Dr Michael Dixon
Chairman, NHS Alliance
In December the government published its new NHS Outcomes Framework, which outlines 60 targets in five areas, all of which are relevant to general practice – especially those relating to long-term conditions and patient experience.(1)
Although in general we would welcome the move to a health service recognised for its outcomes – as opposed to ticking boxes that are often process-driven – things are not quite that simple.
For instance, the NHS will still need to meet some process-related targets, such as the 18-week waiting times for secondary care, which are not part of the NHS Outcomes Framework. GPs and GP practices will also still have their income determined, in part, by their ability to meet targets in the Quality and Outcomes Framework (QOF) introduced with the new GP contract.
That said, many of the outcome measures seem eminently sensible. The first area in the new framework is concerned with preventing people from dying prematurely. One of its first indicators is the “under 75 mortality rate from cardiovascular disease”. In my GP practice, the number of people under 75 dying from heart disease has been reduced remarkably over the past 30 years, partly due to better primary and secondary prevention and partly due to earlier diagnosis, faster care and better treatment available.
Clinical commissioning groups (CCGs), and their constituent GPs and GP practices, can have a positive impact on these relevant factors. By working together to improve health in their communities, they will be making a real difference and reducing mortality in various categories, which, ultimately, is more important than many of the biomedical indices rewarded within the QOF.
The second area, around “enhancing the quality of life for people with long-term conditions”, includes indicators such as “ensuring people feel supported to manage their condition” and “improving the functional ability in people with long-term conditions”. Again, these are intelligent indicators, very different from those in the past, which were pretty irrelevant to patients. The challenge for CCGs and their GP practices will be to provide a holistic and population-based care that will be required to make a fundamental difference to the lives of patients with long-term conditions.
Another indicator, which will be a very important challenge, is “enhancing the quality of life for people with dementia”. This will require CCGs to ensure relationships between social and community care are properly organised and, once again, means GPs will need to go beyond simply getting their QOF indicator dials looking good.
“Helping people to recover from episodes of ill health following injury” is, perhaps, less relevant to general practice, although one of these, “improving recovery from stroke”, is very much in the hands of GPs and their CCGs. Indeed, in some ways such indicators are revolutionary: CCGs (and indirectly GPs and practices) will be recognised and paid for actually making patients better rather than fulfilling instructions from further up the NHS food chain.
The fourth area, “ensuring that people have a positive experience of care”, has some points directly relevant to general practice, including patient experience of GP practices and GP out-of-hours services. CCGs will have a key role to play in improving access to services as well as patient experience, even in areas such as outpatients and maternity, which CCGs will potentially commission.
The fifth and final area, “treating and caring for people in a safe environment and protecting them from avoidable harm”, seems aimed mostly at secondary care, though “patient safety incidence reported” and “safety incidence involving severe harm or death” are all areas in which general practice and future CCGs can be agents of improvement.
It is clearly important that GP practices and their CCGs are judged according to their starting points and the difficulty in achieving these targets. That is, they need to be judged by the added value they have provided in terms of creating improved outcomes. The government’s framework does acknowledge this, stating that: “Levels of ambition will need to take into account health inequalities and other variations and outcome indicators”. That is easily said, but not always easily done. It is crucial, however, that we do not demoralise hardworking GPs, practices and CCGs in areas where the challenges are greatest and where current outcomes are the worst.
However good the outcomes, centrally driven targets inevitably have an erosive effect on frontline clinicians and CCGs, who are supposed to be liberated by current NHS changes. If history is anything to go by, targets can quickly become a cottage industry of people enrolled to help hit those targets, with the system then largely missing the point – ie, healthcare improvements for local population and real patients, rather than impressive figures and graphs.
It is difficult to argue with these targets, which seem to be well thought-through. Their sheer number, however, is in danger of sapping the will and innovation of frontline clinicians and CCGs, who may be faced with local priorities that are even more important than some of these indicators.
Furthermore, any set of indicators leaves ‘Cinderella’ areas. For example, focusing on mortality related to cardiovascular, respiratory and liver diseases could disincentivise clinicians to focus equally on kidney or urological diseases. By putting a focal point on mortality, we risk losing our role in promoting wellbeing. The same goes for concentrating on individual patients, which could lead CCGs to focus less on the importance of encouraging co-production of health, where local communities and populations work together to improve health. Although these initiatives will have an impact in the long run, CCGs and GPs under pressure to improve short-term outcomes may see them as relatively expendable.
These caveats should not detract from the conclusion that the Outcomes Framework is a refreshing new look at how we measure performance in the NHS, with a much more intelligent set of indicators. The indicators are themselves symbolic of a new role, indeed a new world, for GPs and practices with a new imperative from April 2013 to be responsible for the health of the whole local population as well as its individual patients, and to be equally responsible for the quality of services provided to those patients.
As CCGs will be clinically led, they will be in a better position than previous organisations to have a real and granular impact on areas such as patient experience and the quality of life for people with long-term conditions. The acid test, however, will be whether an intelligent set of indicators will be implemented with equal intelligence. That is, will they create genuine improved care rather than the semblance of improved care?
For substantial improvement to happen, we need a completely new culture and set of relationships when it comes to performance management, and a real sense of connectivity and understanding between the NHS Commissioning Board and CCGs, and between CCGs and their constituent practices.
Without such a change in culture and relationships, the Outcomes Framework could be consigned to the bin of “good ideas that never worked”. That said, it would be hard to argue that this new focus on NHS outcomes is not a step in the right direction.
1. Department of Health. NHS Outcomes Framework 2012-13. London: DH; 2011. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...