Whatever happened to NHS performance reporting?

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The Scottish Government assesses NHS performance via a performance contract with NHS Boards. The Local Delivery Plan (LDP) guidance 2015-16 set out the LDP standards, priorities that are agreed between the Scottish Government and NHS Boards to provide assurance on NHS Scotland performance. These standards are a suite of nineteen measures that are compared against targets.  

Until 2022, the Scottish Government presented the latest performance against the LDP standards in a single place, showing national and health board performance. At the time of writing (Feb 2025), this page hasn’t been updated since September 2022. According to the Scottish Government, the LDP standards are currently under review. So how is NHS performance currently being assessed? 

There are clues in the 2024-25 Delivery Plan Guidance. This more recent guidance doesn’t provide a tidy list of performance standards but instead refers to a range of government strategies, action plans and measurement frameworks, some of which contain standards. While this format makes it difficult to be certain, many of the 2015-16 measures have either been retained or at least continue to be published. Other targets have been introduced, but a comprehensive list is elusive. This leaves a lack of clarity around how NHS performance is currently assessed. 

So, how has the NHS performed since 2015 against the LDP standards? 

We were able to find up-to-date statistics for most of the LDP measures and have combined them in a single chart below. This chart sets out whether the standard has been met or missed in each measurement period.  

NHS performance has been sub-standard on most measures 

Missed and met Local Delivery Plan standards for NHS Scotland, 2015-2025

For one measure, it was unclear to us how it was assessed against the target. The Financial performance standard requires Health Boards to have balanced budgets each year. It is unclear whether this standard is to be met before or after any additional financial support or brokerage is provided from the Scottish Government. Therefore, this measure is not included in the chart.  

Of the remaining eighteen measures, eight measures have never met the standard between 2015 and 2025. Six measures have always met the standard. And four measures show a mixed picture with more misses than hits. 

A short history of health targets

A review of targets in healthcare was undertaken at the Scottish Government’s request in 2017 by Sir Harry Burns. It is a far-reaching report, covering much more than the counting and comparing of the various measures chosen. It is hard to see what impact his work has had on NHS and social care policy, especially in relation to outcomes and targets. 

He traces the history of targets back to the 1980s when there was a drive to improve the efficiency of public services. Citizens, he says, at this point, became customers. Of course, to make sense of this change of focus, this coincided with introducing market-like structures within the NHS. Scotland moved away from this approach quite early, but the tenets of efficiency, monitoring of performance and value for money remained. His critique included that targets ‘are the remnants of a discredited command and control system which demotivates staff and causes them to focus on the wrong aspects of their work’. 

What are some of the skewing effects of targets? 

There are other issues with targets. They can become the key focus for staff, and, when there is a desire to shift policy action to other areas, such as prevention for example, the effect of targets can seem perverse, because the effort required to meet them sucks all the resources in their direction. A focus on cutting waiting times in the clinical areas dictated by the targets can work against retaining a system-wide focus.  

In recent budget scrutiny of the plethora of health and social care outcomes by the Health and Social Care Committee, some of the challenge was highlighted: 

• National Performance Framework: 11 national outcomes and 81 national indicators 

• LDP standards: 19 in number 

• National health and wellbeing outcomes: 9 in number, towards which the activities of integration authorities are required to contribute. 

This is what some stakeholders said to the Committee about targets and outcomes: 

The current approach to setting and reporting on national targets and measures, while having initially delivered some real improvements, is now often skewing clinical priorities, with a confusing myriad of often competing measures the NHS has to achieve.

(Royal College of Nursing Scotland)  

…it can be easy for a health service to end up in a position where the barometers that we put in place to gauge how a service is performing can end up actually driving the short-term decisions we make to satisfy expectations instead of measuring the longer-term impact of our policies, as they are intended to do.

(Community Pharmacy Scotland)

Overall, there remains a continued focus on input and output measures rather than outcomes when it comes to public spending. This drives behaviour and spending in ways that are not necessarily best value.

(COSLA)  

All of these frameworks and targets are carefully designed, but their sheer number and complexity can make it difficult for senior decision-makers to see the wood for the trees or to translate all these requirements into meaningful, effective and efficient service offerings.

(Community Pharmacy Scotland)

But there are circumstances where targets can be useful. The logic of the A&E targets and delayed discharge, in the context of integration (and prevention) was that these measures would provide an indication of pressures at each end of the hospital ‘system’.  This in turn, it was thought, would be a guide as to where to direct resource – into social care and preventative initiatives. The aim being to prevent emergency admissions. However, as time, and the skewing effects of targets themselves have shown, they clearly haven’t worked in that way, and it has proved impossible to re-direct funding away from the immediate and very visible challenges at the hospital doors. 

Conclusion 

If the government is committed to using targets as a guide to performance, it is vital that these are easily tracked via accessible publications. If, however, the government has decided that targets no longer provide the appropriate levers to shift the balance of care from acute care to prevention and longer-term outcomes, then this needs to be made clear.  

As long as these somewhat crude measures are used, they are all we have to monitor performance, and they need to be available to scrutiny. However, the government could choose to be bold in its review, whatever that entails, and return to Sir Harry Burns’ report. It could consider both, what the main issues and desired outcomes are for integrated health and social care, and for national wellbeing, (on which there appears to be widespread agreement over many years). It could decide what policies are required to lever transformation. Simultaneously, it could plan what data, measures and indicators are best to track that transformation. Which is pretty much what Audit Scotland has repeatedly recommended:

Given that outcomes are long-term in nature, milestones are helpful in judging progress. The current lack of milestones for National Outcomes will make monitoring how changes to budgets and public sector reform impact on people and longer-term goals much more difficult. It also makes it harder for parliament and other bodies to scrutinise the work of public bodies and have assurance that spending and reform is delivering improved outcomes and providing maximum value for money.

Anne Jepson & Maike Waldmann