Healthcare needs judgement, not just metrics
Dr Sandra Romenska, Senior Lecturer in the University of St Andrews Business School’s Department of Management, is the course leader on the Executive Education programme Value-Based Healthcare.
Here, she reflects on why healthcare leaders can end up focusing on what is easiest to count rather than what most needs attention, drawing on one of the most widely used leadership case studies: the story of Robert Falcon Scott and Ernest Shackleton, often described as a natural experiment in leadership, where similar conditions and ambitions led to very different outcomes.
Climbing the 25-metre mast of RRS Discovery in Dundee recently made me think again about a question I come back to often in leadership: what do you hold on to when the original plan no longer works?
The ship is central to one of the best-known leadership case studies: the story of Robert Falcon Scott and Ernest Shackleton. I use it regularly in my teaching with students and in Executive Education. Both Scott and Shackleton sailed on Discovery before setting out on their own Antarctic expeditions. They worked in extreme conditions, under intense strain and with ambitious aims. Neither achieved the original mission. But when circumstances changed, they responded in very different ways. Scott stayed fixed on the objective, and his team did not survive the return journey. Shackleton focused on his people, and brought every member of his crew home.
Healthcare is not polar exploration, but its leaders face their own version of that choice. Faced with rising demand, tighter resources and increasing scrutiny, they have to decide what they are really trying to protect and improve.
Funding is a constraint, but the more important issue is how leaders define and act on value. If they are not clear about priorities, trade-offs and the kind of care they are trying to improve, better reporting or greater efficiency will not change very much. It will simply make the system more efficient at repeating its existing weaknesses.
That is why value-based healthcare matters. Not as a slogan, and not as a tidy framework sitting beside the real work, but as a way of asking more searching questions. What are we trying to improve? For whom? What are we choosing to prioritise? What are we prepared to stop doing? Where are time, effort and money going without enough benefit to patients?
Those questions are uncomfortable because they force leaders to look beyond visible activity and ask what all that effort is actually producing.
When measurement starts to drive the system
Organisations under strain often centre on what is most visible and most defensible. Waiting lists, throughput, local targets, performance indicators and efficiency metrics quickly take over. That is understandable, but it can narrow judgement. Leaders start running the system through what can be counted rather than through what they are actually trying to improve.
What sits on the surface is only part of the picture. Like the visible tip of an iceberg, those measures can draw attention while deeper problems in coordination, culture, decision-making and patient experience remain harder to see.
The result is a familiar pattern. A hospital may meet its targets, a process may move faster, a department may increase output, but patients can still experience care as delayed, fragmented or poorly coordinated. More activity does not tell us enough on its own. A system can be busy, costly and exhausted while still falling short in the areas that matter most to the people moving through it.
The same applies to efficiency. Lean, for example, is sometimes reduced to the language of speed, savings and productivity. Used well, it asks more of leaders than that. It should help them identify waste, improve flow and redesign services in ways that support better care. Efficiency only matters when it serves a clear purpose. Otherwise, it becomes another way of refining the mechanics without asking what the system is really there to do.
This is not an argument against measurement. Healthcare needs data, accountability and operational discipline. But leaders still have to decide what deserves attention and what success should mean. Metrics must inform, not replace judgement.
Leadership when conditions shift
Scott and Shackleton’s stories still hold up because they are not just stories of endurance. They show what leadership looks like when conditions change. When events stop following the plan, leaders have to decide what they are really trying to protect. The mission still matters, but so do the people delivering it, and so does the judgement to recognise when an inherited objective no longer fits reality.
Healthcare leaders face that kind of judgement all the time. They cannot avoid trade-offs, and they cannot rely on measures alone to make those choices for them. They have to decide what improvement should mean, where effort should go and what good care looks like in practice.
That is why value-based healthcare matters. It asks leaders to be clearer about purpose, more honest about priorities and more disciplined about what resources are actually for. Funding, measurement and operational management all matter. But none of them can substitute for leadership that is clear about what it is trying to improve.
The central question is not whether we can measure more. It is whether we are clear enough about what we are trying to improve.
Learn more
These ideas underpin Value-Based Healthcare, a three-day Executive Education programme at the University of St Andrews Business School led by Dr Sandra Romenska, with collaborators value-based healthcare consultant Dr Slaveyko Djambazov.
The programme runs in St Andrews from 23 to 25 June 2026 and 24 to 26 November 2026.