A further difficulty arises since some Performance Indicators are composite measures across numerous domains. There is currently no Performance Indicator that fulfils all of these attributes and the existence of multiple indicators raises questions over which should be used вЂ“ we return to this issue below. Theoretically, Pringle and colleagues identify twelve methodological attributes of an ideal indicator: validity, communicable, effective, reliable, objective, available, contextual, attributable, interpretation, comparable, remediable and repeatable (see Table 1 for definitions). Trusts may also game with definitions of required standards, such as determining when the 8 minute ambulance call-out time actually starts. In addition, Star Ratings have induced adverse effects, such as distorted clinical priorities, bullying and reduced morale in acute hospital trusts, often resulting in institutional stigma.

However, a recent action research report has highlighted that the UK public do not like performance league tables and consider sources of information on quality as inadequate. Furthermore, performance assessments in health care should promote patient involvement, provide accountability and enhance patient choice. Public services, including health, have increasingly been subjected to performance assessments, designed to fulfil the Government's 'commitment to providing patients and the general public with comprehensive, easily understandable information on the performance of their local health services'. Yet the results of this analysis provide little evidence that the current indicators have sufficient construct validity to measure the underlying concept of quality, except when the specific area of screening is considered. Performance assessment in healthcare remains on the Government's agenda, with new core and developmental standards set to replace the Star Ratings in 2006. Likewise we found no relationship between either Star Rating or Litigation Authority Standards and hospital mortality (F = 0.61, p = 0.61 F = 0.31, p = 0.73). There was no correlation between different measures of access to services. There were however positive correlations between Quality and Outcomes Framework total and patient satisfaction (r = 0.61, p < 0.001) and between screening/'additional services' indicators on the Star Ratings and Quality and Outcomes Framework (F = 24, p < 0.001). Star Rating and Quality and Outcomes Framework total, both summary measures of global quality, were not correlated with each other (F = 0.66, p = 0.57). Forward stepwise multiple regression analysis to determine the effect of Primary Care Trust characteristics on performance.

MethodsД¬ross sectional quantitative analysis using data from six 2004/05 PCT performance indicators for 303 English Primary Care Trusts from four sources in the public domain: Star Rating, aggregated Quality and Outcomes Framework scores, Dr Foster mortality index, Dr Foster equity index (heart by-pass and hip replacements), NHS Litigation Authority Risk Management standards and Patient Satisfaction scores from the Star Ratings. Secondly, we wanted to find out whether broad (global) indicators correlated with any particular features of Primary Care Trusts, such as expenditure per capita. Firstly, to find out whether pairs of indicators that purport to measure similar aspects of quality are correlated (as would be expected if they are both valid measures of the same construct). The performance of Primary Care Trusts in England is assessed and published using a number of different performance indicators.

Construct 3 game performance