Handicaps, Relegation, and the NHS League Table

Is the government's new ranking system a useful and fair representation of NHS trusts?

Months ago, the On-Call team wrote about the speculated government plans to publish an NHS league table holding trusts to account. On 9 September 2025, the government released England’s first quarterly table under the updated National Oversight Framework (NOF).

This ranking was divided up into 3 separate tables (acute, non-acute and ambulance) and in each table, trusts are ranked into four performance segments to drive improvement and target support for weaker services.

In his final act as Conservative leader, Rishi Sunak criticised the government for agreeing to the resident doctor pay deal without securing productivity reforms. For years, concerns have been raised that the NHS is wasteful, inefficient in places, and in urgent need of measurable comparisons between trusts.

Enter Keir Starmer who came into office pledging a “government of service,” promising to end scandals and enforce financial transparency and discipline. We believe greater transparency, so patients and taxpayers can clearly see how local services are performing, is often overlooked as a key reason behind the new rankings.

So How Does This Table Work ?

The key word here is ‘NOF’ and not the kind that your local orthopod wants to repair on a 97 year-old with one kidney and a past medical history totalling five pages. The National Oversight Framework metrics include waiting times, elective backlog, ambulance response, patient experience, workforce sickness rates, and many more. Scores are aggregated into an average, and trusts are placed into four ‘segments’ or quartiles.

There is, however, one fairly large caveat: the financial ceiling. Any trust reporting a financial deficit cannot be in segment one or two; it is automatically capped at segment three. This means, theoretically at least, a trust could excel in A&E performance, patient experience, and backlog reduction, yet still be ranked lower simply because it is overspending.

This financial ceiling is incredibly important because we know as of 2023/24, 112 of 205 trusts reported overspends and were therefore in a deficit. All these 112 trusts will start with a hard ceiling on their ranking. In response to this hypothetical, you may be thinking, well, it is highly unlikely that a trust suffering financially is going to be performing amazingly on those metrics.

While it may seem intuitive that financially struggling trusts perform poorly across the board, the link between financial health and clinical quality is weaker than many assume. Overspending often reflects disproportionate demand, not inefficiency. For example, a teaching hospital with a trauma centre and specialist services in a deprived area may run a deficit precisely because it is stretching resources to deliver high-quality care where it is most needed. In fact, we know the trusts with the deepest deficits tend to be located in deprived parts of the country.

When the government rolls out a shiny new set of performance tables, it would be naïve to think the NHS will not bend around them. Boards will sit around in far-off corners of the hospital and naturally steer attention towards the metrics that matter most for composite scores. The financial ceiling adds extra pressure, tempting trusts to trim training budgets or staffing allocations.

Inform or Misinform?

The government has taken something messy and complex, from trust finances and waiting lists, to patient experience and ambulance response times, and boiled it all down into a single league table number. The format practically begs to be read as winners and losers, no matter how much nuance hides behind the data.

As The King’s Fund pointed out this week, a good A&E time tells you nothing about how a hospital performs on, say, its 18 week elective backlog. A single score cannot tell patients what really matters for their situation.

For patients and doctors, the risk is obvious. A hospital could be doing great work day to day yet still look like it is fighting relegation on paper. And once the rankings are out, who is going to explain that nuance before patients start voting with their feet and flooding the next trust up the table?

The Health Secretary is not buying that concern. When challenged on BBC Radio 4, echoing warnings from the King’s Fund, he dismissed it as “elitist nonsense.” Yes, the tables may lack the nuance buried in pages of reports and metrics, but the government argues that what the NHS needs most is incentive: a clear and accessible ranking, and the fear of slipping to the bottom of it, to drive improvement.

Senior Government Ministers Want To Get In On The Doctoring Act

The prestige of being a doctor still reverberates around all corners of society.

Whilst the current government go through a period of moral questioning and aim to clean up the mess after one of their senior ministers made an error in our very ‘simple’ tax system, it seems the Conservative leader Kemi Badenoch, also has some claims to answer for.

She has long claimed she was offered a place to study Medicine at Stanford on a partial scholarship after stellar US SAT results at 16 while living in the UK. Recently, that story has begun to unravel.

In the US, Medicine is a graduate-entry programme with students undertaking an undergraduate ‘pre-med’ degree first before acceptance into medical school. Badenoch never mentioned a pre-med degree, but lets give her the benefit of the doubt and assume she was referencing a pre-med place at Stanford.

Well Stanford doesn’t offer pre-med degrees or majors… Bit awkward, and the Guardian didn’t stop there, contacting Jon Reider, the Stanford admissions officer at the time. He confirmed he never offered Badenoch a place and noted that scholarships at Ivy League universities are almost never awarded on SAT scores alone. Add to that her B, B, and D in O-levels (the old GCSEs for you young ‘uns) for Biology, Chemistry, and Maths, and those “dazzling” SATs look doubtful.

This seems like a good old case of ‘LinkedIn-style’ CV inflation. How many other people in society are trying to get in on the doctoring act?

Winners and Losers in the New Student Finance Changes

Why the New Lifelong Learning Entitlement will benefit both ends of the earning spectrum, but squeeze the middle

How medical students fund their degrees is changing and it will have significant impacts on the finances of doctors in the future. From January 2027, the Lifelong Learning Entitlement (LLE) will be rolled out and reshape student finance as we know it. So, what will it mean for future doctors? Let’s break it down.

Where else to start but the ‘funding cliff’ many medical students face. After year four of the traditional five or six year medical degree things get tough. Student Finance England (SFE) covers tuition and living loans for the first four years of a traditional five or six year medical degree. From year five, the NHS bursary takes over tuition fees and offered a means-tested grant that you didn’t have to repay for living costs, topped up by a reduced-rate SFE loan if needed.

For students in expensive cities or without parental support, this left a gap. Many had to take demanding jobs to stay afloat. The BMA campaigned specifically with this in mind, citing a funding drop of £3,979 in the final years of undergraduate degrees (the same drop happened from the second year onwards for graduate-entry degrees).

The LLE will shake up this system with the NHS bursary’s role being significantly reduced (although not completely eradicated). From 2027, tuition fees for the whole degree will be funded by an LLE loan (not the NHS bursary in later years).

Students will effectively be able to access full tuition fee and maintenance support for the duration of their course, meaning funding will never have to be an issue for medical students. The NHS bursary will still exist but purely for living costs in later years.

More Debt?

As you may have worked out, the LLE comes with a larger debt burden than the old system with the significant changes around later tuition loan funding.

To really understand this, we need to add in the student loan changes. For courses starting after August 2025, students will be on Plan 5 student loans. We have highlighted the key differences between the two student loan plans below:

The big talking point is the interest change down from RPI + 3% to just RPI, meaning debt will not grow as rapidly overtime. Graduates will also start repaying their loans sooner during parts of their careers when salaries are lower.

Who Are The Winners?

So, Foundation doctors will now graduate with a higher debt burden, but on loans with a lower interest rate and a longer repayment period. Does your head hurt? Mine too. In practice, this means high-flying consultants who move quickly through training and top up their income with locum or private work will benefit most, since they stand a real chance of clearing the debt at a cheaper rate.

Foundation doctors will continue paying 9% above a certain threshold, but that threshold has reduced slightly. In reality this shouldn’t have a significant affect on take-home pay.

The bigger challenge comes later. The 40-year repayment period means those who spend longer in training, take career breaks, or go part time may never pay their loans off. This will disproportionately affect groups such as women who are more likely to step away from full-time work.

Another group set to benefit are students who previously struggled just to get through medical school due to financial hardship. With full tuition and maintenance loans available throughout their degree, the barrier of affordability is removed.

So, in conclusion: those at the very top gain from lower interest rates, those at the bottom gain from improved access to finance, but as usual, those in the middle are the ones who will feel the squeeze.

“The Neuro exam paradox seems to be affecting many new F1s. If one attempts the neuro exam prior to referral, they face the examination being repeated by neurology who proclaim the original exam was useless. If one does not attempt a neuro exam prior to referral, they face being lambasted. Accept your fate and just have a go”

“If patients get sicker following your shift, that does not necessarily mean you are at fault. Patients can get sicker independent of our best efforts”

“Create a system where success in medical school requires an internet connection and access to a question bank at your own peril. Recognition of ‘the sick patient’ or prioritisation of jobs based on clinical urgency is only full appreciated whilst spending time on the wards”

“Still thinking about that episode of House MD where House prescribed a cigarette to help a patients constipation”

What’s on your mind? Email us!

Some things to review when you’re off the ward…

Could we have reached a huge breakthrough in our scientific understanding of Chronic Fatigue syndrome (CFS)? Researchers from the UK have identified 8 genetic variants that seem to predispose individuals to CFS. We know that most conditions in medicine are part genetic, but having specific DNA targets may allow the development of treatments.

To all our FY1 readers, the BMA ballot for speciality training places and pay restoration is now open. If you want your say on whether you support or oppose industrial action, here is where you need to go.

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Last week’s poll:

What do you think should happen to the PLAB exam?

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What Do the Numbers Say About the Gender Gap in Medicine?

Early this year, the headlines showed that female doctors now outnumber their male peers on the UK medical register. GMC data showed that as of 28th February 2025, women make up 50.04% of the doctors in the country. That’s quite a change from when the first register was created in 1858 and contained just one woman, Elizabeth Blackwell, who was American at that.

A look beneath the overall figures is more interesting. Women dominate in obstetrics and gynaecology where they make up 63% of the workforce. The next most highest on the list are paediatrics (61%), and general practice (58%).

They remain a minority in surgery (17%), ophthalmology (35%) and emergency medicine (37%), fields where long, inflexible training and cultural barriers can be hard to reconcile with going part-time or having a non-linear career through breaks, to have children for example.

Right, so men are underrepresented in O&G and women are underrepresented in surgery. The crucial question is why. Are doctors being pushed out by structural barriers, or are they self-selecting out of certain specialties by choice?

In surgery, the evidence points to systemic inflexibility and lingering cultural biases, however, in O&G it looks more like preference.