Why outcomes measurement is the key to fixing healthcare

18 November 2014

The solution to delivering more value in the NHS is not increasing budgets. Spending does not guarantee success, as demonstrated by the United States (US) that leads the world in per capita health care spending, as well as the modest gains achieved despite the U.K.’s major increases in NHS expenditures since the early 1990s.

The only way to be sure that the NHS is truly delivering value for the taxpayer is to measure it. Value is the health outcomes achieved for patients relative to the cost of delivering these outcomes. Value cannot be measured for a hospital, a consultant, or an entire system. It can only be accurately measured by clinical condition, whether it be breast cancer or back pain.

Historically, the NHS has focused on measuring ‘inputs’ such as attendances, hospital admissions, and waiting times. These are easy to measure, but fail to capture whether the patient’s care was good or bad, or even clinically effective. There is no substitute for measuring the actual outcomes as well as the costs involved over the full cycle of care for the patient’s problem. Recent efforts to capture patient “experience” are useful, but are not the same as outcomes.

Many individuals and organisations across UK health care are now talking about value, an encouraging sign. A few organizations are beginning to measure outcomes, which is a major step forward. For example, Cambridgeshire and Peterborough Clinical Commissioning Group (CCG) are amongst those exploring alternative delivery models for patient groups, and measuring outcomes. Starting with the frail elderly, they are seeking to measure the outcomes that matter to this population, such as whether a patient can walk to their local community centre and live at home independently. These things are what really matters to patients, not whether they were discharged from the hospital within 4 days. The outcomes framework has been co-developed by clinicians, patients, carers and medical experts.

In a new contract recently tendered by Cambridgeshire and Peterborough CCG, a significant proportion of total reimbursement for care is based on results against these outcomes. Given the multiple health and social needs of many frail elderly people, this emphasis on outcomes will inevitably drive greater collaboration between health delivery, local authorities, and other services such as NHS 111 and the ambulance service.

Five Clinical Commissioning Groups across North Central London (Barnet, Camden, Enfield, Haringey and Islington) are also collaborating to adopt a value based approach to commissioning care for frail elderly, patients with diabetes, and individuals with mental health problems. Their approach started with defining outcomes for these population segments via interactive workshops involving stakeholders from across the care cycle, including patients. Contracting models encompassing multiple providers are currently being evaluated, with the conviction that an outcomes-driven approach will drive service redesign for the populations served.

Outcomes-based approaches apply as much to mental health care as to physical health care. At the time of writing, Oxfordshire CCG is currently negotiating a fully compliant NHS standard outcomes-based contract with Oxford Health NHS Foundation Trust as lead provider together with voluntary sector providers across the care pathway including Oxfordshire Mind, Restore, Response, Connection and Elmore Community. Many of the outcomes that matter are best defined not just by health care professionals but also by adult social services, so that an outcomes-based approach is driving greater collaboration with Oxfordshire County Council.

The key challenge now is defining the outcomes that matter for each condition, and how to measure them. Efforts thus far in the UK and elsewhere have been bottom up and different across organizations and geography. There is a pressing need to develop standardized sets of outcomes by condition to enable comparison and learning, and put in place the infrastructure and tools needed to collect and measure them across the entire system.

We co-founded the International Consortium for Health Outcomes Measurement (ICHOM) in 2012, an international organization seeking to define Standard Sets of outcomes that matter across multiple medical conditions. Through international working groups of leading clinicians in each field, together with patient representatives, ICHOM has already developed standard outcome sets and risk adjustments for low back pain, localized prostate cancer, Parkinson’s disease,  cataracts, and coronary artery disease, with seven more on target for completion this year. Collectively these will address 35 percent of the disease burden. Over the next three to five years, ICHOM will produce standard sets of outcomes for many more conditions.

ICHOM opened a London office earlier this year, led by Dr Thomas Kelley; to drive the adoption of ICHOM Standard Sets by condition as the benchmarks across the U.K. Bedfordshire CCG has been one of the early adopters of ICHOM’s Standard Sets as part of their recent musculoskeletal care contract with Circle Healthcare.  The Lower Back Pain Set was incorporated into the 5-year contract, with annually demonstrated improvements in clinical and patient reported outcomes attracting financial rewards.

In the run up to the 2015 general election, we challenge UK health care policymakers and commissioners to commit to the path of universal outcomes measurement by conditions across the full range of diseases in this country. This is the single most powerful step that could be taken to drive rapid outcomes and value improvement for patients as well as for taxpayers. The U.K. should adopt globally vetted outcomes rather than bear the expense and inefficiency of reinventing the wheel in each local area, which also obscures comparison and learning. NHS England should become the central repository for outcomes from all entities in the NHS, with responsibility for ensuring the reliability of the outcomes reported, providing rigorous comparisons for clinicians and transparency for the general public.

Professor Michael Porter, Bishop William Lawrence University Professor at The Institute for Strategy and Competitiveness, Harvard Business School

Dr Emma Stanton, Chief Executive, Beacon UK



Elizabeth Lloyd

26 April, 2015

In view of the failure of the Bedfordshire MSK model in fairly spectacular form, you might like to think about changing the reference. Of course, as the carer of two MSK LTC sufferers as I call my husband and daughter now and having participated in trying to agree outcome measures which might actually reflect the improvement in their lives and signally failed, I cannot actually see any benefit to patients (which is the point of health care in this country (I think) - so apologies to those who might have "attracted financial rewards" for completing an episode of care had the project I was involved with proceeded.