Performance measurement of “knights” and “knaves”: differences in approaches and impacts in British countries after devolution

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