Impact of star performance ratings in English acute hospital trusts

Objective: To explore some of the impacts of star performance ratings in acute hospital trusts in England. Methods: A multiple case study design was used which incorporated purposeful sampling of 'low' and 'high' performing trusts using the star rating system. In each case study site, data collection comprised semi-structured interviews and documentary analysis. Between eight and 12 senior managers and senior clinicians were interviewed in each organisation. Results: There was a general view that the star ratings as presently constituted did not represent a rounded or balanced scorecard of their own organisation's performance and a widespread belief that the information used to calculate the ratings was often incomplete and inaccurate. The star ratings were viewed by some managers as useful, in that they gave added weight to their trust's modernisation agenda. In addition to driving beneficial change, the ratings were also sometimes reported to have inadvertently induced a range of unintended and dysfunctional consequences, including tunnel vision and a distortion of clinical priorities, bullying and intimidation, erosion of public trust and reduced staff morale, and ghettoisation. Conclusions: Set in the context of an international body of research, this study highlights some important gaps in knowledge and failings in current policy and practice. In particular, the many dysfunctional consequences of publishing star ratings indicate a need for a re-examination of performance management policies.