For the past three years, the performance of NHS organisations in England has been assessed by performance (star) ratings based on targets—“key targets” and indicators in a “balanced scorecard.”1^–4 In the first two years, NHS managers knew only (until about a week before publication) that ratings would reflect stated government priorities. In response to demands for greater transparency the Commission for Health Improvement, when it took over responsibility for the third set of ratings from the Department of Health, published lists of the targets to be used in advance of publication of ratings but during the year to which the targets applied. Demands have been made for greater transparency in the NHS—for example, by publishing full specifications of targets and how ratings are to be calculated before the start of each financial year. Such …