The NHS Performance Assessment Framework

A critique and an alternative...

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Now…The NHS Performance Assessment Framework

The recently published NHS Performance Assessment Framework for 2025/26 presents an approach to evaluating the performance of Integrated Care Boards (ICBs) and NHS trusts. While the framework aims to enhance oversight and accountability, a critical analysis reveals several concerns regarding its potential impact on organisational performance, efficiency, and employee well-being. In this paper I outline some of these concerns and propose and alternative approach, because I don’t believe that getting a tighter more centralised grip is the answer.

Centralised Oversight and Its Implications

The framework introduces a model that categorises organisations based on performance metrics, with varying levels of oversight and intervention from ‘the centre’. This centralised approach may stifle local autonomy and innovation. Research indicates that excessive top-down control can hinder the responsiveness of healthcare organisations to local needs and reduce the effectiveness of care delivery.

Impact on Psychological Safety and Organisational Culture

The emphasis on stringent oversight and accountability mechanisms may inadvertently foster a culture of fear and blame, detrimental to psychological safety. Psychological safety, defined as a shared belief that the team is safe for interpersonal risk-taking, is crucial in healthcare settings. A culture lacking psychological safety can lead to underreporting of errors and hinder open communication, ultimately compromising patient safety and staff well-being.

Potential for Increased Bureaucracy

The framework’s detailed segmentation and assessment processes risk introducing additional bureaucratic layers, potentially diverting resources from patient care to compliance activities. This has happened before! Historical analyses have shown that increased administrative burdens can lead to inefficiencies and detract from the core mission of healthcare organisations.

Patriarchal and Dated Approach to Management

The centralised, top-down nature of the framework reflects a patriarchal management style that may be considered outdated in contemporary healthcare management. Modern leadership and governance theories advocate for collaborative and participatory approaches that empower frontline staff and encourage shared decision-making. The framework’s approach appears to me to be poorly aligned with these contemporary practices.

While the NHS Performance Assessment Framework for 2025/26 seeks to enhance oversight and accountability, its centralised and hierarchical approach raises concerns about its effectiveness in promoting high performance, efficiency, and a positive organisational culture.

A more balanced approach that fosters local autonomy, supports psychological safety, and reduces bureaucratic burdens may be more conducive to achieving the desired outcomes in NHS efficiency, performance and patient care.

Toward an Alternative NHS Performance Ethic: Trust, Reflection, and Relational Accountability

The prevailing paradigm of NHS performance assessment, as codified by the 2025/26 framework is, in my view, shaped by a technocratic ethos that equates oversight with control and accountability with surveillance. It reflects a managerialist inheritance, a “high modernist” faith in central measurement, top-down intervention, and system-wide optimisation. Yet the problems facing the NHS are not, fundamentally, ones of compliance, but of coherence: coherence of values, relationships, and purpose in the delivery of care.

I propose an alternative.

A performance ethic built not on oversight but on trust, not on external pressure but on internal reflection, and not on punitive escalation but on relational accountability. This model would take seriously the psychological, moral, and ecological realities of contemporary healthcare work, and aim to produce both excellent patient outcomes and a culture in which staff can flourish.

From Control to Care

At the heart of this alternative framework are three foundational shifts:

From oversight to stewardship:

Senior leaders and national bodies should act not as inspectors but as stewards of culture, trust, and learning. Their task is to tend the soil, not test the fruit.

From Metrics to Meaning:

While quantitative indicators have their place, performance should be judged primarily by the coherence between an organisation’s stated values, its lived experience, and the outcomes it generates—especially those that are relational or experiential in nature (Tronto, 1993).

From Compliance to Conscience:

Real accountability is not achieved by external coercion but by the cultivation of a moral and professional conscience within individuals, teams, and systems. This entails support for self-reflection, peer dialogue, and moral maturity (Palmer, 1998).

Creating Conditions for Flourishing

This approach would require new practices of performance development at three interwoven levels:

Individual: Professional Maturity and Self-Reflection

Healthcare professionals should be supported to:

- Engage in regular reflective practice; not as a box-ticking exercise but as a valued part of their development.

- Participate in confidential peer circles where they explore the ethical and emotional dimensions of their work.

- Be given time and space for rest, regeneration, and meaning-making, recognising that resilience is a systemic and relational property, not a personal trait.

Team: Collective Accountability and Psychological Safety

High-performing teams are not produced through external pressure but through mutual care and commitment. Key practices here include:

- Team-based learning reviews, where success and failure are examined with curiosity rather than blame.

- Facilitated dialogues around relational breakdowns, system pressures, and value conflicts.

- Shared rituals and practices that foster a sense of belonging, significance, and care.

Place: Trust-Based Assurance and Local Stewardship

Integrated Care Systems (ICSs) and place-based partnerships should be seen not as administrative boundaries but as communities of shared responsibility. Performance development at this level could include:

- Local “listening inquiries” where staff, patients, and community members reflect together on what is working and what is not.

- Trust-based peer reviews between organisations, focusing on culture, relationships, and integrity.

- Developmental partnerships with universities, community organisations, and citizen panels to support co-created learning.

Governance: Embedding Relational Accountability

Accountability does not disappear in this model; it is relationally redefined. It rests on:

- Narrative-based reporting, where organisations tell the story of their challenges, experiments, and growth rather than simply publish metrics.

- Ethical reflection boards, made up of staff, patients, and laypeople, who provide commentary and challenge on how the organisation is living its values.

- A new covenant of trust between national bodies and local systems, grounded in shared moral commitments rather than bureaucratic expectations.

Why This Matters: For People and Outcomes

Studies consistently show that staff experience and patient outcomes are deeply intertwined. Cultures that are compassionate, safe, and developmental tend to:

- Reduce burnout and absenteeism

- Improve communication and continuity of care

- Increase patient satisfaction and trust

- Enhance innovation and quality improvement

NHS organisations that score highly on staff engagement metrics also perform better on a wide range of clinical and financial indicators. A system built on fear and surveillance may appear efficient in the short term, but it hollows out the relational and ethical fabric on which good care depends.

Data-Informed, Not Data-Driven: Using Performance Metrics in a Culture of Trust

Rather than rejecting performance data, this approach repositions it within a relational and reflective culture. Data becomes a prompt for inquiry, not a verdict for judgment.

Valuing Data as a Mirror, Not a Whip

In traditional performance frameworks, metrics often serve as instruments of compliance, with poor results triggering punitive responses. In contrast, a trust-based model treats data as a mirror—a way to see ourselves more clearly, provoke reflection, and inform wise action.

For example:

- Declining patient satisfaction scores would trigger a facilitated dialogue involving patients and staff, not just a performance review.

- A rise in staff sickness absence would lead to exploration of workload, morale, and team dynamics—not assumptions of inefficiency or absenteeism.

- Unexpected financial overspends would prompt collaborative re-prioritisation, rather than finger-pointing.

The key is contextualisation: embedding data in the stories, relationships, and systems in which it emerges. This aligns with contemporary best practice in learning health systems, which treat data as “sense-making tools” rather than absolute truths (Tsoukas, 1997).

Qualitative and Quantitative Intelligence in Dialogue

The framework would explicitly integrate both qualitative and quantitative evidence. For instance:

- Staff surveys would be complemented by ethnographic “listening walks” and narrative-based interviews.

- Hospital readmission rates would be discussed alongside patient and staff stories of continuity, discharge planning, or system bottlenecks.

- Financial performance data would be paired with case studies on how local constraints or innovation affected delivery.

This practice aligns with dialogic accountability, an approach that insists data must be explained, interpreted, and held within ethical conversation.

Financial Responsibility Within a Developmental Ethos

A trust-based system must not appear fiscally lax. On the contrary, it invites deeper and more shared financial accountability through the following principles:

Transparency Through Dialogue

- ICS-level financial dashboards remain essential, but their interpretation becomes a collective act, shared with citizen panels, boards, and clinical leaders.

- Places that are underperforming financially are invited into learning partnerships, not named-and-shamed lists.

- Each organisation publishes a Financial Stewardship Narrative; a public account of how resource decisions were made, reflecting moral, clinical, and community perspectives.

Relational Budgeting

- Financial planning is integrated with workforce and care planning at team and place-based levels.

- Budget holders are supported to have relational conversations with those affected by spending decisions, using participatory tools (e.g., deliberative budgeting).

- Overheads and support functions are examined not only for cost, but for their contribution to care, using appreciative inquiry methods

Collective Risk and Reward

Risk-sharing agreements between providers within an ICS are strengthened. If one provider faces financial pressure, others work collaboratively to support and rebalance.

This reduces the tendency to game the system or hoard surpluses—aligning with the principle of mutual aid.

Accountability Reimagined: Still Robust, But Humanising

Contrary to assumptions, this approach does not eliminate accountability. It transforms it:

Traditional Model

- External performance targets

- Top-down inspections

- Escalation to national teams

- Compliance with central KPIs

- Blame for variance

Relational Model

- Internally owned developmental goals

- Peer-led learning reviews

- Support from local networks and stewardship bodies

- Accountability to shared values and narratives

- Curiosity about causes of difference

In this model, everyone remains accountable: to themselves, to one another, and to the public. But this accountability is grounded in care, maturity, and truthfulness, not fear or managerial coercion.

Bringing Myron’s Maxims to Life: Performance through Participation, Not Prescription

Myron Rogers, a key figure in the development of participative and emergent organisational approaches, offered a set of wise provocations, now known as Myron’s Maxims, that articulate a deep philosophy of change and organisational life. They are particularly relevant to health and care systems, where complexity, emotion, and relational depth are ever-present.

Below we explore how each of Myron’s Maxims can guide a reimagined NHS performance framework:

“Real change happens in real work.”

Rather than pulling staff away from their practice for abstract compliance exercises, the proposed model embeds development within the everyday work of care. Performance improvement arises organically through reflective practice, joint inquiry, and sense-making, not from separate performance initiatives. Data becomes a catalyst for real work conversations, not a distraction from them.

Example: A team experiencing high patient turnover doesn’t attend a ‘performance seminar’—instead, it pauses to reflect on discharge planning with peers, patients, and social care partners, using real stories and data as their shared ground.

“Those who do the work do the change.”

Accountability shifts from being externally imposed to internally owned. Teams define meaningful goals and interpret data through the lens of their context. The performance framework thus becomes a process of empowerment, not enforcement.

Example: A midwifery team is supported to develop its own indicators of success—based on trust, continuity, and birth experience—alongside standard clinical metrics. These become part of their internal review and learning cycles.

“Start anywhere, follow it everywhere.”

This maxim reminds us that performance change is not linear. It begins with what matters most to those involved. A small insight in one area can ripple outward, transforming practice in unexpected ways.

Example: A small experiment in end-of-life care in one community hospital sparks a wider conversation about the quality of dying across the ICS, eventually leading to new place-based learning networks and revised funding priorities.

“The process you use to get to the future is the future you get.”

If the assessment process is experienced as punitive and mistrustful, the culture it creates will be fearful and defensive. Conversely, if it is collaborative, compassionate, and curious, it models the very future the NHS seeks: one of care, maturity, and moral coherence.

Example: A trust undergoing financial pressure is invited to co-create its improvement response with a peer organisation and community leaders, with NHS England acting as a supportive listener, not a disciplinarian. The resulting plan is both financially sustainable and relationally intelligent.

“The people in the system know what needs to happen.”

Top-down solutions often fail to grasp local nuance. This model affirms that those closest to the work, patients, families, clinicians, and support staff all hold critical insight into what needs to change. The role of performance leadership is to listen deeply, convene wisely, and remove barriers.

Example: A GP practice with growing health inequalities is enabled to host participatory community forums where lived experience and local data shape targeted interventions, backed by ICS investment.

“Connect the system to more of itself.”

High performance is not produced by escalating accountability chains but by deepening relationships across the system. Place-based performance development becomes a process of relational weaving; connecting people, insights, and resources in new and generative configurations.

Example: Instead of quarterly reporting meetings, the ICS convenes seasonal “Listening Assemblies” where care providers, patients, VCSE partners, and public health teams engage in sense-making together, fostering shared intelligence and emotional resonance.

Together, these maxims point to a radically different paradigm: one in which the purpose of performance work is not simply control, but coherence, the alignment of intention, experience, and outcomes across the ecology of care. Rather than “delivering” performance, the system cultivates it.

This is not a soft option. It is a more human, more accountable, and ultimately more real one.

Data, money, and accountability are not enemies of care, they are essential tools. But like all tools, they must be used with skill, ethics, and a deep respect for the human beings they affect. This alternative performance framework offers a way to remain financially responsible and data-informed without losing the soul of the NHS.

Conclusions: A Call for Moral Maturity

The crisis in NHS performance is not simply technical or financial, it is a crisis of ethics, meaning and maturity. We cannot dashboard our way to better care. What is required is a new ethic of performance: one that trusts people to care, gives them the time and space to reflect, and holds them accountable not to abstract targets but to the human reality of those they serve.

This is a call not for softer expectations, but for deeper ones. For the kind of performance that arises not from compliance, but from integrity.

Mike Chitty