The National Health Service (NHS) in England has been subject to ongoing structural change since the early 1990s. (1) Recently this has been accompanied by the increased recourse to performance management and evaluation systems, such as performance grading, systematic reviews, and clinical governance. This increased generation of information and evidence, combined with structural reform, has been hailed by Donald Light (2001) as affording the opportunity for the devolution of power from the organized medical profession and politicians to the wider community, particularly concerning decisions of rationing, prioritization, and funding. Light's optimistic scenario of community empowerment resonates with John Dewey's (1981) notions of "warranted knowledge" and the instrumental valuation principle, as part of the process of forming efficacious policy in the "Great Community."
Indeed, advocates of NHS reform argue that the increased generation of information will provide an objective assessment for gauging the performance of NHS bodies over a range of activities, thereby increasing transparency and accountability, as well as furnishing agents within the NHS with incentives to enhance the efficiency and effectiveness of health care provision (Department of Health 2000, 2002).
This paper concentrates on an aspect of this recourse to performance evaluation: the performance grading of NHS bodies under the auspices of the performance assessment framework (PAF) and the performance rating system (PRS). The paper challenges the notion that performance assessment represents an objective evaluatory benchmark, resting as it does on primarily outcome measures. PAF/PRS demonstrates an inherently consequentialist orientation that invokes a particular utilitarian-grounded value-frame. Moreover, it is predicated on a tacit hierarchy of evidence that potentially masquerades a misleading scientific aura of "truth revelation." The object-subjective dual is queried: after all, the philosophy of medicine can never address the "is-ought gap," since the whole basis of medicine is normative (Tonelli 1998). Indeed, the institutional arrangements of the reformed NHS do not highlight mutuality as envisioned by Dewey (see also Keaney 2001), but instead quantifiable outcomes are de rigueur, relegating the intrinsic value of process and potentially engendering mechanical rigidity.
Performance Assessment in the English NHS
Information on performance is the sine qua non of the "new," reformed NHS. Given the historically ad hoc nature of information generation and its ineffectiveness in informing the distribution of resources in the NHS (Webster 1996) it would seem that the reforms, as its proponents claim, offer the potential for improvement in health care provision, both in terms of effectiveness and efficiency. Certainly the development of systems of assessment--the PAF/PRS--has led the government to claim that this represents a considerable advance in that performance and "best practice" are placed at the center of health care provision. (2)
Generally, health economists have cautiously welcomed increased information on (and measurement of) performance (see for instance, Hutton and Maynard 2000 and also Gravelle et al. 2003). Indeed, John Hutton and Alan Maynard (2000, 93) claimed,
The circumstances [health reforms] are probably the most favourable ever created for the proponents of economic evaluation in health care to justify their activities. Of course such a position stems directly from mainstream economists' preoccupation with information as a signaling mechanism for the efficient allocation of resources. Arguably the seminal contribution to this literature is Kenneth Arrow's analysis of information "as the negative measure of uncertainty" (1984, 138). For Arrow information essentially relates to statistical data, as he noted, "Statistics is ... the science of extracting information from a body of data" and "The statisticians' model of information seems appropriate for our [economists'] purposes" (138-9).
Peter Smith's observation that "the British have adopted a multiprong strategy for improving the performance of the NHS based on empirical evidence, concrete goals, and quantifiable results" (2002, 103, emphasis added) suggests a certain resonance with Arrow's delineation of information.
This emphasis on quantification is obvious from PAF/PRS. PAF is composed of approximately sixty indicators of performance grouped into a six-dimensional framework, which includes health improvement (such as variations in death rates across population groups), fair access, effective delivery, efficiency (cost effectiveness), quality of patient/carer experience, and health outcomes. PRS is the principal method of signaling performance, eliciting a discrete ranking scale (the four-point star system) on the basis of weighted aggregation of an extensive range of component areas. The three-star grade is awarded for "excellence" in performance over defined thresholds, declining to zero stars where it is deemed that performance is not satisfactory in key areas. If a trust produces a score of three over two consecutive assessment periods, it potentially qualifies for greater financial independence from central government.
The process of quantifying these elements is of some interest. Some indicators are constructed on the basis of the result of some specified numerator and dominator, the...