The next stage of NHS reform will be about improving quality - and an ambitious outcomes measurement regime will be crucial, say Jon Sussex and Adrian Towse
Better quality care is the dominant theme of NHS reform in England. The Darzi report is entitled High Quality Care for All. The regulator of health and social care is to be called the Care Quality Commission. Providers of NHS care will have to produce quality accounts. The commissioning for quality and innovation scheme will add financial incentives as mark-ups to payment by results tariffs. Whitehall will have its National Quality Board, watching. So much quality.
It can be difficult to define "quality" in a measurable way - the variety of quality indicators available, not to mention reams of learned academic literature on the meaning of quality, are indicative of that. Yet the purpose of the NHS is to improve the health of the population. So the most important measures of quality are measures of the outcomes of care. The best assessment of that will usually be provided by the patient. The simple notion that people can express the extent to which care leaves them feeling better or worse is the essence of measuring patient outcomes. These measures already exist and could be brought into routine use in almost all areas of healthcare within a few years.
There are condition-specific measures of patient outcomes and there are generic patient outcome measures that permit comparisons between disease areas. The best-known of these, favoured by the National Institute for Health and Clinical Excellence in its economic evaluations of health technologies, is the five dimension measure EQ-5D, which can be used to derive the quality-adjusted life years so beloved of health economists.
The EQ-5D requires patients to answer just five questions. For each of the five dimensions - mobility, self-care, usual activities, pain/discomfort and anxiety/depression - the respondent is asked whether they have no problems, some problems or extreme problems.
Condition-specific and more general questions can be combined into single questionnaires. For acute episodes of illness, patients can be asked to complete questionnaires about their quality of life when treatment starts and again a short time after. For chronic conditions, patients could be asked to complete a questionnaire annually, as part of regular follow-up either in outpatients or, in many cases, at the GP's surgery.
Data on patient outcomes is needed to provide vitally needed answers to four types of questions:
NHS staff who deliver healthcare and commissioners need information on outcomes to help them benchmark and improve the effectiveness of what they do;
patients need information on outcomes to be available to enable them - should they so wish - to compare different providers;
commissioners need information on performance and productivity, to decide how to get the greatest benefit from the resources at their disposal and how to allocate resources between different patient groups and types of care;
the government needs to know how productive the NHS is: how much health benefit the NHS is producing for the funds it receives. Currently, productivity is measured in terms of the amount of activity in the NHS - the numbers of patients seen and treated - but there is no reference to how successful the activity is in improving patient health.
The Department of Health has made a welcome start but on too narrow a front. The 2008-09 operating framework requires providers to collect and report patient reported outcome measures for elective primary hip and knee replacements, groin hernia surgery and varicose vein procedures. But a recent report by the Office of Health Economics commission on NHS outcomes, performance and productivity made clear it is possible to be much more ambitious.
The commission reviewed the evidence on outcomes measures already in use, focusing on four "tracer" disease areas: elective surgery, mental health, chronic obstructive pulmonary disease and colorectal cancer. Together they cover acute and long term conditions, primary care and hospital care, life-extending care and quality of life improving care.
There is a lot of evidence demonstrating the feasibility of collecting and using patient outcome measures. But so far this has only been done in the context of discrete, one off projects, such as clinical trials. Based on the evidence, routine measurement of patient outcomes in the NHS is a practical and essential proposition. Furthermore, outcomes measurement is possible in all types of NHS care. The measures are not perfect but they are more than adequate to be getting on with. It is time to stop waiting for further refinements; time to use the tools that are already available. Although it is not practical to apply outcomes measurement everywhere at once, it is reasonable to expect that within five years patient outcomes data should be collected for the majority of NHS activity.
Generic and specific data
For maximum effect and to ensure clinical engagement with collecting and then acting on the evidence about outcomes, it would be wise to collect simultaneously both condition-specific measures of patient outcome - of the kind often favoured by clinicians as being most useful in assessing the impact of care - and generic measures of health-related quality of life, such as the EQ-5D, to permit comparison and aggregation of outcomes across different types of healthcare.
Improved patient care is the ultimate reward from improved NHS performance and productivity. In addition, informed patients provide an important lever to stimulate better outcomes from healthcare. The use of outcome measures may be particularly useful to patients with chronic conditions, as they will be able to track the progression of their disease over time and may consequently be able to take a more active role in their treatment. But asking patients to assess how much they have benefited from their healthcare needs to be done in a way that is easy and quick for them.
Successful implementation requires buy-in from managers and clinicians alike on measuring the outcomes of healthcare for patients. If either group fails to see the benefits to their own work of the outcome measures, adequate data is unlikely to be collected in practice. There is likely to be a need for clinical champions to drive the use of outcome measurement, with the focus on enabling self-improvement. Professional and public kudos for the clinical teams doing the work is a strong incentive - as it is for managers in providers and commissioners alike.
The big prize
Receiving regular and timely feedback of outcomes data is important for clinicians and commissioners. Without this they will be unable to make decisions based on the data at the appropriate time and so will see little point in collecting it. And data needs to be presented in a way that individual clinicians, commissioners and providers can act on the results. The importance of suitable IT infrastructure and appropriately trained staff to enable this is clear.
The incremental running costs entailed in collecting outcomes measures will be small. Estimates vary from£3-£6 per patient. The likely benefits vastly outweigh the costs.
But after so much encouragement to action on a large scale, a word of caution is needed where incentives are concerned. The next stage review talks of financially rewarding providers for the outcomes they achieve and doing so "from no later than 2010". This sounds risky - too much pressure too soon. It will require more than one year of experience with collecting, analysing and using outcomes data to permit glitches to be ironed out, make adjustments for unavoidable variations in outcomes, and allow clinicians, patients and commissioners to come to trust the evidence. It would be better for the first three years to reward collection and use of outcomes measures rather than to reward measured levels of outcomes.
So let us be ambitious about spreading outcomes measurement into all areas of NHS care and soon, but let us then allow time for everyone to get used to dealing with the results. The prize will be great: an NHS able to measure and respond to the quality of care it is delivering to all of its patients; an NHS able to set out to taxpayers and patients how it is using its resources and just how much it is improving the health of the British people.
The report of the commission on NHS outcomes, performance and productivity can be found at www.ohe.org/page/Commissionreport.cfm