How NHS performance is evaluated is a crucial issue for the suppliers of medical products and services. Thoreya Swage examines the new NHS Outcomes Framework, which promises to keep the patient clearly in view.

The coalition Government's scheme for the health service, Equity and Excellence: Liberating the NHS, was launched in July, proposing fundamental changes in the way our healthcare is delivered. It was soon followed by a flurry of consultation papers - one of which is a proposed outcomes framework against which the performance of the NHS will be assessed.

For a number of years, the NHS has tried to demonstrate its effectiveness using various methodologies. The latest consultation paper is no exception. Liberating the NHS: Transparency in outcomes - a framework for the NHS is the Government's attempt to refocus the accounting of the many and varied NHS interventions that are carried out on a daily basis.

Showing an improved quality of care has always been difficult - particularly with nationally determined process targets, which the current Government claims has distorted clinical priorities and restrained innovation. However, it is a tall order to measure the success of approximately 300 million consultations in general practice and 1400 different types of hospital-based treatments for 7 million routine admissions and a similar number of emergency admissions each year.

The paper proposes that the Secretary of State will, following consultation, set the national outcomes which the newly established NHS Commissioning Board will be expected to deliver. In turn, the new GP commissioning consortia will be held responsible by the Board for improving health outcomes through their local commissioning of services. The document is at pains to say that the indicators for measuring the outcomes will be based on the best available evidence, and the framework will not be used as a stick to beat providers of NHS care.

First night of the PROMs

Once the indicators are set, the Board will decide how best to deliver improvements. This will be done by working with the GP consortia and using the tools and levers available. For example, the Board will be able to commission Quality Standards from NICE. These will inform the development of commissioning guidance, which will provide details on how the national outcome goals in the framework can be met. The Board will also use the Quality Standards to design mechanisms for incentive schemes, such as Commissioning for Quality and Innovation (CQUIN) and other payment frameworks.

The principles guiding the development of the NHS Outcomes Framework include the long-held ideals of accountability, transparency and balance, with a focus on achieving what matters to healthcare professionals and patients, as well as working in partnership with other public services as necessary. The requirement for balance is what remains of Lord Darzi's proposed review of the NHS (published in 2008 under the previous administration), whereby services would be assessed in terms of effectiveness, patient experience and safety.

The new framework places emphasis on ensuring excellence and moving away from minimum standards, which are the responsibility of the Care Quality Commission. A new direction has been set with the requirement that measures must be internationally comparable and the data collected must be publicly available. Furthermore, in addition to clinical outcome measures, patient reported outcome measures (PROMs) will feature equally as a means of recognising patient experience and safety.

There will also be measures that the NHS can only meet by working with other public sector agencies such as social services and the new Public Health Service. The NHS is working to construct and consult on outcomes frameworks for these bodies so that they can integrate well with those for the NHS.

The first outcomes framework will be modest, using current indicators for which data can be collected, and is due in 2011/12. The intention is to develop this over time as the NHS landscape changes, with annual reviews of the indicators.

From process to outcome

The proposed measures, which are taken from the principles identified by Lord Darzi, are placed in five domains:

• Domain 1 - preventing premature deaths.

• Domain 2 - improving the quality of life for people with-long term conditions.

• Domain 3 - facilitating the recovery of people who have had episodes of illness or injury.

• Domain 4 - ensuring a positive experience of healthcare.

• Domain 5 - looking after people in a safe environment and protecting them from avoidable harm.

Domains 1-3 cover effectiveness, while domain 4 covers patient experience and domain 5 patient safety.

Each domain consists of three sections: an overarching indicator, improvement areas and NICE Quality Standards. The overarching indicator for each domain allows the progress of the NHS to be assessed in the broad activity areas relevant to that domain.

Under each overarching indicator, there will be identified areas where improvements are expected to be made. These will be accompanied by specific outcome indicators against which the NHS Commissioning Board will be held to account for progress achieved.

Supporting all of these outcomes will be Quality Standards produced by NICE and commissioned by the Board. The GP consortia are expected to refer to the commissioning guidance (based on the Quality Standards) when commissioning services locally.

NICE has already published three Quality Standards this year, covering stroke, dementia and venous thromboembolism (VTE) prevention. A further 10 are in development; furthest down the line are specialist neonatal care, depression, chronic obstructive pulmonary disease and chronic kidney disease, with the expected publication date June 2011 (except for neonatal care, which is October 2010). The final tally is anticipated to be around 150 Quality Standards, providing guidance on what high-quality care should look like for a specific pathway or service.

The outcomes framework has a different structure from those developed in the past. Figure 1 below shows what the five proposed domains look like. All of the domains, overarching indicators and improvement areas shown will be supported by Quality Standards.

Clearly the Government is trying hard to shift the focus of the effectiveness of healthcare from processes to outcomes, and many possible indicators have been identified in the consultation document to get the discussion going.

Opportunities for medtech

The Government is keen for GP consortia to have the flexibility to commission services according to local needs - which means that medtech companies need to get close to the emerging commissioning groups and start discussions around pathways of care and service redesign. Although the pioneer GP consortia will have their own ideas on how to change services, there will be many who require more help and support. Solutions such as telemedicine, near patient testing and deployment of other diagnostic equipment in the primary or community care setting will be attractive.

The first NHS outcomes framework, due next year, will use many of the current indicators that cover processes. However, in the future the indicators will need to reflect outcomes. This will mean that new indicators need to be identified and the appropriate data to support these collected. New IT systems will need to be developed to meet these needs, and the medtech industry could be an important resource here.

New or redesigned services in which innovative medical technologies are utilised will need appropriately-trained staff to use these technologies. An important role for the medtech industry will be to ensure that health workers who are handling such technologies have the appropriate competencies and skills to use them correctly.

With the dual focus on providing care closer to home and evidence-based practice, consortia will be looking hard at specific medical technologies that improve clinical outcomes. Possible examples include continuous subcutaneous insulin infusion devices as well as such homecare services as continuous ambulatory peritoneal dialysis, stoma care and administration of chemotherapy and HIV drug therapy.

Transparency in outcomes - a framework for the NHS has set the scene for assessing the performance of the NHS through patient outcomes - including measures of patient experience - rather than process targets. Much more work clearly needs to be done - but while they await the published outcome of the consultation in December, medtech companies can do much to prepare for the new world.

 
Dr Thoreya Swage has several years' experience in the NHS, both as a clinician (psychiatry) and as a senior manager, including Executive Director for a Health Authority, in various NHS organisations covering acute and primary care. She has expertise in commissioning health services, most recently working with the independent sector as part of the Independent Sector Treatment Programme at the DH. She is currently working for a number of NHS organisations, including DH agencies, to develop a more commercial approach to the commissioning of healthcare.

The Government is keen for GP consortia to have the flexibility to commission services according to local needs - which means that medtech companies need to get close to the emerging commissioning groups and start discussions around pathways of care and service redesign.

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