and losers. But interviews with organisation leaders as part of our research on interorganisational collaboration have shown that competition is no longer seen as the main route to achieving high performance. 

A case in point is the formation of provider groups, which has allowed some NHS trusts to strengthen mutual aid arrangements, pursue opportunities to achieve back-office economies of scale and foster learning across organisational boundaries. In some circumstances, group formation is also helping to chip away at the ‘organisation-first’ mentality that has historically shaped the thinking of many NHS trusts. In the past, this mentality made some staff reluctant to share learning and innovations with their peers at neighbouring organisations, hampering the NHS’s efforts to spread good ideas at pace and scale. (A note of caution is needed here. The ways in which groups are being conceived and implemented vary enormously, and some groups may struggle to achieve the benefits described here. Nonetheless, the group model is a good illustration of how trust leaders are turning to partnership working to achieve performance gains.)

As the Darzi review notes, there has been ‘a decisive shift in the [NHS’s] improvement philosophy away from competition and towards collaboration’. A change in emphasis now could cause not only disruption but confusion and uncertainty. At a challenging time for the NHS, organisation and system leaders need strategic clarity and consistency from national bodies more than ever – something Streeting himself highlighted in his speech.

Granting organisations more autonomy doesn’t have to mean greater competition between providers. A policy aimed at incentivising performance improvements at the individual provider level is perfectly compatible with one focused on boosting interorganisational collaboration. In fact, a defining characteristic of high-performing organisations is their receptivity to insights, learning and ideas generated elsewhere, and their involvement in networks spanning multiple organisations. 

How to support collaboration

As the Darzi review made clear, the NHS is ‘still reeling from a turbulent decade’. Policymakers should be supporting the increasing amount of collaborative working now happening across the NHS, and wary of measures that might undermine or dilute it. This means developing large-scale learning communities to share knowledge and ideas – the Q community being a prime example; encouraging greater interorganisational and cross-system collaboration; building the capability and capacity needed to identify, test, implement and spread proven innovations; and strengthening system leadership skills. Another priority, as the health secretary recognised in his speech, is to strengthen the NHS’s management capacity and capability, so that providers have the means both to drive change internally and collaborate with their system partners. 

Reconsidering a league table approach

Given that the most pressing challenges facing the NHS today require integrated, cross-system responses, it is questionable how a league table that promotes interorganisational competition will help such efforts. It may risk making it harder to develop the cross-system initiatives the health service will surely need to make the long-term shifts in care the government is rightly pursuing. 

Bryan Jones is Senior Improvement Fellow at the Health Foundation.

Nicola Burgess (@DrNicolaBurgess) is Professor of Operations Management at the University of York and Senior Visiting Fellow at the Health Foundation.