The white paper, Equity and Excellence: Liberating the NHS, set out the government’s intention to achieve better outcomes in the NHS and become more responsive to patients’ needs.
The government also launched a consultation on a new outcomes framework that aims to refocus the NHS on the outcomes achieved for patients rather than the process targets of the past that had no clinical justification. It begins to describe what the framework will look like.
It includes a set of national outcome goals which patients and the public can use to judge the overall performance of the NHS and hold the government to account for progress. The framework and the national outcome goals will form a combined mechanism by which the health secretary can hold the new NHS Commissioning Board to account.
Defining and measuring quality is central to meaningful accountability. The NHS Next Stage Review, led by Lord Darzi, helped the NHS define quality as: the effectiveness of the treatment and care provided to patients; the safety of the treatment and care provided to patients; and the broader experience patients and their carers have of the treatment and care they receive.
In terms of measuring these three areas, the government believes it is legitimate to look at:
• the structures of care - based on robust evidence, how should treatment and care be structured in order to maximise the chance of a good outcome for the patient?
• the processes of care - based on robust evidence, what are the things that should be done to maximise the chance of a good outcome for the patient?
• the outcomes of care - what actually happens to the health of the patient as a result of the treatment and care they receive?
However, at a national level the focus and accountability should, as far as possible, be centred around the outcomes of care. Locally, the structures and processes of care will need to be monitored but focusing on these too heavily at a national level can lead to a distortion of clinical priorities and risks creating a whole system of accountability that it is more concerned with the means than the result - an accountability system that has lost sight of the purpose of the NHS.
While the outcomes framework is intended to sharpen the accountabilities in the system for delivering better and more equitable outcomes, it is not about setting priorities for the service. It will be used by the health secretary as a balanced scorecard or dashboard to monitor the progress of the NHS in delivering care to patients.
Accountability can only be effective if it is matched by transparency. The data against each of the outcomes that are presented in the framework will be made publicly available, so that the NHS and public can see the progress of the NHS for themselves.
Striving to free professionals from excessive bureaucracy means measuring the progress of the NHS against outcomes that are clinically relevant and that professionals themselves recognise as accurately tracking the delivery of improved quality and outcomes for patients.
The framework should also recognise the importance of reducing inequalities and promoting equality. For example, because of the social gradient in most health outcomes, the most potential health gain will often be available from the lower reaches of the gradient, from disadvantaged groups and areas.
The government’s vision for the NHS is for it to be a world leader in healthcare provision. However, outcomes included in the framework should not be selected solely in areas where the NHS is performing less well than other international healthcare systems, as this perspective may not identify what matters most to patients. International comparisons can only be based on what comparable data is available and this may not always reflect the most important quality improvement challenges facing individual healthcare systems.
The consultation document suggests five outcome domains and is seeking views from clinicians and patients on the structure and the core principles that should underpin the development of the framework, as well as the more specific outcome measures that should be used.
The proposed domains are:
1. Preventing people from dying prematurely.
2. Enhancing the quality of life for people with long-term conditions.
3. Helping people to recover from episodes of ill health or following injury.
4. Ensuring people have a positive experience of care.
5. Treating and caring for people in a safe environment and protecting them from avoidable harm.
The consultation asks two key questions about these: Do you agree with the five outcome domains that are proposed for the NHS Outcomes Framework? Do they appropriately cover the range of healthcare outcomes that the NHS is responsible for delivering to patients?
Once set, it will be for the NHS Commissioning Board to determine how best to deliver improvements against the selected outcomes by working with GP consortia and making use of the various tools and levers it will have at its disposal. For example, the board will be able to commission quality standards from NICE, which it will then use to provide more detailed commissioning guidance on how best to meet the national outcome goals included in the framework.
The board will also be able to draw on these quality standards to support it in designing payment mechanisms and incentive schemes such as the Commissioning for Quality and Innovation Payment Framework.
The first publication of the framework will, as a starting point, use existing outcome indicators for which data can be collected. This will mean that the NHS Outcomes Framework for 2011/12 may not necessarily meet all of the principles set out in this chapter. However, the nature of the changes to the NHS landscape that were announced in the white paper and the time lag to develop new indicators means that the NHS Outcomes Framework will evolve over time. It will be reviewed annually.
Health secretary Andrew Lansley commented: “Instead of politically motivated targets which lack clinical evidence, we will measure the outcomes that are most important to patients and that are relevant to healthcare professionals. These will be backed up by authoritative, evidence-based quality standards that will ensure everyone understands how those outcomes can be achieved.
“I want to hear the views of healthcare professionals, patients, carers and the public on how the new system should work, and what we should measure to ensure the NHS is focussed on what is important to patients and what improves their overall experience of NHS care.”
Views can be submitted via email at nhswhitepaper@dh.gsi.gov.uk. The government will publish a response to the consultation prior to the introduction of a Health Bill later this year.
Read the full consultation document.
Tags: Health policy
The anxiety expressed by the health secretary over attaching political direction to an outcomes framework for healthcare is a weakness. The domains are a further expression of this. A principal difficulty facing the NHs is its lack of political direction , not its lack of quality clinical care. An outcomes focus may only re-invigorate the NHS, if there is political will to clarify what it is we want the NHS to achieve. The outcomes so far identified set no new challenges either for the NHS or for patients. They are detached from the social economic and indeed moral context in which they ought to be embedded. The right’s fear of big government limits its ability to embrace radical new thinking that would allow health to work alongside education and The DWP in a partnership that supports all its citizens to be fully socially engaged.
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