Organisations that can’t measure performance end up measuring performativeness instead.
This is what's happening everywhere. Inside surgeries. Inside ICB boardrooms. Inside the NHS and inside of General Practice every day.
When you cannot measure whether care is actually being delivered, you start rewarding the theatre of trying. You celebrate the appearance of progress rather than progress itself.
Performance is value created per unit of activity. In clinical work, that means fewer missed reviews, parameter completion, and higher QALYs per pound spent. It is tangible, measurable, and defensible. Performativeness is the opposite. It is the ritual. The dashboard. The screenshot of a recall sent. It is the template ticked without checking the patient’s bloods. It is governance paperwork written once for audit and never wired into daily work.
The shift from performance to performativeness is subtle. It happens when the metric is easier to measure than the outcome. When a manager reports messages sent instead of patients reviewed. When surgeries talk about activity levels rather than clinical loops closed. When static filters are rebranded as intelligence because the list they produce looks clever.
This is how Goodhart’s Law takes hold. The measure becomes the target. The more you chase it, the less it tells you.
If you want to spot performativeness, look for where numbers grow without physiology changing. Look for metrics that can be gamed. Look for teams succeeding by being visible, not by getting work done. Most dashboards in primary care tell you nothing about actual patient safety. They track the surface tension of activity, not the substance of care.
The way out is to measure at the right level, the level of work. In long term condition management, that means parameters. A CHD review is not a single code. It is a chain of physiological checks: blood pressure, lipids, smoking status, medication optimisation, and follow up. Unless those parameters are documented to standard, the review is not complete. The same applies to diabetes, COPD, and Asthma. You cannot improve what you cannot see, and you cannot see what you refuse to measure.
When you measure at parameter level, the noise drops away. The data is ungameable. A missing blood pressure is a missing blood pressure. Half complete is half complete. The work becomes visible in a way no dashboard or list can replicate. It also forces governance to mature. Once you can see every incomplete parameter, you can build control around it. Escalation rules. Safety nets. Real oversight.
That is what we built into BookYourGP from the start. Not a reporting tool. Not a messaging widget. Clinical oversight infrastructure. Every recall, every upload, every coded entry tracked, auditable, and parameter based. A living record of work done and work outstanding. It does not reward visibility. It rewards completion.
The tragedy of general practice is that most surgeries still live in the world of performativeness. They send messages, tick boxes, fill spreadsheets, and call it safety. But it is not. It is pantomime. It burns staff time, hides risk, and gives regulators the illusion that care is under control.
Performance is quieter. Less visible. But it is the only thing that moves the needle.
We do not need more dashboards. We need systems that can tell us, precisely and in real time, which patients are clinically safe and which are not. Until then, the NHS will keep rewarding theatre and mistaking noise for progress.