Barbara Harpham, Chair of the Medical Technology Group, considers the implications of the NHS new performance ranking.
The NHS league table of trusts has finally been published to a mixture of welcome and concern. Reactions mirror the longstanding debate from the Blair era over whether league tables drive and encourage better performance or simply highlight embedded variations.
The rationale should at least be admired amidst the ongoing effort, in the aftermath of the Ten Year Plan, to drive the implementation of the best innovation and technology and end the postcode lottery of access to the best of the NHS.
As the Health Secretary put it: “These league tables will identify where urgent support is needed and allow high-performing areas to share best practices with others.”
But how easy is this to achieve in practice?
The Medical Technology Group has previously looked at how ranking health services can be used to understand how innovation and technology is driving that improvement. Our two Ration Watch reports used referral to treatment data to understand the ranking of the highest-performing ICBs when it came to working through the backlog.
In our research, we could not only see where patients were being treated more quickly, but also used this as an opportunity to understand why some areas consistently outperformed others.
For example, the 2024 Ration Watch analysis showed Wakefield, Dorset and North East Lincolnshire consistently ranking in the top 10 performing Sub-ICB locations for completed patient pathways.
Of course there were other factors at play, as is always the case. But these areas managed to maintain consistently high levels of performance even at times of stress. In our qualitative assessments, leadership often mentioned innovation, such as the shared referral pathway in Wakefield.
But another striking pattern emerged. The same report highlighted major variation in performance within the same ICB. In Humber and North Yorkshire, North East Lincolnshire ranked third nationally, while neighbouring Vale of York languished at 98th.
These contrasts show that excellence exists side-by-side with poor performance – and also highlights the difficulties driving best practice, spread and adoption at a local level.
Staff and leadership were often aware of varying performance and the reasons for it. But turning that around, particularly when it comes to dealing with longstanding pressures around clinical capacity, capital investment and the resources and planning needed for pathway transformation and spread and adoption of innovation is another challenge.
The new Ten Year Plan promises to cut red tape around technology and adoption, and the league tables are now there to incentivise and encourage leadership to learn from the best.
But there are also potential obstacles. The weighting towards finance may encourage the sort of short term thinking that often stifles long-term investment in transformation of pathways and models of care through technology and innovation.
Metrics that reward waiting-time reduction may not sufficiently capture how trusts or ICBs are embedding innovation, improving patient outcomes through medical technology, or tackling structural issues that hold this back.
Additionally, the integrated care model, and the technology and innovation needed to support this model may not be fully incentivised by the current metrics.
This is where the department and other NHS bodies may need to be more creative in identifying not just why trusts perform highly, but the sort of innovation and technology we need in order to build the future of our preventative, community-focused, innovation-led model of care.
We are starting to see encouraging frameworks for using patient insight to drive NICE approved technologies and better involve patients in decision making around their care. At present, just 40% of ICBs have patient representation, and there is an ongoing issue with how to fully integrate meaningful patient insight.
In the light of the Ten Year Plan and its allocation of 3% of spending for transformation, there is also now a renewed focus on spread and adoption. Expect then to see a shift from not just talking about performance metrics, but in depth attempts to understand the kind of organisational culture and practice that drives successful adoption of technology and innovation.
The Department for Health and Social Care and other central organisations need to also establish forums and mechanisms for not just sharing the right technology and innovation, but understand in depth the right culture for enabling this through patient involvement, an understanding of value aligning with the three shifts beyond financial cost, and improved collaboration between NHS bodies, policymakers and local leadership.
The lesson from our Ration Watch studies is that good practice and innovation are abundant in the NHS and indeed leading to variation in performance. But driving its wider implementation through the sharing of best practice is another challenge we are only starting to get to grips with.
