Intended for healthcare professionals

Rapid response to:

Information In Practice

Performance league tables: the NHS deserves better

BMJ 2002; 324 doi: (Published 12 January 2002) Cite this as: BMJ 2002;324:95

Rapid Response:

NHS: National but not uniform

This article presents a good arguement for the use of control charts
in place of performance league tables. The charts appear more
understandable and are likely to cause less confusion. The statistical
problems of league tables are well put and valid.

I disagree with the authors' view of the NHS, it cannot be regarded
as a single unifororganisation. The Dr Foster data identified that
staffing levels greatly affect mortality. Trusts differ in their staff
retention rates and policy and do not always attract the same quality of
applicants. From this point of view comparing one trust with another may
be more similar to comparing Ford with Honda than looking at different
units in the same company. This does not detract from the use of control
charts but it is important not to view the NHS as adhering to a uniform
pattern as trusts differ in their priorities, incentives and abilities.
As an outcome measure mortality is still too rare an event to be very
sensitive and thus no matter how it is presented it will not be very
informative. There is a need for new more sensitive outcome measures to be
developed. It is also a mistake to look at outcomes without looking at
resource use. As an example if comparing two coronary bypass units it is
not sufficient to know the 30 day mortality for each unit without
calculating the costs per patient of each unit also. This has been the
gaping hole in most of the recent published data including that from the
Dr. Foster team.

Competing interests: No competing interests

12 January 2002
Tom Aslan
Salaried PMS GP partner and also health economics consultant at BUPA
1 Binfield Rd Stockwell London SW4 6TB