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Insight: Figuring Outcomes

Insight: Figuring Outcomes
4 June 2014

Commissioning according to the needs of patients requires significant changesin the way services are designed and delivered

Commissioning according to the needs of patients requires significant changesin the way services are designed and delivered

The five clinical commissioning groups (CCGs) in North Central London (NCL) – Haringey, Barnet, Enfield, Islington and Camden – representing a population of 1.4 million people, are collaboratively developing a value-based commissioning (VBC) programmme for three defined population segments with similar needs: 
 – Older people living with frailty. 
 – People with mental health problems.
 – People with diabetes. 
The aim of the programme is to incentivise all providers (who deliver care across a whole care cycle for a patient) to deliver outcomes that matter to people by developing outcomes-based contracts. 
What we did
Outcomes Based Healthcare (OBH), together with Beacon UK and CapGemini, supported the CCGs in defining the outcomes that mattered to people within each defined population segment. Outcomes workshops were designed and a wide range of stakeholders attended. A large proportion were patients, but also included patient advocates and professionals (commissioning leads, relevant clinicians, managers, providers and third sector partners). Each workshop had nearly 100 participants. To ensure a representative patient population inputted into the process of defining outcomes, questions asking people what outcomes were important to them were designed and distributed to patient groups, general practices and care homes (as appropriate for each population segment). Responses were collected through social media and interactive technology. 
The workshops encouraged collaborative working within small groups to achieve set tasks. We started by introducing outcomes, how they can be structured around an outcomes hierarchy (a structured form of thinking about outcomes), to ensure everyone had a shared understanding around the concept and terminology. 
The main focus of the workshop was the session during which we defined the outcomes in small groups. Patients were the main driver behind defining these outcomes supported by Outcomes trained facilitators. The final session brought people within each local population into groups to prioritise the outcomes defined earlier.
What we achieved
A co-produced1 shortlist of outcomes for each population segment, pan-NCL. These are outcomes that matter to the very people they concern. They represent patient views, and when measured can give providers and commissioners a view on whether the care they are delivering is making a difference. 
The outcomes are designed from the patients’ perspective, so naturally span provider boundaries, and therefore require shared accountability to achieve; something that is leading to genuine integration of care across full care pathways. Redesigning care around people’s needs is a radically different approach to improving health outcomes. We believe that by engaging in systematic outcome measurement, this programme will have a significant impact on the lives of people within NCL, resulting in care which is genuinely organized around the outcomes which are important to people. It can also demonstrate how outcomes-based commissioning can improve outcomes even within a budget-constrained environment.
The VBC programme moving forward
We are now researching how the outcomes co-produced by patients will be measured. If data already exists which supports the outcome, a description of the data source and analysis required is recorded. However, there are many outcomes for which data is not being systematically collected to measure them. For these, many existing patient reported outcome measurement (PROM) tools can be used. Where data currently exists, baseline values can be calculated for those outcomes and benchmarked. Parallel to this process, the care delivery system is being re-designed through Integrated Practice Units (IPUs) described below. 
About value-based healthcare delivery
Currently, healthcare in the UK is largely delivered around specialties, organisations and departments, rather than structured directly around peoples’ needs. 
Value-based healthcare delivery2 centres on the integration of services around groups of people with similar needs. It is underpinned by the principles set out in the value-based system agenda3 shown in Figure 1. This system realignment around peoples’ needs represents a significant shift from the status quo (legacy system), because fundamentally it requires significant changes in the way services are designed and delivered.
Outcomes are holistic, person-centred measure of how well the patients’ needs (as defined by them) are met across the full care cycle, rather than how well the system is functioning from a care process point of view. For example, for a person with diabetes, our work in NCL has shown that patients care more about “feeling that they are supported in managing their health” and avoiding preventable complications than the specific processes of care that they receive, such as having blood tests e.g. Hba1c (process of care) and the subsequent results of these (indicators). This is not to say that processes and indicators aren’t important. In fact, they are an essential part of a patient’s care and provide important information to particular care providers. However, that does not make them outcomes.
If the focus of the design and shape of care delivery is placed on outcomes, it highlights the other integral parts of the care pathway. The focus then shifts from a narrow view of acute and primary care, to incorporating the wider health economy, eg. social and community care, the role of self-management. If patients are involved in co-designing outcomes their viewpoints are inherently incorporated in how care is delivered through the outcome-driven Integrated Practice Unit (IPU) design.
About Outcomes Based Healthcare
OBH is one of the leading organisations supporting outcomes-based approaches to healthcare in the UK. We work with healthcare providers and commissioners who wish to define outcomes which matter to people and organise processes of care around these outcomes. Over the last year, we’ve worked with over 15 different NHS organisations on outcomes/lead provider contracting. We also support NHS England working groups on commissioning for outcomes. 
1. Bovaird T, Loeffler E. We’re all in this together: User and community co-production of public outcomes. University of Birmingham, October 2012.
2. Porter, ME. What is Value in Health Care? N Engl J Med 2010;363:2477-81.
3. Thomas Lee. Value-Based Healthcare Course. Harvard Business School 2014.
Dr Rupert Dunbar-Rees is founder of Outcomes Based Healthcare.

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