The Health and Social Care Outcomes Accountability Framework Explained
Introduction
Health and adult social care services are entering a new phase. The NHS has met national targets and improved standards. The time is now right for a change in the balance between national and local provision. We want to make it easier for the NHS and local authorities to work together. Make it easier to use resources to achieve the best outcomes for local populations. When local areas set their own goals, they are more appropriate, more stretching and create a sense of local ownership.
To do this we want to put the things that matter, to the people who matter, at the heart of our services. That means listening to, and reflecting, the things that patients, users, staff and the public find important. And finding ways to focus on those things across all that we do.
Locally responsive system
The NHS is moving to a system where the main drivers of change are patients, users, carers, commissioners and staff, rather than national targets and top-down performance management. We want to learn from staff providing outstanding care and finding new ways to improve services, and share this good practice so that the whole health and social care system can benefit.
We propose a new set of outcomes for local areas that replaces the previous national target regime in health, and supports a series of “conversations” between:
· Local commissioners and their populations, on the care they receive and the independent, healthy lives they support
· Local commissioners and national government, on the outcomes they achieve for their populations given the funding they get
· National government and Treasury, for the national outcomes achieved given the funding invested
Shift of accountability
To do this, the nature of accountability, relationships and behaviours need to change:
· Local boards will need to take greater ownership for continuous service improvement, and be accountable to their local communities for the outcomes
· Effective partnership working will need to be built on, particularly by Primary Care Trusts (PCTs) and local authorities to improve health and well-being and achieve a shift towards prevention of ill health
· The performance relationship between the Department and the health and adult social care system will need to be less about managing poor performance and more about supporting Strategic Health Authorities (SHAs) and Government Offices for the Regions (GOs) to help commissioners to achieve the best possible outcomes for their populations
Specific targets will no longer be set from the centre. In the future consideration of priority outcomes, such as GP access or improved patient/user experience, will be up for local determination, priority setting and delivery.
New framework for outcomes
We are developing a new outcomes framework, which supports reform, by shifting the focus of performance from central direction to locally driven improvement; by building the framework around a clear set of outcomes across the whole range of health and social care services; and by supporting local integration to encourage holistic improvement across health and social care services. The main features of this new approach are:
· A clear statement of the Department's vision and strategic objectives: to deliver better health and well being, better care, and better value for all
· A set of more specific outcomes and supporting indicators – one for each outcome. This supports the strategic objectives and fulfils the commitment to a single outcomes framework made in the Our Health, Our Care, Our Say (OHOCOS) White Paper. We want the indicators to be outcome focused and as far as possible, to be focused on public and patient/user experience.
· An approach that allows PCTs and local authorities to determine their local priorities from the “menu” of outcomes to include in their Local Area Agreement (LAA) and local delivery plans, using the supporting indicators and other data as evidence, and to agree those with their local populations and regional tiers as appropriate (SHAs and GOs)
· A public "report card" through which the performance of PCT and Local Authorities (LAs) are benchmarked against their comparator peers in each of the key outcomes, and against which PCTs and LAs are accountable to the public
In setting the high-level outcomes and indicators, the Department will define the 40 outcomes and indicators, which will appear in the PCT “report card”. Performance levels will be benchmarked and could relate to top percentile performance, or acknowledged international best practice.
How the indicators support our outcomes and overall vision
The framework starts with the vision and the three objectives. Underlying these objectives are the aims and outcomes of the health and social care service. The indicators measure these outcomes, with one indicator per outcome.
The outcomes and indicators, along with other information, such as joint strategic needs assessments, productivity data, programme budgeting, and other best practice guidance can then be used by PCTs, working with the Local Authority and Practice Based Commissioners, to consult with their population on what areas are to be local priorities.
Partnership working
This new outcomes framework supports and reinforces the new roles for organisations laid out in recent policy documents. Importantly, it will allow commissioning to be:
· Focussed on outcomes, leading to more innovative provision, tailored to the needs of individuals, rather than central government
· Integrated, with common outcomes that will support and empower the NHS and Local Government and their local strategic partners to provide strong strategic leadership and deliver services that reflect local needs
· Open and transparent to enable local accountability, show the value that local people are getting from investment in public services and reinforce the efficient use of public funds
Engagement
The very nature of this approach means that commissioners, staff, patients, users and the public should understand and own the system in their local area for improving its performance.
It is therefore vital that colleagues working in the NHS, Local Authorities and the voluntary and community sectors, patients, users and the public have a chance to shape the outcomes and measures that will form the basis of local priority setting discussions to achieve improvements in the areas that matter most. Please make your views known through the following website: http://www.dh.gov.uk/en/Consultations/index.htm.
Frequently Asked Questions (FAQs)
If PCTs and LAs performance is to be judged against all the indicators, how are these different from targets?
The set of outcomes and supporting indicators, like those in the local government national set, are intended to provide a full “menu” from which local areas can prioritise the areas most in need of improvement. We will still want performance on all indicators to be published to demonstrate public accountability, but improvement is only expected on those agreed as local priorities. In general, the level of performance will also be set locally, not nationally.
What about areas that are not covered by the measures – does that mean they don’t matter?
The broad set of outcomes covers the range of areas on which local areas might seek to improve their performance. This should take health organisations beyond the national targets already achieved, such as 4-hour access to A&E and 48-hour access to GPs, where these levels of performance will be embedded in the system. This framework is also not a substitute for fulfilling statutory duties (such as abiding by discrimination legislation) nor a substitute for all the information local commissioners will need to fulfil their duties and require in contracts from providers.
Don’t patient reported measures simply reflect differing expectations rather than improvements in services?
Patient experience indicators measure just that – a patient’s experience with the service. Whether it was timely, seamless, personal and respected their dignity. These are areas that are important for assessing overall levels of care and can be best answered directly by patients. There are also Patient Recorded Outcome Measures (PROMs) which calibrate the extent to which patients are able to function in their daily lives. These have been used robustly for a number of applications.
Are we dropping existing targets that need to be met in future?
All the existing commitments we made in the previous spending review (SR04) are carried forward in our new approach. We have plans in place to meet them and have funded the system to do so. We will continue to report on them and fully intend to meet them. Some may exist as “sub-parts” to an overall outcome, for example, the proposal for discussion is to move to an overall measure of mortality at local level, but continue to report on the separate commitments to reduce mortality due to cancer, CVD and suicide.
Are we dropping existing targets that should have already been met?
Where organisations have been funded to provide a universal level of service, such as access to A&E in 4 hours and a GP in 48 hours, there is an expectation that this will be maintained.
How does this fit with the 7 White Paper outcomes?
In the OHOCOS White Paper the Department committed to a single outcomes framework. The “seven outcomes” for adult social care described in the OHOCOS White Paper for well-being are at the heart of the aims and outcomes in the framework. The objectives, aims and outcomes have been informed by a number of sources, including those seven outcomes, the NHS principles and international evidence around what works.
Can we be more explicit about the direct connections and directional links to the Local Government Framework (200 indicators) and the changing LAA process?
In the OHOCOS White Paper, the Department committed to a single outcomes framework. We have brought together the outcomes across health and social care, and will ensure that we are joined up with our local government partners. As part of forming the set of 200 National Indicators proposed in the ”Strong and prosperous communities” – the Local Government White Paper, the Department will contribute a sub-set of our overall indicators which have local authority involvement, principally public health and social care.
How will new Local Area Agreements be agreed?
From 2008 - 09 each locality will agree a new LAA. Their new LAA will contain up to 35 targets drawn from the new Local Government national indicator set established out of the CSR07 and 18 statutory education/early years targets...
The national indicator set will have around 200 indicators representing all activities for which Local Authorities are responsible for on their own or in partnership with others. Frequency of reporting on each of the national indicators will be confirmed when the national indicators are published, along with the spatial level of which the data is to be collected.
Local Authorities and partners will negotiate with Government Offices, which 35 indicators from the national indicator set they propose should have targets set against them and these will be agreed with central Government.
Won't all this local priority setting this increase the postcode lottery?
For a long time, variation has been part of the health and social care system. A more transparent set of relationships and information will “shine a light” on those differences and prompt areas to address relative under-performance where this is not justifiable, and to improve in the areas relevant and desired by local areas.
How can we be assessed on something that we might have no responsibility for?
The set of outcomes are the broad set of outcomes across health and social care that organisations should be working towards for their populations. This will require them to work in partnership with local authorities and other organisations. It is this broader set of health and social care outcomes that we should hold commissioners accountable for. The Local Area Agreements process is designed to involve partners in setting goals for local populations and then working together to achieve them.