An OVID Health article by Carys Lloyd
Earlier this week, the government unveiled the first UK-wide NHS league tables, ranking all 205 trusts in England on 30 metrics that included waiting times, financial health, and patient experience. Streeting hailed it as a ‘landmark’ moment, promising a new era of transparency designed to ‘empower’ patients in choosing their care. With the tables updated quarterly, top performers will be granted greater autonomy over finances and decision-making, while those at the bottom face intensive NHS England oversight, targeted improvement support, limits on autonomy, and the reputational damage of being publicly branded as failing trusts.
The move is strikingly reminiscent of Milburn’s early-2000s star ratings, which pursued the same vision of patient empowerment through competition and choice. Those ratings were scrapped within a few years amid criticism that they were crude, distortive, and demoralising. While today’s metrics are more sophisticated, the underlying premise remains the same – that patients experience the NHS primarily as consumers, with agency.
Patients as Consumers: Policy vs Reality
The rhetoric of ‘empowering patients’ through league tables echoes early-2000s consumerist logic, but in practice, the analogy is limited. Patients rarely navigate the NHS as a market. Emergency admissions bypass choice entirely, while GP referrals and waiting lists often constrain movement even in elective pathways. For most patients, proximity and capacity, not preference, determine access. The Care Quality Commission’s 2024 inpatient survey found one in five patients treated in corridors, nearly 10% waiting over 24 hours for a bed, and more than half waiting over six hours to be admitted. In this context, league tables offer little genuine choice or empowerment.
Public confidence in the NHS is also at historic lows. The British Social Attitudes survey shows overall satisfaction at 21% in 2023, down from 70% in 2010, with dissatisfaction driven primarily by access rather than quality. A&E satisfaction stands at just 19%, while GP and dental services are also performing poorly. Framing league tables as tools for patient empowerment risks overstating their influence in a system where patients are often overwhelmed and constrained by circumstance.
Metrics that Flatten Complexity
League tables inherently reduce complex, multi-dimensional performance into simplistic tiers. Under the government’s system, 80% of trusts fall into tiers three or four, effectively labelling the majority of providers as subpar. Yet, trust performance varies significantly across services. A trust may excel in elective surgery while struggling in cancer diagnostics or A&E. Multi-site trusts further complicate the picture, with one hospital outperforming whilst another drags down the aggregate score.
Financial measures also risk distorting outcomes. Trusts running deficits can be downgraded regardless of clinical performance, which penalises providers serving areas with entrenched demand pressures and chronic workforce shortages. If interpreted uncritically, today’s supposedly more ‘sophisticated’ tables risk repeating the mistakes of New Labour.
Risk of Entrenching Inequalities
Perhaps the greatest danger is that league tables cement structural inequities rather than correcting them. Trusts serving deprived or rural populations are inherently disadvantaged, struggling with higher demand, staff shortages, and ageing infrastructure all skew metrics. Labelling these trusts as ‘poor’ risks further damaging public confidence, discouraging recruitment, and demoralising staff. A vicious cycle can emerge. Negative ratings reinforce challenges, which then drive further underperformance.
Queen Elizabeth Hospital in King’s Lynn illustrates this vividly. Ranked lowest in the new tables, it suffers from extreme infrastructure decay, A&E performance at 59% against a national target of 72%, and high-profile care failings, including missed critical illness in babies. However, geography dictates attendance, and for the surrounding population there is no realistic choice. Labelling the hospital as failing offers little empowerment for patients, provides limited support to staff, and risks entrenching a narrative of institutional inadequacy without addressing underlying causes.
A Familiar Reform Cycle
League tables are the latest turn in a long cycle of NHS reform. Since the 1990s, governments have oscillated between centralised performance management and promises of patient choice. New Labour’s star ratings were abandoned once their distortive effects became clear. Coalition reforms emphasised localism and clinician-led commissioning, before austerity hollowed out both capacity and morale. Today’s league tables carry new branding, but the underlying assumption – that competition and consumer-style choice can drive improvement – is familiar.
Yet the NHS is not a market, and patients are not free agents. Over-reliance on consumerist logic risks shifting responsibility for systemic shortcomings onto patients rather than addressing the chronic issues of underinvestment, workforce gaps, and regional inequalities.
If used carefully, the new tables could strengthen oversight and accountability by making performance data more visible to policymakers and regulators. But if framed as tools of patient empowerment, they risk misrepresenting reality and entrenching inequities. Transparency should illuminate, not obscure, and must be paired with investment, capacity building, and structural reform to address the NHS’s enduring challenges.
Article originally published on LinkedIn on 12th September
