Intended for healthcare professionals

Snakes, Ladders, And Spin

How to make a silk purse from a sow's ear—a comprehensive review of strategies to optimise data for corrupt managers and incompetent clinicians

BMJ 2003; 327 doi: (Published 18 December 2003) Cite this as: BMJ 2003;327:1436
  1. David Pitches, specialist registrar (,
  2. Amanda Burls, senior clinical lecturer1,
  3. Anne Fry-Smith, information specialist1
  1. 1Department of Public Health and Epidemiology, University of Birmingham, Birmingham B15 2TT2
  1. Correspondence to: D Pitches

    The introduction of performance league tables for UK surgeons and hospitals has forced them to learn how to present data in the best possible light. Though there is anurgent need for guidance, official guidelines on how to optimise performance data are lacking

    Surgeons' and hospitals' positions in league tables can make or break their reputations. They therefore need to learn how to present data in the best possible light. Although some may protest about “sexing up” poor performance data, “creative accounting” adds a positive spin. In contrast to the plethora of clinical guidelines, there is still no official advice on how to optimise performance data, and wide variations in practice persist. This review provides a timely, evidence based response to the urgent need for guidance.


    We searched Medline for empirical examples of creative accounting (using the search terms “gaming”, “mortality“, “league

    table$”, “upcoding”, “fraud$”, “quality“, and “quality indicators, health care/”) and identified 284 papers, of which we reviewed the most relevant for suitable examples. We also searched the web with Google using “examples hospital healthcare fiddling figures.” We included anecdotes from personal experience.

    Categories of creative accounting

    In addition to fraudulent or biased research, which has been thoroughly reviewed elsewhere,1 we identified three broad categories of creative accounting:

    • Gaming of non-clinical performance data

    • Fraudulent reimbursement claims

    • Gaming of clinical data.

    Manipulation of non-clinical performance targets

    This is particularly important for managers when meeting so called P-45 targets—an expression used by Tony Wright MP while examining Sir Nigel Crisp for the House of Commons Select Committee on Public Administration2 and meaning targets for which failure to meet can result in redundancy (in Britain the P-45 is the tax form people receive when leaving employment). A House of Commons investigation in 2002 uncovered strategies to bring waiting times and numbers of patients waiting for treatment within national targets.3 …

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