NHS and Public Health Outcomes Frameworks

To improve healthcare quality, performance targets are to be replaced by outcome measures, as detailed in recent government consultations.1,2

Quality of healthcare can be measured in terms of structure, process and outcomes.3 In recent years the NHS has largely relied on setting targets for structural and process measures. Examples of structural measures include staff numbers and the number of hospital beds, while process measures include waiting list times and screening rates.

Evidence of the possible benefits

‘Outcome targets’ are designed to measure the ultimate aim of healthcare services – improvements in health. Process targets only measure what a health system is doing, rather than the effect it is having on health itself. In doing so, outcome targets leave providers free to chose how they are going to reach the target. This is thought to encourage innovation as new solutions are found to meet the outcome target.4 This is a shift in emphasis in health service management and it is too early to assess the impact of this move to outcome measures.

Targets give information about healthcare, which can enable people to choose between providers, e.g. which hospital to attend or which surgeon you would want to perform your operation. Evidence shows that people want choice and believe choice is important.5 Outcome data are proposed to be publicly available, allowing patients to choose healthcare according to the quality of care provided.

Several experts believe some process targets are not linked to improving health care or outcomes, are examples of centralisation and are sensitive to political interference.6,7

A general criticism of any target is that if poorly thought through, targets can create ‘gaming’, such as keeping patients in ambulances outside Accident & Emergency departments to avoid starting the clock on the 4-hour waiting time limit.8,9

A report on failings at Mid Staffordshire NHS Foundation Trust highlighted an ‘over reliance on process measures, targets and striving for Foundation Trust status at the expense…of providing quality services for patients’.10

Evidence of the possible risks

Process targets have been a legitimate means of measuring productivity in the NHS.11 Indeed, there were notable successes such as waiting list, infection control (e.g. reducing MRSA infections) and the target for a patient to get a hospital appointment within 18-weeks of referral.6,12,13 The scrapping of these could risk progress made so far.

Outcome measures must be reliable and valid. Outcomes can be difficult to measure and often the outcome may not be obvious for some time e.g. reduced mortality due to a disease, or a large sample size may be needed to detect a measureable change.14 It can also be difficult to relate improvements in outcomes to specific policy changes when a number of policies may have contributed to that improvement.

One of the stated aims of the outcomes frameworks is for the NHS to deliver the best health outcomes in the world. However there are difficulties in comparing data across international boundaries and inappropriate comparisons can mislead the population and demoralize healthcare staff.15 Collecting and collating target data can also be time-consuming and costly, re-directing NHS resources from patient care.8

Implications for health and well-being

Better outcomes often stem from treating people faster, and scrapping targets may lead to poorer health outcomes. There is evidence, however, that reporting of outcomes data could lead to improvements in clinical quality.16

Author: Allison J Duggal, Specialty Registrar in Public Health, London Deanery

UK area affected: England only

 

References

1. Liberating the NHS: Trasparancy in outcomes – a framework for the NHS. http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_117583

2. Healthy Lives, Healthy People: Transparency in Outcomes. Proposals for a public health outcomes framework http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_123113.pdf

3. Donabedian, A. (1966). Evaluating the quality of medical care. Milbank Memorial Fund Quarterly, 44, 169

4. Redefining Health Care. Michael E Porter and Elizabeth Olmstead Teisberg. 2006. Ch. 4. Priciples of value-based competition

5. Dixon A, Robertson R, Appleby J, Burge P, Devlin N, Magee H. Patient Choice: how patients choose and how providers respond. Kings Fund 2010

6. Bevan G, Hood C. Have targets improved performance in the English NHS? BMJ 2006; 332:419-22

7. Carter N, Klein R, Day,P. How organisations measure success. The use of performance indicators in government. London: Routledge, 1995

8. Gubb J. Why are we waiting? An analysis of waiting times in the NHS. London: Civitas, 2008:10-5. http://www.civitas.org.uk/nhs/download/waitingtimes_jan_08.pdf

9. Martin D. A&E patients left in ambulances for up to FIVE hours ‘so trusts can meet government targets’ . The Daily Mail. 18 February 2008 http://www.dailymail.co.uk/news/article-515332/A-E-patients-left-ambulances-FIVE-hours-trusts-meet-government-targets.html

10. Mid Staffordshire NHS Foundation Trust: A review of lessons learnt for commissioners and performance managers following the Healthcare Commission investigation. Dr David Colin Thomé, April 2009

11. Public Accounts Committee 26th report. Management of NHS hospital productivity. March 2011. Available at: http://www.publications.parliament.uk/pa/cm201011/cmselect/cmpubacc/741/74102.htm

12. Lewis R, Appleby J. Can the English NHS meet the 18-week waiting list target? J R Soc Med 2006; 99:10-13

13. Appleby, J. What’s happening to waiting times. BMJ 5 March 2011, vol 342, p.526

14. Detels R, McEwen J, Beaglehole R, Tanaka H (Eds.) Oxford Textbook of Public Health, 4th Ed, Vol 3. 2002. Oxford University Press, Oxford UK

15. Appleby J. Does poor health justify NHS reform? BMJ 2011; vol 342; p. 310-11

16. Report of the Office of Health Economics Commission on NHS Outcomes, Performance and Productivity. 2008. Office of Health Economics Commission