Performance Measurement of “Knights” and “Knaves”: Differences in Approaches and Impacts in British Countries after Devolution

Abstract

Policies for publicly-financed health care in Britain have traditionally assumed that all the key players were “knights” who struggled to deliver the best possible services within the constraints of available resources, and hence if they failed to do so, needed extra resources. The Labour government elected in 1997 was confronted with a National Health Service in a parlous state, which following devolution became a challenge for four different territorial governments. The governments in Scotland and Wales used systems of performance measurement of hospitals that assumed “knightly” behaviour and were ineffective: the government in Scotland assumed that hospitals did not need to be held to account for performance measured by an intelligence system to identify and act on shortcomings; and the government in Wales assumed that, as hospitals would endeavour to achieve targets for waiting times, if they failed to so, they needed extra resources. Only England introduced a ranking system of performance measurement dominated by targets for waiting times that aimed to discriminate between “knights” and “knaves” and “name and shame”“failing” hospitals, which resulted in dramatic improvements in reported performance and gaming. Analysis of these different approaches to performance measurement of hospitals in Britain, and of ranking systems in the US, suggests that, for a system of performance measurement to have an impact, it needs to have potential to inflict reputational damage by producing information that is reliable, robust to criticism from the hospitals being assessed, understood in broad terms by the public, and published and widely disseminated.

Acknowledgements

Earlier versions of this paper were presented at the 7th International Summit on Indicators and Performance Measures, International Society for Quality in Health Care, Amsterdam, October 2004; the workshop organized by the Journal for Comparative Policy Analysis, Yale, New Haven, April 2007; and the Governance seminar, Institute of Health Policy and Management, Erasmus University Rotterdam, June 2007. I am grateful to those who made comments at these meetings and also to comments from Julian le Grand, Ted Marmor and Joe White.

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Notes on contributors

Gwyn Bevan

Gwyn Bevan is Professor of Management Science in the Department of Management and associate of two research centres at the London School of Economics and Political Science: LSE Health and the Centre for Analysis of Risk and Regulation. He is a member of the Department of Health's two advisory groups on resource allocation. His current research includes: performance assessment, modelling acute hospitals and priority setting for populations. He was seconded (2001 to 2003) to the Commission for Health Improvement (CHI), where he was Director of the Office for Information on Health Care Performance; and has worked for a nationalized industry, a economic consultancy, HM Treasury and, as an academic, in Business and Medical Schools.