Performance league tables: the NHS deserves better

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Abstract
League tables are frequently used to depict comparative performance in sport and commerce. However, extension of their use to rank services provided by healthcare agencies has attracted resistance, criticism, and anxiety. In this article we discuss the benefits and drawbacks of league tables and suggest that an alternative technique, based on statistical process control, could be introduced in their place. We believe that this technique would have the dual advantage of being less threatening to providers of health services and would be more easily understood and correctly interpreted by patients, auditors, and commissioners of services. ### Summary points League tables are an established technique for displaying the comparative ranking of organisations in terms of their performance League tables provoke anxiety and concern among health service providers for several reasons, including concerns over adjustment for case mix and the role of chance in determining their rank Control charts, used for monitoring and control of variation in the manufacturing industry, overcome these problems by displaying performance without ranking and helping to differentiate between random variation and that due to special causes League tables are useful for comparing quality or outputs from different systems, whereas control charts are more useful for comparison of units within a single system, such as the NHS Control charts avoid stigmatising “poor performers” and promote the use of a systems approach to quality improvement For many years league tables have been used to rank the quality of goods or services provided by competing organisations. They are commonly published in the popular press and magazines, specialist journals, and the internet. These tables range from those that simply rank crude performance on indicators to those that report sophisticated comparisons of summary adjusted statistics (such as those with uncertainty intervals around the rank). The public is prepared to pay intermediaries, such as financial advisers, …

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