Summary of Liberating the NHS: Transparency in Outcomes a Framework for the NHS

Summary of Liberating the NHS: Transparency in outcomes – a framework for the NHS

This is a summary of the consultant document, Liberating the NHS: Transparency in outcomes – a framework for the NHS, prepared by the Royal College of Psychiatrists Policy Unit. It does not constitute a response to the consultation (which the College is currently preparing) but rather is intended to provide members with an overview of the main proposals contained in the document.

The consultation document can be accessed at:

The numbers in brackets throughout this document refer to numbered paragraphs in the consultation document itself.

What, in broad terms, does the consultation document cover?

The coalition Government set out – in Equity and Excellence: Liberating the NHS - its desire to put in place a framework for accountability in order that the success of the NHS can be determined (fully implemented by 2012). This consultation therefore asks those working in the NHS, as well as patient and carers, for their views on:

the principles of this outcomes framework
the structure and approach whereby this framework could be developed
how the proposed framework can support equality across all groups and reduce health inequalities
how the proposed framework can support the necessary partnership working between public health and social care services needed to deliver outcomes
potential outcome indicators that could be presented in the framework

The consultation employs Darzi's definition of quality as comprising the effectiveness, safety and experience of patients' treatment and care, then suggests that it is legitimate to look at three domains when measuring these three areas, namely the structures, processes and outcomes. The document states that, at a national level, focus and accountability should only apply to the third of these three – outcomes - as anything but a local focus and system of accountability for structures and processes of care can lead to a distortion of clinical priorities.

What does the consultation document mean by an 'NHS Outcomes Framework'?

The NHS Outcomes Framework will comprise:

a focused set of national outcome goals that will provide an indication of overall performance of the NHS (1.13)
a means whereby quality across all NHS services is improved (1.15)
a starting point for the NHS Commissioning Board to determine how best to deliver improvements against the selected outcomes (1.16)
a set of national indicators – devised by the NHS Commissioning Board along with clinicians, patients and the public – to operationalise the outcome goals (1.17)
allied policy documents, such as a commissioning framework which will flow from and support the delivery of the national outcome goals set in the NHS Outcomes Framework (1.18)

Suggested scope, principles and structure of the NHS Outcomes Framework

primary focus on outcomes that the NHS can deliver (2.2) while acknowledging that some outcomes will not be the preserve of the NHS alone (2.3)
a key element of designing the Outcomes Framework will be how to incentivise more integrated care (2.4)
proposed principles are:

◦accountability and transparency

▪NHS Outcomes Framework intended to sharpen the accountabilities in the system for delivering better and more equitable outcomes (2.7)

▪data against each of the outcomes to be made publicly available (2.8)

◦balanced

▪balanced set of outcomes to be chosen in order to ensure the commissioning of a comprehensive healthcare service (2.9)

◦focused on what matters to patients and healthcare professionals

▪indicators to record not only effectiveness of treatment from clinical perspective but also patient perspective (e.g. using patient reported outcome measures (PROMs) (2.13)

▪measuring the progress of the NHS against outcomes that are clinically relevant and credible to professionals

◦promoting excellence and equality

▪Outcomes Framework aims to drive the NHS towards excellence rather than meeting minimum standards (2.16)

▪Outcomes Framework will recognise that the biggest potential gains in health reside in disadvantaged groups (2.17) and that delivery of outcomes will vary according to geographic area and population group (2.18)

◦focused on outcomes that the NHS can influence but working in partnership with other public services where required

▪Outcomes Framework will identify the extent to which the NHS will be held accountable as distinct from the contribution of public health interventions or social care (2.19)

◦internationally comparable

▪Outcomes in the framework will include indicators which are internationally comparable

▪although the NHS has relatively poor outcomes in some major areas compared to its peer countries (2.21), the outcomes in the framework will not solely concentrate on these are there may be other aspects of the healthcare system which matter more to patients (2.22)

▪given the complexity of international comparison in healthcare, intra-UK metrics will be developed in the first instance (2.23)

◦evolving over time

▪first publication of Outcomes Framework may not meet all the suggested principles since it will only use existing outcome indicators for which data can be collected but will be reviewed annually to accommodate new and better outcome indicators (2.24)

What is the proposed structure of the NHS Outcomes Framework?

The Framework will have five domains (2.25):

Preventing people from dying prematurely
Enhancing quality of life for people with long-term conditions
Helping people to recover from episodes of ill health or following injury
Ensuring people have a positive experience of care
Treating and caring for people in a safe environment and protecting them from avoidable harm

Each of these domains will have an overarching outcome indicator or set of indicators which will provide a mechanism for ensuring that the NHS Commissioning Board does not lose sight of its role in overseeing the commissioning of a comprehensive healthcare service (2.1); and a small set (approximately five) of specific improvement areas (each with a corresponding outcome indicator in order to hold the NHS Commissioning Board to account for progress being made) identified in which the NHS Commissioning Board will be tasked with securing improved outcomes through its role in overseeing the commissioning process to be led by GP consortia (2.28).

The delivery of outcomes will be supported by a suite of NICE Quality Standards (of which three have already been produced by NICE (2.31), although responsibility for these standards will transfer to the NHS Commissioning Board) (2.29). These Quality Standards – of which there are expected to be 150 (2.31) - will provide an authoritative definition of what high quality care is for a particular pathway or service (2.30).

Proposed details for each of the five domains of the Outcomes Framework

1. Preventing people from dying prematurely

The consultation proposes that the overarching indicator Mortality amenable to healthcare – which measures the number of deaths that occur from a pre-defined set of conditions that have been judged to be amenable to healthcare interventions, and so should not lead to deaths at specified ages (3.6). This indicator, it is proposed, should be underpinned by the following principles:

people should not die early where medical interventions could make a difference
focus on what the NHS can do (i.e. the NHS should be clear about where it can and should improve outcomes).

Improvement areas for this domain should be heart disease and stroke (3.7), although cancer is also suggested as a possibility (3.8 and 3.9). The possibility of including an outcomes indicator that specifically addresses mortality in older people (such as healthy life expectancy at 65) is also mooted (3.12) as are indicators regarding children of infant mortality and respiratory diseases (in children 0-14).

The consultation recognises that some group of people, for example those with serious mental illnesses, have significantly worse mortality outcomes than the population as a whole and suggests that it may be desirable to select some improvement areas in which there are significant inequalities in outcomes (3.14).

2. Enhancing quality of life for people with long-term conditions

The consultation states that no overarching measure of quality of life for those with long-term conditions is currently available and hence suggests that measures of 'percentage of people with long-term conditions where day to day activity is affected' and 'percentage of people feeling supported to manage their condition' (from Labour Force Survey and GP patient survey respectively) could be appropriate overarching outcome indicators (3.19).

Alternatively, the consultation suggests that standard quality of life measures, such as EQ-5D could be used (3.20).

The principles which the document suggests should underpin this domain are 'Treating the individual' (i.e. taking a view of the needs of and desired outcomes for those with long-term conditions), 'Functional and episodic outcomes' (i.e. recognising the debilitating effect that conditions can have on people's lives, such as preventing them from being physically active, working or living independently) and 'Meeting the needs of all age groups' (i.e. separately identifying appropriate functional outcomes for children, adults and older people) (3.18).

Regarding improvement areas in this domain, the paper suggests the following (3.21):

Children / Adults / Older people
Functional outcomes / e.g. Able to attend school / be physically active / e.g. Able to work / be
physically active / live
independently / e.g. Able to live
independently / be
physically active
Episodic
outcomes / e.g. Fewer acute episodes, where they can be avoided by better management of the condition

3. Helping people to recover from episodes of illness or following injury

The document suggests using two proxy indicators for this domain (3.27):

emergency hospital admissions for acute conditions usually managed in primary care (i.e. how well the NHS is preventing curable conditions from becoming more serious)
emergency bed days associated with repeat acute admissions (i.e. patients being readmitted is an indication that the outcome of their original treatment was below standard).

The paper also suggests that in future indicators for this domain might be developed which focus more explicitly on outcomes and so reduce the risk of perverse incentives; these may be based on patient reported measures (3.29).

The suggested improvement areas for planned and unplanned care are as follows (3.33):

Children / Adults / Older people
Unplanned care / e.g. fractures, respiratory
conditions / e.g. fractures, stroke, / e.g. falls/hip fractures,
stroke, heart attack
Planned care / PROMs for planned care

4. Ensuring people have a positive experience of care

Based on principles or assumptions (3.38) that:

patient experience must be a vital element of the NHS Outcomes Framework
the existing arrangements for collecting patient experience information do not lend themselves well to the requirements of the NHS Outcomes Framework
it is necessary to measure patient experience now, to drive a step change in improvement
ensuring that a balanced approach is achieved – so that this work fully supports and complements locally-led innovation and focused improvement activity.

The paper proposes an interim approach for immediate use as an overarching indicator, and that a longer term approach be developed (3.40) on the basis that insufficient standardised national data is currently available to make firm suggestions now (3.41).

The five themes which the document proposes be used for the short-term approach are access and waiting; safe, high quality coordinated care; better information, more choice; building closer relationships; and clean, friendly comfortable place to be. It is suggested that this approach can be applied to surveys due to be conducted and published in the next year or so, and could include adult inpatient services and community mental health services (3.43)

The long-term approach, it is suggested, is to develop an overarching outcome indicator that is based on a limited set of core questions that can be included within all surveys. These questions would cover whether patients received the care and services they need, and its overall quality. However, since appropriate questions are not included within the existing survey programmes, development work on the precise indicator would be required (3.44)

While recognising the extremely limited evidence base for identifying possible improvement areas identified for this domain, the consultation paper suggests the following as possible candidates (3.45):

primary and community services
acute care
mental health services (the consultation states that this improvement area could look at the different settings in which care is provided, for example, community mental health services and inpatient mental health services)
children and young people
maternity services
end of life care

Over the medium to long-term, new outcomes indicators for improvement areas should be based on the same principles as the national CQUIN goal for acute services (and which covers issues as such patients being involved in decisions about their care, being able to talk to hospital staff about their worries and fears, having enough privacy, being given information about medication side-effects, and being informed who to contact if worried after leaving hospital). The document proposes that these indicators extend across the full range of services and settings covered by national surveys, and the initial focus will be on surveys which have already been developed (such as community mental health, A&E and outpatients services) (3.48).

Regarding the future development of this domain, the paper suggests that identifying services or areas (such as mental health) where little work has been conducted to date could provide an insight into how best to approach the job of ensuring that work on patient experience is as robust and comprehensive as that for clinical effectiveness and patient safety (3.52 & 3.54).

5. Treating and caring for people in a safe environment and protecting them from avoidable harm

The consultation paper proposes that an overarching outcome indicator for this domain be constructed to include the following three measures:

number of incidents reported
severity of harm
number of similar incidents (3.58).

Work on this domain, it is suggested, should be underpinned by the following principles:

protecting people from further harm (i.e. patients expecting the NHS to provide them with care when they need it, without causing or contributing additional unacceptable harm or injury in the process)
an open and honest culture (i.e. NHS staff should be empowered to expose failings in case)
learning from mistakes (i.e. organisations must be able to learn from incident reports and make tangible changes that improve safety and the public's confidence in the organisation)

The following improvement areas for this domain are suggested (3.65):

safe treatment
safe discharge/transition
patient environment
safety culture
vulnerable groups

The consultation paper concludes with three annexes. The first of these looks at the process for selecting outcome indicators (and provides a substantial number of possible indicators for each of the domains, along with ratings of their appropriateness); the second provides a complete list of the consultation questions which are also interspersed throughout the document; while the third provides details on the consultation process itself.