Star-ratings lead to 'perverse' priorities and wait-list fixing

Trust managers desperate to survive imposition of star-ratings are working to 'perverse' and distorted priorities, a conference heard last week Manchester University reader in public management Dr Kieran Walshe said the targets for starratings forced managers to indulge in 'perverse behaviour' because 'people's jobs ride on indicators'.

He told the Royal Society of Medicine's forum on quality in healthcare: 'Nothing is sufficiently robust to resist fixing if there is enough riding on the results.'

He also said senior staff in some trusts might be minded to miss targets if poor workforce relationships meant they did not want their chief executive to survive.

Several conference delegates - who did not wish to be named - were more explicit, saying they were aware of efforts to change data to meet targets, particularly by removing patients from waiting lists whenever possible, as capacity constraints were preventing the targets from being reached.

Mid-Staffordshire General Hospitals trust chief executive David O'Neill said instead of highlighting the majority of hospitals which had done well, the star-ratings system was overwhelmingly negative: 'I am very cynical about the whole process.

This is so flawed and so badly handled it really doesn't impress me. It could have been a really good-news story.'

Portsmouth City primary care trust chair Zenna Atkins told the meeting that although there were hundreds of targets, everything else took second place to financial balance and access targets. But she said even these could not be met.

'We have been told, 'You will deliver on access and coming in on balance', but it is not going to happen in Portsmouth.We simply can't do it because of resources.'

In a presentation, Oxford University senior fellow in public health Professor Sián Griffiths, previously director of public health for Oxfordshire health authority, said: 'The real problem with targets is their use in league tables to say if you are good or bad, to say if you have earned autonomy or if you are a poorly performing trust.

'I think it is helpful to have the framework. I think targets help to set directions. But failure to meet them needs to be put into context.

For NHS managers, when their job is on the line, they have got to put effort into getting the stars.'

Examining the impact of the star-ratings, Dr Walshe said the majority of trusts, with one or two stars, did not get enough attention.

'If you are a one or two-star trust, There is not a great deal of incentive to improve on that set of indicators. I think there is a rather mixed and inconsistent message. It is focused on the head and tail and not on the others in between.'

King's Fund fellow Dr Nancy Devlin told the forum that the national picture was far from a success story and there was no clear picture of how improvements had been achieved. She said: 'The performance at local level is really patchy - If you look at HAs which have achieved substantial reductions in waiting times and lists, very little is known about how they did it.'