| Streeting’s stance on the NHS – a shift from “zero consequences for failure to zero tolerance” and a promise to root out the “rotten apple” senior managers he calls the NHS’s “guilty secret” – has been met with scepticism, fear and anger by many who work in the health service. After a decade of severe underfunding and institutional crises, many question whether measures like league tables are anything more than a sop to those seeking tough action from a newly elected government. But despite institutional resistance, the health secretary is determined to push on. Streeting is drawing inspiration from New Labour in its first term: it also inherited a struggling NHS and turned performance around by the time it left office 13 years later. “He’s going back to the future with this,” says Denis. Streeting has even appointed Alan Milburn, a former Labour health secretary, as a senior health adviser, seeking to apply lessons from past successes to today’s challenges. What would change? The government argues that the carrot-and-stick approach of a league table will drive faster progress in the NHS. Hospital trusts that perform well will be able to reinvest their budget surpluses into modernising buildings, equipment and technology. On the flip side, struggling hospitals can expect tighter monitoring and tougher measures. The government has also introduced a new pay framework for senior managers, designed to “clamp down on poor performance”. Under this plan, those overseeing trusts with major deficits or poor patient services will not be eligible for pay rises. Hospital bosses have described the new plans to Denis as a “crude” approach to measuring performance, warning that it risks further lowering already fragile morale. The NHS has long struggled with a chronic recruitment and retention crisis, and Dr Adrian Boyle, president of the Royal College of Emergency Medicine, cautioned in a BBC interview that this policy could make the problem even worse. And it’s not just the staff who would be affected – patients may also feel pressured to seek treatment in higher performing hospitals elsewhere, which could be extremely far from where they live. “There are so many practical issues,” Denis says. Why a league table? The government claims that a league table offers a practical way to assess and measure NHS performance across the board. “The rationale for this isn’t clear,” says Denis, “and I’m not sure there’s a solid evidence base for it.” And the idea of a league table is not new. Over two decades ago, a Labour government tried to introduce it but ultimately abandoned the idea after a few years. “It’s easy to see why many in the NHS feel this approach is unnecessary and a bit punitive,” Denis adds. The NHS is already one of the most monitored, regulated and scrutinised health systems in the world. “There are already multiple regulators and an overwhelming amount of data on NHS performance – so as patients, taxpayers and voters, the public isn’t exactly lacking information to judge how different parts of the NHS are doing,” Denis points out. The metrics The Department of Health and Social Care has indicated that the league table will be based on a number of key metrics including patient access to care, waiting times, financial performance (most hospital trusts in England are now significantly over budget) and the quality of leadership. However, it remains unclear whether these disparate data points will be combined into a single ranking. “NHS leaders have also expressed concerns about how this will account for factors beyond hospitals’ control,” Denis says. A hospital’s ability to meet performance targets, for example, is heavily influenced by the availability of local GP services. With many people unable to secure GP appointments, more patients are forced to seek care in A&E, creating additional strain on hospitals. Hospitals where the local population has more health needs than the national average – usually poorer areas – face higher demand compared with more affluent areas with generally healthier populations. If the league table does not account for these factors, hospitals serving low-income areas will fare worse, and be penalised, due to challenges outside their control. Tough on NHS failings, tough on the causes of NHS failings There is also a clear element of political theatre in play. “A big part of Streeting’s speech is about showing the treasury and the rest of government that he’s being tough on the NHS,” says Denis, “that he’s not just accepting the £22.6bn increase in day-to-day NHS funding without ensuring the government gets value for its money. “I think we will see more of this tone from Streeting during his tenure as health secretary, where he will be seen to be giving the NHS a bit of a kicking and treating it as if it’s on the naughty steps to justify the money.” | 