The NHS goes to great lengths to implement complex and ever-changing outcome measures, but do they pay enough heed to how well patients feel, asks Mark Gould

'And how are you feeling in yourself?' It's the metaphysical question that doctors and nurses ask after the usual battery of tests and measurements.

But it is the question that is increasingly on the minds of academics and policy-makers, and even some public health directors. Number 10 policy adviser David Halpern has said that in future, government - and that includes public services like the NHS - will be measured in terms of how happy they make us feel.

But it seems that existing performance measures do not tell the public or Whitehall enough about what we get for our taxes or if what is being spent is being spent in ways that maximise happiness. After all, the NHS has public service agreements binding it to improve the quality of life and well-being of citizens.

Now wider, quality and performance indicators that have proved somewhat intangible in the past - including patient satisfaction and the health service's impact on commerce - are being quantified by the Office for National Statistics as it sets out on an ambitious voyage of discovery: to measure 'societal well-being'. To do that it has got to find ways of measuring exactly how the NHS budget of some£90bn per year actually increases the well-being of the public.

In 2005, the ONS set up the Centre for the Management of Government Activity to implement the recommendations of the Treasury-commissioned Atkinson review, which declared the nation needed to get a better handle on the measurement of government output and productivity.

CMGA head of health Philip Lee has a few preparatory obstacles. 'If you are going to bother measuring health output and productivity you are going to need to measure activities. An operation is output, a GP appointment is output, preventive care is output. What we are not doing very well beyond measuring that activity is measuring how much better those operations are. How much better is the service provided by GPs?'

The ONS is embarking on this project from an almost standing start, as there is little data available and existing information is not useable as it only measures activity and does not take into account quality changes and improvements that are made over time.

That quality change factor is a vital one. Exclude it and it seems we should not feel very happy about what we get for£90bn.

One set of ONS estimates of NHS productivity is based on current estimates of output in 2005. It shows that NHS output is believed to have increased by 3.2 per cent per year from 1995-2004, with the volume of NHS inputs rising over the same period by an average of 3.9-4.6 per cent per year. This means that productivity has fallen in that period by an average of 0.6-1.3 per cent per year.

But the Atkinson review stated that NHS output should be adjusted to take account of quality change, where health outcomes are based directly on NHS output as well as other measures of change in the NHS.

The Centre for Health Economics at York University, the National Institute for Economic and Social Research and the Department of Health have come up with a model that measures quality change using data supplied by Bupa, which has been measuring output in terms of quality change and patient satisfaction for nearly a decade (see below).

This model produces a flat graph, suggesting productivity seems to be more or less stable. Mr Lee thinks that is a good message, as the NHS is not about making sure you get maximum output. 'It's about equity of access - it's also about making sure you are delivering healthcare to a population with ever-increasing expectations. When a new breast cancer drug comes in, people want it. To a certain extent the NHS delivers those things, but in doing so it is ratcheting up the technological base, which is expensive.'

But then Mr Lee throws in a word from the world of quantum physics, 'complementarity': a principle of quantum theory, which refers to effects such as wave-particle duality, where systems reveal different characteristics depending on how you measure them.

He explains the effect in terms of a Ford car factory, whose access to raw materials to produce cars and to markets is via a high-quality A-road.

'What happens when the government builds a motorway next door? All of a sudden it's a lot easier to get parts in and a lot easier to get cars to the market. The 'complementarity' here is that the private sector benefits from activity of the government to increase its productivity.'

The argument is that the same sort of thing could be happening with the health service, where 'good health' created by the NHS is fed into private sector productivity - a healthier worker is more productive and a retired person in good health can enjoy life to the full.

The Atkinson review recommended quantifying that complementarity by factoring in the trend growth in real earnings - 1.5 per cent a year at a low estimate. Add that in and you get a graph showing a rise in productivity.

Conceptual problems

So should we measure NHS productivity by including factors for quality change in NHS output and an allowance for 'complementarity'? That debate is still raging and is part of consultation that ended in early April and will inform the ONS plan of attack.

The ONS also wants to move away from the messy job of collecting billions of bits of individual data to a more holistic model for measuring output - the healthcare pathway.

That will iron out problems that might arise from reducing accident and emergency attendance and keeping people out of hospital. If the health service is successful in doing this, the balance sheet will show NHS output has dropped.

Atkinson recommended that rather than count all the activities provided by different parts of the NHS, you ought to sum those activities for any patient with a particular diagnosis to create a healthcare pathway. While we know how many operations there are and how many GP appointments, the current state of data collection means the two cannot be linked to a healthcare pathway. Connecting for Health, the multi-billion-pound NHS IT strategy, will solve the problem but it is some years from full operation.

But there are also conceptual problems. 'It's easy to visualise what the health service does when someone breaks a leg,' says Mr Lee. 'But what about longer-term issues - diabetes or vaccination programmes. What about palliative care? We know people are going to die in the short term and the NHS isn't saying we are going to make you better, but we are going to manage your decline. I find it difficult to visualise the pathway for a substantial number of people.'

Manifesto for well-being

So when will we be able to get an ONS well-being forecast along with the pollen count and weather? Mr Lee chooses his words carefully: 'One of our visions is that we have this single line where we can say what health output and productivity are definitively - here is our best estimate. But all of the things we have talked about suggest the state of the science, let alone the state of the art, is so far away from knowing that.'

Economist Lord Layard set out a manifesto for well-being in his book Happiness: lessons from a new science. He says it is not only possible to measure well-being but 'vitally important to do so. The big issue is the nation's well-being.

'On a simplistic level it's about life satisfaction, from 'very satisfied' to 'not at all' - and these are the questions being asked all over the world now.'

With mental illness affecting one in six and rising by a statistically significant amount, Lord Layard has a simple solution: tackling depressive illness with an army of 10,000 NHS psychologists and spending less on areas where outcomes are not so good. 'Every primary care trust should provide a proper psychological therapy service that is evidence based and staffed by properly trained people. Mental illness has massive implications for industry, for employers and for family life and well-being.'

In Dumfries and Galloway, public health director Dr Derek Cox is already convinced that happiness is the best medicine and may be a better predictor of health than smoking, drinking or blood pressure. He is recruiting an army of volunteers, trained in Lord Layard's favoured cognitive behavioural therapy, to go into the community, challenging depression and anxiety.

But it is the work of Chilean economist Manfred Max-Neef, who has devised a universal measure of well-being, that Dr Cox hopes will not only tell us what is wrong but also what to do to improve well-being. The Max-Neef theory is based on 10 basic human needs that are ultimately unchanging over centuries. They include: safety, affection, understanding, participation, creativity, leisure or idleness, freedom, self-actualisation, spirituality and transcendence.

For two years Dr Cox has worked with Vic Marks from the New Economics Foundation on a questionnaire that he feels will give a measure of well-being. It has been sent to 2,250 people in Dumfries and Galloway and the results will be presented at a conference in July, where Mr Max-Neef will be guest of honour.

'If for example a lot of the people said they did not feel they participated enough, we could do something about it,' says Dr Cox. 'When I worked in the Shetlands people felt they lacked participation so we got a local authority grant to start a club - it was a terrific way of stimulating participation.'

Eureka moment

Dr Cox says preliminary work makes him confident that the questionnaire will become both an accurate predictor of well-being and an aide to targeted interventions. 'If you can detect people who have low levels of well-being and offer interventions that positively improve it, you will do more for them than offering interventions that focus on physical health.'

His long-term goal is to carry out a study which examines the link between low levels of well-being and high levels of chemicals in the body that are associated with future ill health.

'That will be my eureka moment. But it won't be before March 2009.'

If the research stands up, Dr Cox says it would be a simple step to introduce one or two interventions to improve well-being and lower the level of these chemicals.

When will this become mainstream thinking? 'I have been talking about this for the past 10 years now. When you talk to community workers and members of the public they say: 'Wow, that's terrific. It makes complete sense'. But when you talk to doctors they say: 'Oh Derek, what are you talking about? We need to lower people's blood pressure and get them on statins.''

Key points

- The previously neglected performance measure of 'satisfaction' is now being gauged by government.

- A new centre set up by the Office for National Statistics is measuring whether activity leads to improved quality.

- A raft of theorists suggests that happiness is as key to good health as more clinical interventions.


Satisfied customers? the bupa approach

Bupa has been using patient-reported satisfaction surveys to measure quality outcomes and improvement for over a decade and has the largest database in Europe, with over 100,000 patient records.

Director of clinical services Dr JJ de Gorter says Bupa has focused on measuring overall 'health gain' rather than simply avoiding complications.

This is done with validated off-the-shelf questionnaires called patient-reported outcome measures, which are sold under licence and cannot be amended. The most common is the SF36, a generic questionnaire that asks 36 short questions about physical and mental well-being.

The other is VF (for visual function) 14, which is a more specific tool for measuring health gain after cataract operations.

'You ask the questions before the intervention and then ask them three to four months after and you expect to see a health gain,' says Dr de Gorter.

Bupa consultants get a yearly performance report, which scores overall health gain by doctor and by procedure and identifies areas for change. But it seems they are not entirely happy with the system. 'The occasional push back we get is they would say it's not valid for their procedure. We pull out references to show that it is.'

Patient satisfaction reports account for nine of the 36 metrics on which each Bupa hospital is tracked and scored.

Dr de Gorter says a fully functioning NHS Connecting for Health information system will allow managers to track the lifetime health and welfare journey of a patient.

'We will move away from episode cost of care to cost of care from the cradle to the grave. Theoretically, if you invest in preventive measures, people will lead healthier lives, their lifetime cost should reduce and they should live longer.'

For NHS managers Dr de Gorter says patient-reported outcome measures are an unambiguous measure of quality with which you can make comparisons between organisations or consultants.

'The numbers stack up as it improves safety, efficiency, performance and well-being,' says Dr de Gorter. 'It's not complicated and it's cheap - it cost us about three quid per patient but if the NHS cannot get that down to 50p I would be very surprised.'

Find out more

Atkinson review final report, click here

The Centre for Health Economics at York University, the National Institute for Economic and Social Research and Department of Health. Model that measures quality of change, click here

Lord Layard's manifesto for well-being, click here

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