Filed Under (Clinical Commissioning Groups, Health Improvement, Public Health, Targets) by Paul on 02-05-2012
No 1 Working towards improving health care outcomes
We are now a few weeks on from the passage of the Act. The glimpses of the direction of its implementation that we have had since then are as contradictory as the Bill itself. The Secretary of State writes to the NCB saying that they must ensure that there is autonomy for CCGs and the Chair of the NCB responds by saying that it will be some time before the NHS will be liberated from its centre.
What should a growing CCG make of this confused messaging? The answer must be that if you wait to be told what to do, the centre will issue instructions that will firmly contradict itself and tell you (very loudly and with force) to go in the opposite direction from the previous instruction.
So the lesson from this is? Best not wait to be told what to do.
Over the next few weeks I want to share some of the developments that are happening on the ground which in my opinion are progressive NHS activities that local people can carry out.
What is my definition of progressive? An activity which will improve the lives of NHS patients and improve the impact of NHS care on their lives.
But many of my readers may say, “Don’t you think that the Act is a shambles? How is it possible within that shambles to do anything progressive? “
The answer of course is it’s difficult to do progressive things from within this shambles, but it will be possible to develop progressive practice precisely because it doesn’t know what it is doing.
Today I want to concentrate on the possibility in local health economies of developing health care that is incentivised to provide health care outcomes. Why do I think health care outcomes are more progressive than say, inputs? And what do I mean by ‘outcomes’?
The best way I can explain the difference between inputs, outputs and outcomes comes from my time in local Government in the mid 1990s. One of the biggest issues in local government at the time was how can we know whether the school dinners in one local authority are as good or better than another. As I hope readers will know we can always make a joke or two about school dinners, but for many children they are a vital part of their nutrition and many schools recognise that without good school dinners the afternoon sessions at school are worth very little.
In the early 1990s local authorities judged their dinners to be better than others because they paid more for them. “Our school dinners have had more inputs in terms of cost and are therefore much better than yours”. It wasn’t difficult to point out that a school dinner could be expensive and wasteful while another could be cheaper and better. So if measuring input – what you paid for the meal – didn’t work local government moved on to look at outputs.
This was the beginning of the argument about the importance of much better nutrition in school meals. So some local authorities said – “Of course inputs are not a good way of measuring success. We need to move on to outputs, and the output that really matters is the nutritional content of the meal.” – Some local authorities were certain that their nutritional content was not only better than others but could be demonstrated to be better. Chips gave way to brown rice; trifle to a piece of fruit. It was clear that one school dinner was better nutritionally than another and therefore one output was much better than the other.
However the problem was that even if the output had improved a lot and was providing really great nutrition – what if the children didn’t eat them? In that case a very good output created zero ‘outcome’. A high nutritional meal which stayed outside the child would meet all the output criteria but as a way of getting nutrition into the child and creating an outcome was of no use at all.
So high outputs could still lead to zero outcomes. And this is the trick. This is why, for me, outcomes are inherently more progressive than outputs or inputs. Outputs and inputs can be measured and delivered without the public being involved at all. A service can be doing really well with either but it doesn’t involve the child. Only outcomes do that.
An outcome is different from an output because it must involve the member of the public in some part of the delivery of the outcome.
Yet the professionals – in this case the people who created the school meal service – always felt it was unfair because they could their job very well. These were great dinners, but they were ‘marked down’ if the public did not engage with these wonderful outputs. That wasn’t fair. We do all that brilliant work and just because the public didn’t like it we’re told it wasn’t good enough.
This is my point as to why outcomes are inherently progressive. The only way that a successful outcome can be constructed is if the members of the public do their bit in its delivery too. But the professionals say, “That’s not fair! We’re judged not just on our work but on whether the public do some work as well. That’s not fair because we don’t control that part of the outcome!”.
And yes, that’s true. Professionals don’t control the outcome – but they need to persuade the public to do their part or there is no outcome.
What might this mean for health care?
Readers will have heard of PROMS (Patient Recorded Outcome Measures). These contain outcomes that go beyond the particular intervention that the health service has carried out. So, for example, a hip replacement is an operation which can be carried out well or badly.
If it is carried out badly in the operating theatre it will have a big impact upon the mobility of the patient and if, as a part of a PROM, the patient is asked whether they can get up the stairs or down to the shops after a certain period of time, they are likely to say they find it difficult.
But it is also the case that the operation might be carried out in the operating theatre well, but the aftercare would be such that the outcome of ‘getting to the shops’ still can’t be achieved. So if the surgeon is worried about the impact of outcomes on their work, it is in their interests (and the patient’s) to ensure that the aftercare is very good.
So measuring professional staff on outcomes directs the professionals to concern themselves beyond the specific moment of their work. It involves them much more in the ensuring that the patient’s lives are improved by the intervention.
This is a very considerable change for a public service such as the NHS which, until a few years ago, was not measured very much at all and which since then has been measured mainly by inputs and a few outputs.
This will not be an easy shift for the NHS, but I do think it is a progressive shift.
The government’s outcomes framework stresses five things that the NHS should be measuring,
- Preventing people from dying prematurely
- Enhancing quality of life for people with long term conditions
- Helping people to recover from episodes of ill health
- Ensuring patients have a positive experience of care
- Treating and caring for people in a safe environment and protecting them from avoidable harm
Success in each of these will need patients to be involved in their NHS health care.
At its crudest there is a great deal of evidence that people are much less likely to die if they have something to live for. The same is true for those who recover more speedily from episodes of ill health.
The quality of life of people with long term conditions will depend upon a range of factors that will involve their NHS treatment, but on other issues as well.
What does this mean for local health economies? I know that many patient groups are working with the NHS to work out what a good outcome might be for, for example, a muscular skeletal disorder. These need to be picked up by clinical commissioning groups and discussed as a part of the commissioning process with NHS provider organisations.
As next year’s commissioning negotiations start in the autumn I think there will be a number of health economies that will be commissioning for some pathways towards outcomes.
This won’t happen everywhere. It won’t happen with every condition. But it will happen in some places and for some conditions – and it will be a good thing.
Over the next few weeks I will return to this with examples of how this can work for patients in a progressive way.