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Editor’s blog Monday 19 July 2010: Transparency In Outcomes - the triumph of Darzi and Donabedian

A DNA paternity test carried out by Health Policy Insight reveals that the Coalition government's new outcomes consultation is the lovechild of New Labour peer Lord Darzi's 2008 next-stage NHS review and Professor Avedis Donabedian's 1966 classic on 'Evaluating The Quality Of Medical Care'.

Transparency In Outcomes’ – who could object to such a thing?

Lansley’s introduction states, “All too often, the NHS has been hamstrung by a focus on nationally determined process targets which have had a distorting effect on clinical priorities, disempowered healthcare professionals and stifled innovation”.

As Flaubert pointed out, all generalisations are dangerous – even this one. Targets were imperfect (but they improved real patient concern areas: waiting, access, healthcare-associated infection), and they had perverse consequences. Sometimes, they did distort clinical priorities and disempower clinicians.

Yet to claim that they stifled innovation would require evidence. Targets drove innovation, both positively (see and treat; Productive Ward) and negatively (redefining waiting areas as clinical decision units; parking people in ambulances to avoid 4-hour breaches).

Intellectual honesty would recognise this.

Lansley’s foreword adds, “Liberating the NHS from central control and political interference does not mean abdicating responsibility for whether the NHS succeeds or fails. I, and all future Secretaries of State should be judged on our success in creating a continuously improving NHS as measured by the outcomes that it is achieving for patients.

(This is) “an NHS Outcomes Framework … that will act as a catalyst for driving up quality and promoting equity and excellence across all services and that will provide an indication of the overall performance of the system in an international context. A transparent framework that will be used to hold the new NHS Commissioning Board to account for progress but equally one that patients, carers and the public can use to hold the Government to account”.

Sentences without grammar. Bad Blairite habit. More bad grammar follow: What are we consulting on?
1.7. The purpose of this consultation is to seek the help of those working in the NHS and the patients, carers and public it is there to serve in developing the first NHS Outcomes Framework”

Look, I know this is rushed, but the grammar stinks. Don’t end sentences with prepositions (as Churchill famously wrote, this is the sort of thing up with which I will not put”). Some punctuation is needed before “it is there”, too.

'The document picks up on the Darzi domains of quality: effectiveness safety and patient experience, and aims to filter them through Donabedian’s quality measurement framework – structure, process and outcome of care.'

The document picks up on the Darzi domains of quality: effectiveness safety and patient experience, and aims to filter them through Avedis Donabedian’s quality measurement framework – structure, process and outcome of care.

Um. So we are having a review of outcome  measures, marking a move away from structure and process measures – using structure and process analysis?

All is explained: “Locally, the structures and processes of care will need to be monitored but focusing on these too heavily at a national level can lead to a distortion of clinical priorities and risks creating a whole system of accountability that it is more concerned with the means than the result” .

It is, therefore, a question of balance. Structure and process are the Ugly Sisters: outcomes are the Cindarella of the ball. Andrew Lansley is their Prince Charming.

Donabedian’s classic 1966 paper is candid about the challenge of measuring outcomes: “Although some outcomes are generally unmistakable and easy to measure (death, for example) other outcomes, not so clearly defined, can be difficult to measure. These include patient attitudes and satisfactions, social restoration and physicial disability and rehabilitation.11 Even the face validity that outcomes generally have as criteria of success or failure, is not absolute. One may debate, for example, whether the prolongation of life under certain circumstances is evidence of good medical care. …  Finally, although outcomes might indicate good or bad care in the aggregate, they do not give an insight into the nature and location of the deficiencies or strengths to which the outcome might be attributed.

“All these limitations to the use of outcomes as criteria of medical care are presented not to demonstrate that outcomes are inappropriate indicators of quality but to emphasize that they must be used with discrimination. Outcomes, by and large, remain the ultimate validators of the effectiveness and quality of medical care”.

What is the Outcomes Framework for?
It is to focus on ends rather than means. The document suggests that the Outcomes Framework will be “a means by which patients, the public and Parliament can hold the Secretary of State for Health to account for the overall performance of the NHS. They will also provide a mechanism by which the Secretary of State can hold the new NHS Commissioning Board to account for securing improved health outcomes for patients through the commissioning process” .

So it is also going to be, metaphorically, a police force, and “will
act as a catalyst for driving up quality across all NHS services” .. That is, for the time being, a statement of faith and hope. It may require charity.

The Outcomes Framework “and the national outcome indicators it will include will also bring about greater transparency about the quality of healthcare services by guiding the publication of broader and more locally relevant information for use by patients, their carers and the public” .

This bit sounds good. It may initially be hard to use, but some clever software firm will make sense of it. There will of course be arguments over ranking methodology. Ask Doctor Foster about the HSMR debate.

In each domain, it will set out overarching indicators, which contain improvement areas, backed by supporting quality standards.

If you wanted to think of this in the old money, then an overarching indicator would be something like seeing a GP in 48 hours, underpinned by improvement areas of PCT performance management, backed by supporting quality standards (what the public said they wanted and were unhappy about – timely access to primary care).

But that is in the old money of process targets, This is completely different, honest.

Think of an overarching indicator like healthcare-associated infection rates, underpinned by improvement areas (hospital deep cleans, national support teams, monthly DH returns), backed by supporting quality standards (zero tolerance programmes). Got it?

What is the Outcomes Framework not for?
It is not to “be used as a tool to performance manage providers of NHS care” .

Remember those words, assuming they make the final draft in the Act.

Integrating with other services
The consultation rightly notes that integration with local government, social care and othter sectors wil be essential.

It also clarifies that a leader of this process has been selected, and it isn’t the NHS: “Local authorities will promote integration and partnership working between the NHS, adult social care, public health and other local services. They will bring together partners to agree local priorities for the benefit of patients and taxpayers, informed by community and neighbourhood needs. A crucial element in designing the NHS Outcomes Framework will be considering how it will incentivise more integrated care” .

Guiding principles
The sconsultation document sets out the folloing principles for the OF:
• Accountability and transparency
• Balanced
• Focused on what matters to patients and healthcare professionals
• Promoting excellence and equality
• Focused on outcomes that the NHS can influence but working in
partnership with other public services where required
• Internationally comparable
• Evolving over time

Darzi survives intact
It also states that “a balanced set of outcomes will be chosen. They will be used to hold the NHS Commissioning Board to account for overseeing the commissioning of a comprehensive healthcare service. This will span the definition of quality which Lord Darzi set out in 20087 and which the NHS has embraced:
• Effectiveness
• Patient experience
• Safety” .

Lord Darzi of Denham will be pleased to find that his three domains of quality survive intact. Sir David Ncholson will, too – there was a genuine and touching affection between those two men.

Will Julian Tudor Hart and Michael Marmot be happy?
Health inequalities crop up, which is always good to note: “because of the social gradient in most health outcomes, the most potential health gain will often be available from the lower reaches of the gradient, from disadvantaged groups and areas. Therefore, as far as possible, outcomes will also be chosen so that they can be measured by different equalities characteristics and by local area. The delivery of outcomes is likely to vary according to geographic area and across different population groups. By collecting data that makes the outcomes understandable according to equalities characteristics and by area the Government and NHS Commissioning Board will be in a position to promote equality and tackle inequalities in outcomes” .

The grammar is again all over the place, to the detriment of clarity of meaning  – “measured by different equalities characteristics and by local are”. Times may be tight, and we all appreciate the loss of ther pic-heavy graphic design, but please note, DH policyfolk, commas are free.

Here is a Wicked Issue: “As far as possible, the NHS (and its constituent parts) will be held to account for outcomes that it alone can influence. For all outcome indicators, where relevant, the NHS Outcomes Framework should identify the extent to which the NHS will be held accountable, as distinct from the contribution of public health interventions and social care services” .

This is going to pose real and difficult philosophical problems for Lansley, who has just told food manufacturers that in return for coughing up for public health campaigns, they can carry on feeding the ill-informed or indifferent all the lard and sugar they want (fermented or otherwise).

Deep breath. The determiniants of poor health are often far outwith the NHS’s remit. A Big Society has zero track record in addressing such key things as housing, sanitation, the local and national economy, infrastructure, climate, hope in the future. Equally, it is unlikely that democratic government can fix all these things: it has certainly not done so yet anywhere in the developed world that I know.

After revolution, evolution
There are challenges to implementing the outcome-based approach. Yet equally, it is the correct direction of travel. It does represent a reviolutionary change to NHS management and clinical culture.

What is welcome is a determination that the Outcomes Framework “will be reviewed annually to ensure that it focuses on the most important issues and so that it can accommodate new and better outcome indicators as they become available” .

That is very good news. It would be unwelcome would be if changes arose which (as the Kings Fund’s iridescent chief economist John Appleby spotted with the excised NHS staff survey question on whether you’d want yourself or a family member to be treated at the trust where you work) were driven by political expediency.

Let Donabedian have the last word
This beautiful obituary of Professor Avedis Donabedian, who died in 2000, ends by quoting him. Donabedian was a poet – a great species, poets – and his words are beautiful and should inspire.

“Each one of us is only a link in a chain that began long before us and will continue long after we have gone. Therefore we must honour our predecessors and delight in those who shall follow. Surely this is the secret of our contentment. And ‘what is the secret of quality?’, you will ask. Very simple, it is love – love of knowledge, love of man, love of God. Let us live and work accordingly.”

The name Avedis is reported to mean ‘bringer of good news’. His parents got that right, and much else besides.

The good news of more focus and transparency on outcomes will taste like a bitter medicine at first, but if we get it right, it will benefit us greatly